OOral Maxillolac$ur9 53:572-578, "1995 Orthognathic Surgery 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 orthodontics 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 malocclusion] These approaches include: 1) nights and nearly 3 days in the hospital, patients now growth modification so that the jaw 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 malocclusions. 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