OOral Maxillolac$ur9 53:572-578, "1995 Versus Orthodontic Camouflage in the Treatment of Mandibular Deficiency

MYRON R. TUCKER, DDS*

Although there have been significant advances in the experience on the part of both orthodontists and sur- combined surgical and orthodontic treatment of patients geons in treating mandibular deficiency. Both orth- with mandibular deficiency, many patients continue to odontic and surgery residents generally get adequate be treated by alone without consideration exposure to patients receiving this type of treatment for surgical correction. The correction of Class II maloc- during their training. clusion due to mandibular deficiency can be accom- The use of rigid fixation techniques, and the trend plished in a variety of ways. Proffit and Akerman de- toward shorter inpatient hospital stays have dramati- scribed three primary treatment approaches for cally decreased the impact of surgery on patients. correction of mandibular deficiency and the associated Whereas 15 years ago patients frequently spent 2 Class II ] These approaches include: 1) nights and nearly 3 days in the hospital, patients now growth modification so that the discrepancy is elimi- routinely stay only overnight to as little as a few hours nated as a result of mandibular growth; 2) compensation in an outpatient surgical facility. Instead of having their of the dentition with retraction of the upper incisors and teeth wired together for 6 to 8 weeks, patients routinely proclination of the lower incisors, or both, in an effort undergo mandibular advancement surgery with no to camouflage rather than correct the skeletal problem; maxillomandibular fixation. All of this results in more or 3) surgical correction of the jaw abnormality. In the rapid recovery from surgery, earlier return to work, case of mandibular deficiency, this is usually accom- and much less disruption of the lives of patients and plished by mandibular advancement. A fourth option their families. that could be considered includes orthodontic treatment There do continue to be risks that are associated of the malocclusion, compensating the dentition, com- with surgery, including adverse outcomes such as neu- bined with genioplasty. This option is intended to cor- rosensory abnormalities, failure to achieve the antici- rect the malocclusion with orthodontic compensation pated occlusal result, nonunion, malunion, and the as- and improve facial esthetics with a somewhat simpler sociated risks of general anesthesia. However, the low surgical procedure. 2 frequency and lack of severity of most complications Each of these treatment approaches is associated has made surgical treatment much more commonplace with controversy, including which patients benefit in the correction of Class II . Whereas most from a specific treatment and the timing of treat- surgical treatment was once viewed as a "last resort" ment, particularly when considering growing patients. reserved for those with the most severe abnormalities, During the past two decades correction of Class II it is now be considered a routine treatment for correc- malocclusions with surgical advancement of the man- tion of mandibular deficiency in indicated cases. dible has improved dramatically. This is due in part to significant advances in technology, as well as increased Patient Evaluation

Received from University Oral and Maxillofacial Surgery, Char- Much of the controversy related to treatment may lotte, NC. * In private practice. actually result from each practitioner's assessment of Address correspondence and reprint requests to Dr Tucker: Uni- the clinical problem. A recent study documented sig- versity Oral and Maxillofacial Surgery, 8738 University City Blvd, nificant disagreement between trained orthodontists Charlotte, NC 28213. and surgeons when evaluating patients with dentofacial © 1995 American Association of Oral and Maxillofacial Surgeons deformities. 3 The differences in assessment of the pa- 0278-2391/95/5305-001453.00/0 tient's deformity included the specific nature of the

572 MYRON R. TUCKER 573 deformity, as well as the severity of the deformity. The differences in opinion regarding the severity of the deformity may be compounded by each practitioner's interest or focus on a specific component of the maloc- clusion, ie, skeletal versus dental. In a study assessing patients who were evaluated for orthodontic and surgi- cal treatment, Proffit et al 4 found fewer Class II patients with severe overjet than with significant skeletal defi- ciency. This is probably due to significant dental com- pensation (lower incisor protrusion and upper incisor retraction) reducing the degree of dental abnormality despite a significant skeletal deformity. Focusing more on the occlusal relationship and less on the skeletal position may result in different treatment approaches T than would be generated if more attention was placed on the skeletal component. Most patients seek orthognathic surgical treatment based on the recommendation of the treating orthodon- tist. 5 Because many orthodontists may not focus on the skeletal component of mandibular deficiency, or consider it severe enough to warrant treatment, many patients with Class II malocclusions may never receive a surgical consultation or have this treatment alterna- tive discussed as a viable option. At the present time there are no widely accepted guidelines, nor is there a "gold standard," for determin- ing which cases of Class lI malocclusion would best be treated with surgery versus orthodontic camouflage. Proffit and Akerman, I have described the envelope of discrepancy, which can help serve as a guide when se- lecting appropriate treatment modalities for patients with a variety of maxillofacial abnormalities of varying sever- ity. This envelope of discrepancy is based on the severity of the abnormal occlusal relationships (Fig 1). Using FIGURE 1. The envelope of discrepancy. The limits of tooth this concept, three asymmetric circles are used to help movement that can be accomplished by various types of treatment visualize the range of correction that can be accom- are shown diagramatically in the asymmetric circles. Orthodontic tooth movement is represented by the inner circle or envelope. plished by orthodontic tooth movement alone, a larger Changes that can occur as a result of orthopedic or functional appli- range of correction that can be accomplished by func- ance therapy in growing patients is shown in the middle envelope and tional appliance therapy in combination with orthodontic the limits of surgical change are represented by the outer envelope. treatment, and an even larger range of correction that (Reprinted with permission.~) uses surgery as part of the treatment. Using this concept, the outer limits of correction for each type of treatment can be clearly visualized. However, in this diagram, the surgical treatment, there is a wide variety of chief com- limits of treatment are represented by a finite line sepa- plaints expressed by patients and significant differ- rating each type of treatment. In actual clinical practice ences in patient goals for outcomes of treatment. Pa- such strict division of patients into types of treatment tient's goals for treatment can include: 1) Enhanced cannot and does not occur. A variety of treatment options dental esthetics; 2) Improved dental function; 3) Better continues to exist for each patient based on his or her facial esthetics; 4) Resolution or improvement of tem- primary goals for treatment, as well as practitioner pref- poromandibular joint or muscle pain; and 5) Improved erence and experience. long-term maintenance of the dentition when factors such as periodontal problems are exacerbated by real- Patient Motivations for Treatment occlusions. Each of these concerns must be prioritized by the patient, orthodontist, and surgeon to insure that All medical and dental treatment should initially be the most important goals for the patient are achieved based on the patient's chief complaint. In the case of as a result of treatment. patients who may be candidates for orthodontic and The importance of facial esthetic improvement can- 574 ORTHOGNATHIC SURGERY VS ORTHODONTIC CAMOUFLAGE not be underestimated in patients who are considering growth, tracings generated from cephalometric radio- orthodontic and surgical treatment. In one study, a sig- graphs, can be used with reasonable accuracy to predict nificant percentage of females (53%) and males (41%) surgical outcome. However, it is extremely difficult indicated that esthetics and improvement in appearance for most patients to clearly understand the impact of were a major factor in their goal for seeking treatment. 6 treatment on facial esthetics when viewing cephalo- Flanary et al 7 found that facial esthetics was of signifi- metric profile tracings. The recent use of video imaging cant importance in 78% of patients electing to undergo has enhanced the patient's ability to perceive projected orthodontic and surgical treatment. surgical changes and make a more informed decision When patients describe improvement in facial es- related to possible treatment options. thetics as a high priority goal for treatment, the exact It is obvious that patients with nearly identical man- nature of their concerns and goals must be carefully dibular deficiency and Class II malocclusions will have evaluated. Variation in patients' evaluation of their dramatic differences in facial appearance as a result of own facial esthetics may eventually have a significant orthodontic versus surgical treatment, l~ Variations in impact on the type of treatment. For instance, two orthodontic treatment options can also produce marked patients may present with nearly identical facial ap- differences in facial profile. Paquette et alx2 described pearance, a mild mandibular deficiency and Class II differences in facial profile as a result of correction malocclusion. Each patient may list improvement in of Class II malocclusions with or without extraction. facial esthetics as a primary goal for seeking treatment. Although they are not as dramatic as changes some- One patient may describe dentoalveolar protrusion as times seen with surgical treatment, facial profile the primary facial abnormality. In many cases this will changes as a result of various orthodontic options may be amenable to orthodontic treatment only. On the also be of significant importance to patients. The ability other hand, a patient who describes deficiency in pro- to show patients the effect on the facial profile of both jection of the lower jaw as the facial abnormality, may orthodontic and surgical treatment options provides be treated best with a combination of orthodontics and better information regarding treatment outcome. This surgery. allows patients to interact and participate in their own Even when nearly identical clinical situations exist, treatment planning by providing an assessment of their some patients view their deformity as being much more own perception of facial esthetic changes (Fig 2). At severe than others. Bell et al8 found that patients who the present time the computerization of predicted opted for surgical treatment were significantly less changes is limited to two-dimensional images. In the likely to perceive themselves to be in the normal range future, computer technology will most likely provide when evaluating their own profile. For this reason it the ability to generate predicted facial images in three is important to specifically identify this group of pa- dimensions. tients, so that the treatment plan can be aimed at ad- dressing all of their concerns in order to achieve their Efficacy of Surgical Treatment goals for treatment in the best possible way. The efficacy of treatment can be judged using a Treatment Planning variety of parameters including improvement in occlu- sal characteristics such as , overjet, and buccal The data collection and analysis for treatment plan- interdigitation, and improvement in facial esthetics and ning of mandibular deficient patients are relatively long-term stability. Very few studies have been de- standardized in both the orthodontic and surgical com- signed that directly compare similar homogeneous munities. Data collection includes a patient interview, populations of patients divided into surgical and orth- clinical examination, radiographs, photographs, study odontic treatment groups. Proffit et a113 compared out- models and, in some practices, computerized video comes of orthodontic and surgical orthodontic treat- imaging. The data analysis includes interpretation of ment of Class II malocclusions in 57 adult patients cephalometric radiographic data, model analysis, and treated for similar occlusal and skeletal problems using treatment projections using cephalometric prediction cephalometric data and dental casts to evaluate the tracings and, in some cases, trial setup of occlusal relative success of treatment. The outcome of each models. The importance of each aspect of the decision- individual treatment was evaluated in two separate making process is well known, has been discussed in ways. First, the result was judged based on whether the companion article in this issue, 9 and will not be the final measurement of a particular result of treatment discussed further in this article. fell within a normal range. In this study acceptable The use of video imaging has increased as a result of results were similar in both groups when evaluating improved computer technology, decreased cost, more overbite and buccal interdigitation. However, there accurate imaging projection, and increased acceptance were two obvious differences between the surgical and as a treatment-planning modality, l° In the absence of orthodontic groups: in the surgical group acceptable MYRON R. TUCKER 575

Pretreatment Orthodontic Prediction Surgical Prediction

FIGURE 2. Video imaging treatment options. A, Pretreatment photograph. B, Cephalometric superimposition showing pretreatment profile and results obtained with orthodontic treatment only (extraction of upper and lower premolar teeth) and with surgical treatment. C, Video image of orthodontic only treatment plan. D, Video image of surgical treatment plan. overjet was achieved in 95% of cases versus 74% in the percentage differences of the goals achieved for overjet orthodontic treatment group, and an acceptable ANB and ANB difference are shown in Figures 3 and 4. difference was achieved in 81% of the surgical patients Patients with mandibular deficiency who undergo versus 52% of patients who received only orthodontic orthodontic and surgical correction have greater im- treatment. provement in facial esthetics when compared with pa- In the same study, ~3 the efficacy of treatment was tients undergoing orthodontic treatment only. In the also measured by evaluating the actual change oc- Proffit et al study ~3 previously described, the esthetic curring in a measurement after treatment expressed as outcomes of patients were evaluated by orthodontists a percentage of the change needed to give an ideal and surgeons, comparing orthodontic only treatment post-treatment value. The closer a post-treatment value with surgical advancement of the in combi- was to 100% of the ideal, the more "successful" the nation with orthodontic treatment. There was no sig- treatment. When evaluating treatment efficacy in this nificant disparity between the opinions of orthodontists manner, a significantly greater percentage of the ideal and surgeons when evaluating these patients. The es- goal was achieved in surgery patients when evaluating thetic changes from orthodontic treatment only ap- the skeletal ANB difference, soft tissue AB difference, peared to be small and the changes were as likely to the location of the maxillary incisor, and overjet. The be negative as positive (Fig 5A). However, the surgical 576 ORTHOGNATHIC SURGERY VS ORTHODONTIC CAMOUFLAGE

OVERJET CORRECTION-PERCENTAGE OF GOAL ACHIEVED those treated with orthodontic and surgical correction, Percent of patients and those whose orthodontic treatment was judged to 80 be unsuccessful. In this study, successful orthodontic 70 treatment resulted from a combination of retraction of 60 the maxillary incisors and protraction of the mandibu- 50 lar incisors in combination with some continued facial growth. Forty percent of these patients had greater than 30 2 mm of anterior-posterior growth during the treatment 2O period. The unsuccessful treatment group initially had 10 greater overjet, more severe mandibular deficiency, in- 0 creased anterior facial height, and less retraction of <20% 21-40% 41-60% 61-80% >80% Percent of goal achieved maxillary incisors and less growth during treatment. 1~3Orthodontics mmSurgery The recommendation of this study was that in Class II adolescents who are beyond the growth spurt, sur- FIGURE 3. Graphic representation of the percentage of an ideal gery is most likely to be needed for successful correc- goal for overjet correction achieved as the result of orthodontics only and surgical and orthodontic treatment. (Reprinted with permis- tion of the malocclusion if the overjet is greater than sion. 14) 10 mm, if the distance from pogonion to nasion perpen- dicular is 18 mm or more, if mandibular body length is less than 70 mm, or if facial height is greater than 125 mm. group had significant improvement in esthetic ratings for 11 of 13 patients (Fig 5B). As would be expected, the improvement appeared to be greatest in patients Other Considerations with the lowest pretreatment ratings. Although the es- thetic changes were evaluated by orthodontists and sur- In addition to the functional, occlusal, and facial geons who may evaluate these features more critically, esthetic considerations, several other factors must be it has been shown that the lay public can also detect considered when developing a treatment plan for cor- changes in facial esthetics as a result of surgical treat- rection of Class II mandibular deficient malocclu- ment. In a study by Dunlevy et a114 there was general sions. Patient compliance may be a significant factor agreement among laypersons, orthodontists, and oral in the outcome of any type of treatment. Some types and maxillofacial surgeons when asked to evaluate pa- of treatment require much more compliance or partici- tients' improvement in facial appearance after ortho- pation on the part of the patient to achieve the desired gnathic surgery. goal. Maxillary retraction dependent on use of a head- It has also been shown that patients undergoing or- gear is an important part of orthodontic treatment to thognathic surgical treatment experience greater im- eliminate overjet in many patients. Headgear must be provement in facial body image scores when compared worn consistently and for the appropriate amount of with patients undergoing orthodontic treatment only or time each day to maximize the effect of this type of patients who decline any type of treatment whatsoever treatment. Patients who are unable or unwilling to (Fig 6). As with professionals' judgement of facial esthetics, overall body image and facial image appear to be lowest at the initial assessment for patients who ANB ANGLE CORRECTION-PERCENTAGE OF GOAL ACHIEVED elect to undergo surgery, when compared with patients undergoing orthodontic treatment only. Over the time Percent of patients 60 of treatment there is some improvement, but this is less in patients receiving orthodontic treatment only 50 than in those undergoing surgical correction. 40

30 Special Considerations in Adolescents

lO Unlike adult patients, developing adolescents will o - ,r continue to have some facial growth, which can play <20% 21-40% 41-80% 61-80% >80% a part in treating Class II malocclusions. In a recent Percent of goal achieved study, surgical versus orthodontic treatment of Class E3Orthodontics BIBSurgery II malocclusions was evaluated in adolescent pa- FIGURE 4. Percentage of ideal goal for ANB correction achieved tientsJ 5 In this study three groups were identified: as a result of orthodontics only or orthodontic-surgical treatment. those treated successfully with orthodontics alone, (Reprinted with permission. 13) MYRON R. TUCKER 577

ESTHETIC RATING ESTHETIC RATING A BEFORE AND AFTER ORTHODONTIC TREATMENT B BEFORE AND AFTER SURGICAL TREATMENT

MEAN ESTHETIC RATING MEAN ESTHETIC RATING 80 80

60 60

40 ¸ 40 ...... = ......

20 20 2 3 4 5 6 7 8 9 ' 10 '11 ' 12 ' 13 1 2 3 4 5 6 7 8 9 '10 '11 ' 12 ' 13 ' SUBJECT NUMBER SUBJECT NUMBER --- PRETREATMENT -- POST TREATMENT --- PRETREATMENT -- POST TREATMENT

FIGURE 5. Esthetic ratings before and after treatment. A, The orthodontics-only patients started at a slightly higher level than patients undergoing orthodontic and surgical treatment. B, Surgical patients had greater increase in facial esthetic ratings as a result of treatment. (Adapted with permission. 13)

comply with this type of treatment are less likely to ing, and the possibility of intraoperative or postopera- achieve the treatment goals. In many cases, patients tive bleeding. Other long-term complications such as would prefer to undergo surgical correction as op- neurosensory abnormality, nonunion, malunion, post- posed to committing themselves to participation in operative malocclusion, and relapse must also be con- headgear therapy. sidered. Current technology and practitioner experi- Patients undergoing orthodontic treatment alone ence have greatly reduced the complications resulting may be in treatment for shorter periods than patients from this type of treatment and increased the level undergoing surgery in combination with orthodon- acceptance by patients and orthodontists. When pro- tics. L3 There are however, several situations where a viding patients with information regarding surgical combined orthodontic-surgical therapy may decrease treatment, it is important to make it as accurate as treatment time. An example would be when orthodon- possible. In some cases this can be provided by an tic treatment only will require extractions and space orthodontist with wide experience with surgical pa- closure as part of the orthodontic camouflage therapy. tients who is familiar with all aspects of surgical treat- The same patient might be treated quicker without ex- ment; however, in most cases, this information is best traction, allowing for surgery at an earlier time in treat- provided by an oral and maxillofacial surgeon who ment followed by final orthodontic detailing. routinely performs the procedure. The risks of surgery must always be considered and As a part of informed consent, patients should also balanced against the benefits of surgical treatment. Sur- be counseled about alternative treatments and the risks gery will always be associated with some pain, swell- and benefits associated with each of these alternatives. While, in general, orthodontic treatment may be per- ceived as less risky than surgical treatment, there are occasions where certain problems may occur as the FACIAL-BODY IMAGE result of orthodontic treatment that may be less likely to happen with orthodontic treatment in combination with surgical correction. One example would be the possibility of severe resorption of maxillary incisor roots resulting from retraction during orthodontic cam- ouflage treatment. Kaley et all6 recently described a 20 times greater risk of resorption in maxillary incisor roots when they are torqued against the palatal cortical plate, the exact movement required when retracting maxillary incisors in correction of Class II malocclu- Presurg ' 1-2 d postop '4-6 w postop '24 mo postop ' sions. Interval during treatment The current medicolegal environment requires that -- Ortho-Surgery -- Orthodontics only patients be fully counseled regarding all of their alter- FIGURE 6. Facial body-image scores for patients undergoing sur- natives for treatment of a specific problem. When gical-orthodontic treatment, orthodontics only, and no treatment. surgeons discuss the possibility of surgical treatment (Reprinted with permission. 5) of mandibular deficiency it is imperative that they 578 ORTHOGNATHIC SURGERY VS ORTHODONTIC CAMOUFLAGE also discuss the possibilities of no treatment and orth- adequate orthodontic correction may not be odontic treatment only, presenting their assessment of achieved? the advantages and disadvantages of each treatment. 3) Could orthodontic-surgical treatment result in a Orthodontists discussing correction of Class II maloc- significant decrease in treatment time? An exam- clusion and mandibular deficiency also should present ple would be when surgical treatment in combi- the possibility of surgical treatment to the patient nation with orthodontics could be accomplished along with a realistic assessment of the risks and ben- without extraction, whereas orthodontic treat- efits and projected outcome of each type of treatment. ment alone would require extraction and space Failure to provide adequate information that would closure. allow the patient to make an informed decision re- 4) Is there adequate patient compliance? Would garding type of treatment may have medicolegal im- orthodontic treatment alone be as ineffective plications if the patient is not satisfied with the out- without adequate patient cooperation? come of treatment. 5) Are the risks of surgery within acceptable levels? Finances appear to be one of the disadvantageous Are the benefits of surgical treatment, as pre- factors when a patient is considering surgery as part viously described, obvious? of the corrective treatment for a Class II malocclusion. References Because surgery requires operating room time, a same- day admission or overnight hospital stay, and anesthe- 1. Proffit WR, Ackerman JL: Diagnosis and treatment planning, sia and other ancillary fees in addition to the surgical in Graber M, Vanarsdall RL Jr (eds): Orthodontics: Current Principals and Treatment. St Louis, MO, Mosby, 1994 fee, this obviously increases the cost of treatment. The 2. Proffit WR, Turvey TA, Moriarty J: Augmentation genioplasty effect of decreased third-party payment for this type as an adjunct to conservative orthodontic treatment. Am J of surgical treatment has become a major" factor in Orthod 79:473, 1983 3. Phillips C, Bailey LJ, Sieber RP: Level of agreement in clini- influencing many patients to elect nonsurgical treat- cians perception of Class II malocclusions. J Oral Maxillofac ment. Although surgical treatment will always increase Surg 52:565, 1994 the cost to some degree, efforts to reduce operating 4. Proffit WR, Phillips C, Dann C: Who seeks surgical-orthodontic treatment. Int J Adult Orthod Orthognath Surg 5:153, 1990 time and hospitalization have resulted in significant 5. Kiyak HA, Bell R: Psychosocial considerations in surgery and cost reduction. Further efforts in this regard will hope- orthodontics, in Proffit WR, White RP Jr (eds): Surgical Orth- fully ease the financial burden associated with surgical odontic Treatment. St Louis, MO, Mosby, 1991, pp 71-94 6. Kiyak HA, Hohl T, Sherrick P, et al: Sex differences and motives treatment. for and outcomes of orthognathic surgery. J Oral Surg 39:757, 1981 7. Flanary CM, Batnwell GM, Alexander JM: Patient perceptions Summary of orthognathic surgery. Am J Orthod 88:137, 1985 8. Bell R, Kiyak HA, Joondeph DR, et al: Perceptions of facial profile and their influence on the decision to undergo ortho- Surgical correction of Class II malocclusions, when gnathic surgery. Am J Orthod 88:323, 1985 associated with mandibular deficiency, often has im- 9. Thomas PM: Camouflage versus surgery and the treatment of proved results with combined orthodontic and surgical mandibular deficiency. J Oral Maxillofac Surg 53:579-587, 1995 correction compared with orthodontic treatment alone. 10. Sarver DM, Johnston MW, Matukas VJ: Video imaging for Strong consideration of surgical correction of mandib- planning and counseling for orthognathic surgery. J Oral Maxillofac Surg 46:939, 1988 ular deficiency should be based on the following ques- 11. Cassidy DW Jr, Herbosa EG, Rotskoff KS, et al: A comparison tions: of surgery and orthodontics in "Borderline" adults with Class II, division I malocclusions. Am J Orthod Dentofac Orthop 104:455, 1993 1) Do the patient's goals for treatment place a high 12. Paquette DE, Beattie JR, Johnston LE Jr: A long-term compari- priority on improvement in facial esthetics? As son of nonextraction and premolar extraction edgewise ther- apy in "borderline" Class II patients. Am J Orthod Dentofac a corollary, even patients who are not particularly Orthop 102:1, 1992 concerned with facial esthetics, but who may 13. Proffit WR, Phillips C, Douvartzidis N: A comparison of out- have a worsening in facial appearance as a result comes of orthodontic and surgical-orthodontic treatment of Class II malocclusions in adults. Am J Adult Orthod Dentofac of orthodontic camouflage, should be considered Orthop 101:556, 1992 for surgical correction. This may include patients 14. Dunlevy HA, White RP Jr, Proffit WR, et al: Professional and with lack of upper lip support, an obtuse nasola- lay judgment of facial esthetics following orthognathic sur- gery. Int J Adult Orthod Orthognath Surg 3:151, 1987 bial angle, a large nose, and a long lower face 15. Proffit WR, Phillips C, Tulloch JFC, et al: Surgical versus orth- height, all of which may become more apparent odontic correction of skeletal Class II malocclusion in adoles- as a result of orthodontic camouflage treatment. cents: Affects and indications. Int J Adult Orthod Orthognath Surg 7:209, 1992 2) Are the orthodontic movements required in ex- 16. Kaley JA, Phillips C: Factors related to root resorption in edge- cess of the envelope of discrepancy so that wise practice. Angle Orthod 61:125, 1991