“For beauty, a good facial architecture is necessary; whether in man or woman.”

Mario Gonzalez-Ulloa, MD

“One cannot achieve good soft tissue symmetry in the absence of skeletal symmetry.”

David S. Precious, DDS

Introduction

In 1968, the renowned Mexican plastic and reconstructive surgeon, Dr. Mario Gonzalez-Ulloa, published a landmark paper on “The Role of Chin Correction in Profileplasty.”¹ Dr. Gonzalez-Ulloa went on to write that, “the taste for beauty varies according to the culture, the ethnic type, or even fashion. Nevertheless, since man first began to record his enthusiasm for beauty, a good relationship of the facial plane to the skeleton has been important so that a particular face would resist the impact of time.”

While his paper emphasized the importance of the lower facial dimension with reference to achieving an overall aesthetic balance to the face, the philosophy that he espoused can and should be applied to any surgical procedures utilized to correct skeletal abnormalities.

In the other chapters in this book, a multiplicity of soft tissue cosmetic procedures have been presented that show how today’s cosmetic facial surgeons can achieve cosmesis for their patients by improving the myriad of soft tissue problems which with we are presented in our practices on a daily basis. Nevertheless, “for beauty, a good facial architecture is necessary.” These words hold the key to achieving facial cosmesis for our patients. A good facial architecture, a proper relationship of the facial plane to the skeleton, provides the foundation for beauty. And, in this author’s opinion, no procedures can have a more profound effect on establishing facial harmony than orthognathic surgery. For by repositioning the skeletal base in a more harmonious spatial relationship, many of the soft tissue imbalances will naturally correct themselves. Or, in the words of Dr. David Precious, “One cannot achieve good soft tissue symmetry in the absence of skeletal symmetry.”² And while Dr. Precious’ comments were made in reference to cleft palate surgery, these tenets are well founded and should be applied to orthognathic surgery as well.

Historically, the traditional and time-honored goals of any orthognathic surgical procedure have been to establish a stable, functioning masticatory system with an aesthetic result.³ Oftentimes, because orthognathic surgery is considered to be reconstructive in nature, the pleasing aesthetic results that surgeons can obtain for their patients are almost overlooked. In our estimation, orthognathic surgery represents the ultimate aesthetic operation. It provides the surgeon with the opportunity to dramatically and permanently enhance facial balance and proportion, positively alter abnormal dental relationships, and in so doing, positively enhance the lives of our patients forever. In the ensuing pages, we will present a variety of case presentations that will demonstrate the aesthetic benefits of orthognathic surgery for our patients. Certainly, it is not possible in a short chapter of this nature to be all-inclusive on the subject of orthognathic surgery. Rather, it is our intention to illustrate by means of case presentations how, through the integrated treatment of orthodontia and orthognathic surgery, patients can receive outstanding aesthetic benefits resulting from substantial improvements in both the hard and soft tissues of the face.⁴ It is for this reason that orthognathic surgery remains an outstanding treatment modality in the armamentarium of the contemporary maxillofacial cosmetic surgeon.

We will begin by examining various case presentations of patients with Class II skeletal dentofacial deformities, continue with Class III cases, and then consider combination cases. In addition, we will review some of the more common adjunctive surgical techniques that can help to enhance the aesthetic aspects of our treatment when performing orthognathic surgery, and ultimately, deliver a more pleasing cosmetic benefit for our patients.

The Class II Deformity

As maxillofacial cosmetic surgeons, we face an extensive spectrum of skeletal, dental, and soft tissue deformities requiring correction to achieve optimal facial symmetry and aesthetic beauty. The Class II skeletal deformity is the most common developmental musculoskeletal deformity that can benefit from our services. Depending on the source, it is estimated that 5–10% of the world’s population has some degree of mandibular deficiency.⁵ In addition, underdevelopment of the lower jaw may frequently be accompanied by an abnormal maxillary growth, the most common condition being vertical maxillary excess with or without an anterior open bite deformity (apertognathism).

The common morphological finding in all dentofacial deformities is a poor nose-to–lip-to-chin balance. In Class II patients, their profile is characterized by excessive degrees of facial convexity accompanied by posterior facial divergence. The cervical mental angle is obtuse and there is poor definition to the mandibular border. The extent to which the face diverges posteriorly may be moderate or excessive. Extreme posterior divergence is usually accompanied by a severe Class II dental malocclusion necessitating both orthodontia and orthognathic surgery to optimally correct the condition. However, more subtle Class II patients oftentimes may bypass orthodontia choosing instead to address solely the retrusive profile and its inherent skeletal and soft tissue problems.⁶ This less afflicted group of patients can be treated by cosmetic surgeons well versed in mentoplasty, genioplasty, and/or filler techniques. Regardless of the approach employed, one cannot achieve good soft tissue symmetry in the absence of skeletal symmetry.

Mandibular advancement surgery is the most common surgical method employed to correct mandibular deficiency. The sagittal split ramus osteotomy remains the workhorse surgical technique to best accomplish correction of Class II deformities.⁷ Over the past 40 years, there has been a myriad of refinements and modifications purported to address various issues resultant from bilateral sagittal split advancement of the mandible. Nevertheless, regardless of which approach the surgeon favors, this operation remains a time-honored technique for correcting the dental, skeletal, and soft tissue problems inherent to Class II dentofacial deformity.

Mandibular Advancement Osteotomies

Let us first examine a patient with a mandibular deficiency that was treated by bilateral lower jaw advancement osteotomies. The patient seen in Figure 19.1a–f is a 13-year-old female with a Class II malocclusion who was identified at an early age as a candidate for orthognathic surgery combined with orthodontia. Sarah S. exhibits clinical mandibular deficiency resulting in a moderate retrognathic facial profile with accompanying lack of support to the soft tissues of the perioral region and chin. Accordingly, she demonstrates an obtuse mentolabial fold (Figure 19.1a) and a bunching of the submental tissue resulting in the appearance of a double chin as seen in the animated frontal view (Figure 19.1c). The patient demonstrates a Class II dental malocclusion with a significant overjet and deep bite (Figure 19.1d–f). There is an accompanying supereruption of the maxillary anterior incisor teeth and a loss of lower incisal show. The patient’s chief complaint is that, “I look like a duck”—not an aesthetic concern that can be easily overlooked!

Figure 19.1 (a–c) A young Class II patient who represents a good candidate for surgical correction as far as her facial aesthetics is concerned. (d–f) Class II dental malocclusion in a 13-year-old female.

Cephalometric analysis confirms a deformity of the skull, face, and jaw with comorbid abnormal occlusion.

Case 1 Aesthetic Problem List: Skeletal

• Retrusive facial profile
• Inadequate lip posture with lower lip eversion
• Increased mentolabial fold and mentalis muscle strain
• Increased submental soft tissue bunching
• Poorly defined cervical mental angle

Case 1 Aesthetic Problem List: Dental

• Class II dental malocclusion
• Supereruption of the maxillary anterior incisor teeth
• Excessive overjet and overbite
• Loss of lower incisal show

This patient is an excellent candidate for a lower jaw surgery to address the problem list as established in our clinical and radiographic examination of the patient.

Following integrated orthodontic (Dr. Ronald Jawor) and surgical correction via bilateral mandibular sagittal split osteotomies with a 6-mm advancement, noticeable improvement is appreciated. The presurgical submental bunching of the soft tissues has been corrected with the surgery and continued normal development of the adolescent (Figure 19.2a–c). Also note the soft tissue support to the lips and mentalis muscle area eliminating the presurgical soft tissue deficiencies. There is a significant improvement in the cervical mental angle of the jaw and a better definition to the inferior mandibular border. In most instances, surgical correction of Class II deformities can be successfully performed at an early age without concern for the potential of future jaw growth. Once the improved relationship is established between the skeletal and dental bases in most Class II cases, future jaw growth generally results in a proportional vector and facial symmetry.

Figure 19.2 (a–c) Postoperative profile and frontal views following correction via bilateral sagittal split advancement osteotomies. (d–f) Posttreatment occlusion shows correction of Class II dental malocclusion.

It should be recognized that in a single-jaw surgery, the aesthetic outcomes are to a large extent dictated by the occlusion because the maxillary dentition will dictate the position of the mandible in all three spatial planes. Accordingly, re-creating the ideal facial form may require additional cosmetic adjunctive procedures such as genioplasty or mentoplasty to complete the final aesthetics. This was a most gratifying cosmetic result for patient and surgeon alike given the resultant well-defined cervical mandibular angle and the overall balance of the face.

Mandibular Advancement Osteotomies with Adjunctive Submental Osteotomy

The patient shown in Figure 19.3a–f is a 57-year-old male whose chief complaint is, “my chin is weak, my bite is bad and I am concerned about the aging of my face.” John L. exhibits some fairly typical facial morphology for a Class II patient with a significant dental malocclusion. The frontal views (Figure 19.3b,c) illustrate reasonable proportionality and symmetry to the face. There is a modest component of mentalis muscle strain and a slight appearance of a double chin. There is 2–3 mm of maxillary incisal show.

Figure 19.3 (a–c) A patient with mandibular deficiency. Note the retrusive lower facial profile, increased depth to the mentolabial and nasolabial folds, and the excessive submental soft tissue bunching. (d–f) Severe Class II malocclusion with supereruption of the lower anterior teeth and excessive overjet and overbite.

His profile (Figure 19.3a), however, is dominated by excessive facial convexity and posterior facial divergence. The patient exhibits clinical mandibular deficiency resulting in a moderate retrognathic facial profile with accompanying lack of support to the soft tissues of the perioral region and chin. Accordingly, there is an increase in the mentolabial fold, a severe decrease in the lower incisal show, and a pronounced bunching of the submental tissues resulting in the appearance of a heavy neck. The patient demonstrates a pronounced Class II dental malocclusion with a significant overjet and deep bite. There is a comorbid supereruption of the lower anterior teeth and resultant excessive occlusal wear. Cephalometric analysis confirms the skeletal deformity.

Case 2 Aesthetic Problem List: Maxilla

• Increased depth of the nasolabial folds

Case 2 Aesthetic Problem List: Mandible

• Retrusive lower facial profile
• Inadequate lip support with lower lip eversion
• Increased depth of the mentolabial fold
• Mentalis muscle hyperfunction
• Increased submental soft tissue bunching

Case 2 Aesthetic Problem List: Dental

• Supereruption of the anterior teeth
• Excessive overjet and overbite
• Loss of incisal show
• Class II malocclusion

The patient is an excellent candidate for orthodontic therapy (Drs. John and William Redmond) followed by lower jaw surgeries to address the problem lists as established by clinical and radiographic examination. Specifically, the surgical correction involved a mandibular subapical osteotomy to intrude the lower anterior segment and level the occlusal plane in combination with a 10-mm advancement of the mandible via bilateral sagittal split osteotomies.

As previously noted, the presurgical soft tissue bunching in the submental area suggested the aesthetic need for concomitant submental liposuction. However, once the mandibular surgeries were accomplished, the bony advancement provided sufficient support to the soft tissues of the neck, precluding the need for adjunctive soft tissue procedures, such as liposuction or minimally invasive face-lifting. Furthermore, there is no need for cosmetic fillers in the nasolabial areas as the folds have disappeared with the additional bony support to the lower face. The reader is invited to compare Figure 19.4c with its preoperative counterpart and note the vibrant, healthy look of the patient’s face and smile.

Figure 19.4 (a–c) Postoperative profile and frontal views. Note the dynamic soft tissue improvements resultant from improved osseous support. (d–f) The dental cosmesis resultant from combined orthognathic and orthodontic treatment is evident. The patient shows a vibrant smile with a stable occlusion. (g) Preoperative cephalometric profile of the patient. (h) Postoperative cephalometric radiograph shows good improvement in the soft tissue outline.

From a cosmetic standpoint, the aging process has been dramatically reversed on a more permanent basis without fillers, a chin implant, liposuction, or a minimally invasive rhytidectomy.

Mandibular Advancement Osteotomies with Adjunctive Augmentation Mentoplasty

The Class II dental and skeletal individual who lacks sufficient anterior projection of the chin or who has deficient lower face height represents a patient type that is frequently encountered in our practices. These faces are usually characterized by inadequate soft tissue support resulting in lower lip eversion, lip incompetence, deepened mentolabial folds, jowling, and/or submental fullness. Frequently, this class of patient is treated by insertion of a chin implant (mentoplasty) with adjunctive fillers and/or submental liposuction.

As observed in the earlier case presentations, when the accompanying occlusion is significantly Class II, then orthognathic surgery to advance the mandible is considered to be the ideal treatment. However, as previously noted, the ability to advance the lower jaw to cosmetically correct the deformity solely using a mandibular osteotomy is limited by the position of the maxillary dentition. Accordingly, the need for an adjunctive mentoplasty to maximize forward projection of the chin or a genioplasty to increase the vertical height and lengthen the chin is commonly employed to achieve the optimal cosmetic appearance for our patients.⁸

Fred P. is a 47-year-old engineer with a lifetime concern regarding his facial appearance. However, it is only when he sees his general dentist to “glue back a loose front incisor cap” that he begins to appreciate the extent of his dentofacial deformity.

Figure 19.5a–f illustrates the cosmetic soft and hard tissue deficits. In the frontal view (Figure 19.5b), the patient shows loss of proportionality with a short, square face. There is a moderate component of mentalis muscle strain with the appearance of a double chin (Figure 19.5c). There is an uneven cant to his smile line with crowding of teeth and poor quality and failing anterior restorative crowns. The patient has a Class II dental malocclusion with an abnormal overjet and overbite. The profile is dominated by excessive facial convexity and posterior facial divergence (Figure 19.5a). There is a poorly defined cervical mental angle. As would be expected, the lack of good bony architecture has resulted in poor support to the soft tissues. There are numerous creases in the nasolabial and mentolabial areas. Loss of lower incisor show, poor lip competence with lower lip eversion, and a nose that appears unnaturally large due to the loss of dimension to the lower one-third of the face. The esthetic line (E-line) that shows the relationship between the nose, lips, and chin is severely excessive.⁹ There is soft tissue bunching to the submental neck area resulting in the appearance of lipodystrophy. Cephalometric analysis confirms the deformity of the skull, face, and jaws with significantly abnormal SNB and ANB values. In brief, the SNB defines the forward projection of the lower jaw relative to an accepted standard value (normal = 80 degrees). The ANB describes the angular difference (normal = 2 degrees) between the lower jaw projection when related to that of the upper jaw.

Figure 19.5 (a–c) A 47-year-old male patient with a moderate mandibular deficiency. The lack of bony support to the soft tissues results in aging of the face. (c) Note the mentalis strain and the double chin. (d–f) Class II dental malocclusion with generalized poor dental repair, loss of maxillary left first molar, and extreme deep bite.

Case 3 Aesthetic Problem List: Maxilla

• Increased depth of nasal-labial fold

Case 3 Aesthetic Problem List: Mandible

• Retrusive facial profile
• Short, square facial form
• Inadequate lip posture with lower lip eversion
• Increased mentolabial fold and mentalis muscle strain
• Submental lipodystrophy
• Poorly defined cervical mental angle

Case 3 Aesthetic Problem List: Dental

• Class II malocclusion
• Supereruption of the anterior incisor teeth
• Excessive overjet and overbite
• Loss of incisal show
• Poor aesthetic quality of dentition

This patient underwent bilateral sagittal split mandibular advancement osteotomies with an augmentation mentoplasty. The amount of forward projection of the mandible achieved by the bilateral sagittal split advancement osteotomies was limited by the upper dentition, thus necessitating additional augmentation with a Medpor chin implant (Porex Surgical Products Group, Newnan, GA). Figure 19.6a–f shows a successful rehabilitation of his dentition and an equally impressive cosmetic improvement to his facial features. The neck line is significantly better defined and most of the double chin has been eliminated. So too have the creases and folds in the nasolabial and mentolabial areas. The appearance of the nose in the lateral view is now more proportional to the face with the added dimension to the lower facial height. It should be noted that no nasal surgery (rhinoplasty) was necessary with the resulting changes to the facial profile. Finally, incisive show is improved resulting from the combined benefit of the orthognathic surgery, orthodontia (Dr. Mark Detrick), and restorative dentistry (Dr. Brent Bowling). The postoperative pictures were taken 4 years after the initiation of treatment and the patient looks 10 years younger. This is an excellent example of the positive affects that hard tissue balance and position can have on soft tissue symmetry.