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Functional and Aesthetic Endpoints in Orthognathic Surgery
 

Functional and Aesthetic Endpoints in Orthognathic Surgery

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    Functional and Aesthetic Endpoints in Orthognathic Surgery Functional and Aesthetic Endpoints in Orthognathic Surgery Document Transcript

    • Functional and Aesthetic Endpointsin Orthognathic SurgeryM. E. Elsalanty, MD, PhD,* David G. Genecov, MD, FACS, FAAP,1 J. S. Genecov, JS, DDS, MSD*Dallas, Texas, USAAlthough facial deformity can accurately be was this early that the need for cooperation betweendescribed and classified, the treatment goal can surgeons and orthodontists was emphasized,2 whenbe more difficult to define. Functional and esthetic the orthodontist E. H. Angle and the Surgeon V. P.endpoints calibrated to a set of normal facial pro- Blair described the mandibular body ostectomy forportions may achieve a ‘‘normal’’ face but one that is the treatment of mandibular protrusion. Blair2not necessarily beautiful. Results of orthognathic classified jaw deformities into mandibular progna-surgery can dramatically be improved by adding thism, mandibular retrognathism, alveolar protrusion,an aesthetic concept to the surgical plan. We can and open bite, whereas it was Angle3 who intro-achieve a face with both stable occlusion and a duced the standard classification of jaw relations into normal occlusion and class I, II, and III malocclusion.beautiful look each time. Additional soft tissue During the 1950s and 1960s, orthognathicprocedures may be required to perfect the final surgery evolved rapidly with the introduction ofbalance and harmony of the face. mandibular sagittal split and LeFort I osteotomies and other techniques that dramatically improved theKey Words: Functional, aesthetic, endpoints, orthog- treatment results, both in the short and long term.nathic, surgery Orthognathic surgery became a real specialty, with its beacon at the Obwegeser’s unit in Switzerland. At about the same time period, craniofacial surgeryEVOLUTION OF ORTHOGNATHIC SURGERY was born in France at the hands of Paul Tessier.4Y6 In the late 1960s, the concept of rigid internalO rthognathic surgery is defined as surgical manip- ulation of the facial skeletal elements to restoreproper anatomic and functional relationships. Over fixation of the craniofacial bones was introduced by the AO group in Switzerland. This provided an easier and more efficient stabilization method forthe last 150 years, several prominent general sur- existing osteotomies and paved the way for thegeons, dentists, oral and maxillofacial surgeons, plastic innovation of new ones. The use of rigid internalsurgeons, otolaryngologists, and orthodontists have fixation also eliminated the postoperative need fordeveloped this specialty into what it has become today. lengthy, inconvenient, and often hazardous inter- The first reported orthognathic procedure was maxillary wire fixation.performed by Hullihen in 1849.1 It involved a wedge Another important development that shaped theostectomy to correct mandibular alveolar protrusion. future of orthognathic surgery specifically and boneDuring the late 19th and early 20th centuries, several reconstruction in general was the introduction oftechniques were introduced, mainly for treatment of efficient bone substitutes and bone augmentingmandibular prognathism. Surgical procedures were factors. Bone inducing factors have been extensivelytechnically and conceptually simple, but the results investigated in promoting dental implant osseo-were less than satisfactory and carried a high integration,7Y12 bone regeneration in segmentalincidence of complications and relapse. However, it defects,13Y18 and recently in augmenting bone regen- eration produced by distraction osteogenesis.19Y24 Of these factors, the bone morphogenic protein family From the *Baylor College of Dentistry, Texas A&M University (BMP) appears to have the most promising clinicalSystem Health Science Center; and 1International Craniofacial applications.25Y27Institute, Cleft Lip and Palate Treatment Center, Medical City,Dallas, Texas. Address correspondence and reprint requests to Dr. David G. DECISION-MAKING IN ORTHOGNATHIC SURGERYGenecov, International Craniofacial Institute, Cleft Lip and PalateTreatment Center, 7777 Forest Lane, Suite C717, Dallas, TX 75230;E-mail: dggmd@craniofacial.net S ince their inception, the focus of orthognathic procedures has been to achieve ideal dental 725 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
    • THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007occlusion through correction of underlying skeletal Advances in imaging technology and the intro-disharmony.2 Dentofacial deformities have been duction of computerized cephalometric analysis anddefined and understood in terms of deviations in the facial soft tissue analysis software have made itdental or skeletal relationships from a ‘‘normal’’ setup possible to predict the outcome of certain orthog-that was largely arbitrarily defined.28 Orthognathic nathic procedures from a soft tissue perspective. Itsurgery has primarily been indicated whenever the has also become possible to specify the desirable softdeviation in skeletal relations became severe enough to tissue results and design the skeletal and dentalbe functionally or esthetically handicapping28,29 and procedures to achieve them.36 It appears it will be thecould not be resolved by dental procedures. It was ‘‘facial’’ component in a ‘‘dentofacial’’ deformity thatwidely believed that whenever the underlying skeletal dictates the treatment plan in the 21st century.36Y38and dental deformities were corrected, this would The treatment goal of this new ‘‘soft tissueuproot the etiology of any soft tissue disharmony, and paradigm’’ is to achieve normal soft tissue proportionfacial esthetics would be achieved in consequence. while maintaining optimal functional, even if less In any case of dentofacial deformity, correcting than ideal, occlusion.39 Treatment planning is basedthe underlying skeletal problem has been the primarily on clinical evaluation of the facial soft tissueprimary goal of the treatment plan. The prevailing proportions, keeping in mind the limitations of softdogma, the Angle paradigm, stated that achieving tissue adaptation to skeletal changes. Soft tissueperfect dental alignment and temporomandibular limitations involve the proportions of facial features,joint function would bring about facial harmony.3,30 the amount of pressure that the lips and cheeks exertTherefore, soft tissue procedures were rarely incor- on the teeth, the thickness and integrity of facial softporated into the treatment planning, which was tissues, the stresses created by the attached muscles,directed primarily by cephalometric measurements and the patterns of soft tissue kinetics during jawand dental cast maneuvering. movements and facial expression. However, perfect intermaxillary relation did not Classically, several factors help indicate the neednecessarily translate into facial harmony,31,32 and for a specific orthognathic procedure. These includeseveral studies in the 1980s have shed doubts on the unaesthetic facial proportions or interdental relations,validity of using cephalometric analysis of the temporomandibular joint dysfunction, impaired mas-craniofacial skeleton as a basis for treatment.33Y35 It tication, compromised airway, and difficulty inhas been shown that correcting the skeletal deformity maintaining oral hygiene because of deformity.40 Ituntil a certain ‘‘ideal’’ cephalometric relation was is also essential to identify the patient’s needs andachieved did not achieve consistent soft tissue expectations regarding the treatment outcome. Dis-results.33 Moreover, if the soft tissue parameters are cussing the treatment plan with the patient and familyignored, skeletal correction may even have detri- is emphasized now more than ever. This shouldmental effects on the facial appearance. For example, involve understanding and addressing the reason thatmaxillary impaction may improve incisor display but prompted the patient to seek treatment, which maycontribute to early aging of the face, especially when not necessarily be what the physician believes is thethe upper lip increases in length with age. A maxillary main problem. Also, the treatment plan should beadvancement and widening in cases of maxillary explained in detail to the patient, emphasizing thedeficiency may produce an excellent occlusion but rational for alternative approaches, possible compli-with a flat or a denture-looking smile. cations and limitations to each technique, and ways to Surprisingly enough, this revelation was first manage these. The most important piece of informa-articulated by Blair2 himself when he declared that tion that the patient should receive as accurately astargeting the ideal occlusion rarely produced the best possible is what to expect in terms of facial outlook atfacial results. A century later, it became evident that the end of treatment. Defining the endpoint from thethe facial soft tissue cannot be considered simply as a start is key to patient satisfaction with the outcome,‘‘latex glove’’ that takes the shape of the hand that which is a major determinant of success in this game.wears it. Indeed, the soft tissue is the envelope of the The decision to use a specific treatment methodskeleton; however, it has its own variables that are depends on many factors. Purely dental problemsindependent enough to confound the results of any with no underlying skeletal problem can be con-treatment that is solely based on skeletal parameters. trolled by orthodontics alone. However, if theTherefore, because it is the facial outlook that defines deformity is so severe that it cannot be corrected bysuccess or failure, at least from the patient’s perspec- orthodontic treatment or camouflage, then growthtive, it should be the starting point for treatment plan- modification, if the patient still has significant growthning as well (Fig 1). to come, or surgery, if not enough growth is expected,726 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
    • FUNCTIONAL AND AESTHETIC ENDPOINTS / Elsalanty et alwill be needed. The underlying skeletal deformity techniques.39 Furthermore, in severe deformities,and its pathogenesis, stage of patient growth and treatment should be continued until no furtherdevelopment, condition of the soft tissues, and the growth is anticipated; otherwise, relapse is likely topatient’s needs and expectations will help decide how occur. In maxillary deficiency, treatment should bethe treatment plan will be set. Again, the treatment started before the age of 8 to be effective.41,42goal will be facial soft tissue harmony, healthy If the patient does not have enough remainingperiodontium and TMJ, and functional occlusion. growth to allow for an effective growth modification, Generally, for a young patient before or during orthognathic surgery is still not the only answer.the adolescent growth spurt, growth modification Another valid option is to correct the obvious featurestechniques are tried first. The idea is to change the of the deformity without interfering with the under-pattern of growth to slow down, stop, or reverse the lying deformity itself. The decision to ‘‘camouflage’’ aprogress of deformity. Although the amount of gain deformity rather than address its skeletal aspect maycan only be within a few millimeters, this can be a be taken because the patient prefers this over moresufficient correction in some patients. Even if the aggressive surgical procedures. In any case, the simu-condition requires larger skeletal movements, lated outcome should be visualized for the patientgrowth modification can assist in improving the through computer simulation, with thorough empha-condition so that only an orthodontic or surgical sis put on the limitations of such treatment.camouflage procedure are required when growth Orthodontic camouflage can have satisfactorystops, rather than orthognathic surgery. results by itself in mild anteroposterior jaw discre- Some deformities, such as mandibular progna- pancy with dental crowding of less than 6 mm.thism, do not respond well to growth modification However, it is not adequate in patients with increasedFig 1 Seventeen-year-old female with maxillary deficiency. (A to E) Before treatment. (F to K) After treatment. Satisfactoryresults involved correction of occlusion and soft tissue projection. 727 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
    • THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007facial height or when the deformity involves a b. Anteroposterior excess, producing a class IItransverse skeletal component.43 malocclusion An example of combined orthodontic and c. Vertical maxillary excesssurgical camouflage is the retraction of protrusive d. Vertical maxillary shorteningmaxillary incisors with or without anterior move- e. Horizontal narrowing or widening of the max-ment of mandibular incisors in the treatment of a illary archclass II deformity. This can be accompanied or f. Asymmetric vertical height of the maxilla.followed by chin augmentation or rhinoplasty to A patient with a dentofacial deformity will mostachieve facial harmony. If satisfactory results cannotbe achieved by surgical and orthodontic camouflage, often present with a combination of some of theorthognathic surgery is the only remaining option. above-mentioned skeletal deviations, producing class II or III malocclusion, anterior open bite, cross Orthognathic surgery directly addresses the bite, occlusal cant, inappropriate incisor display,underlying skeletal deformity. Treatment is staged unaesthetic smile, disproportionate middle or lowerso that the dental arches are orthodontically pre- facial height, or gross facial disharmony. The focus ofpared before surgery; then, surgery is performed the clinical assessment should be the impact of theto correct the skeletal deformity, followed by post- skeletal deviations on the facial soft tissue featuressurgical orthodontic finish. Treatment planning and not the actual skeletal measurements.should be based on integrated soft tissue andcephalometric prediction. After presurgical ortho-dontic preparation, both the soft tissue and cephalo- ORTHODONTIC PREPARATION FORmetric parameters should be reevaluated. The ORTHOGNATHIC SURGERYdesired skeletal changes are outlined on the cepha- Preorthodontic Treatmentlometry, and the soft tissue effects are predictedusing image analysis software. Then, the surgery issimulated on the patient’s updated models to verifythe feasibility and accuracy of the cephalometric O rthognathic surgery is an elective procedure and should not expose the patient to any unneces- sary risk. Therefore, the patient’s general conditionplanning and to create the occlusal splints accord- should be assessed to exclude any cardiac, pulmon-ingly. Occlusal splints will be used to guide the ary, hepatic, renal, or psychological contraindicationinterdental position at each stage of the surgery. for surgery. Moreover, pathologic conditions and medications that affect bone healing and oral healthCURRENT INDICATIONS FOR have to be addressed. The patient’s nutritional statusORTHOGNATHIC SURGERY should be appropriate for surgery, and he/she should be advised to stop smoking for at least 2D entofacial deformities can be classified accord- ing to the plane(s) through which correction isneeded: months before surgery. Dental caries should be controlled before starting orthodontic and surgical treatment. If possible, it is preferable to retain the natural crown and delay its1. Mandibular: restoration until after the deformity correction. How- ever, if dental extraction or restoration is absolutely a. Anteroposterior deficiency, producing a class II needed, temporary restorations should be used, with malocclusion delay of the application of permanent restorations b. Anteroposterior excess, producing a class III until after the end of postsurgical orthodontics. malocclusion A healthy periodontium should be established c. Vertical ramus excess or shortening before treatment. It may be necessary to perform a d. Anterior vertical excess or shortening gingival graft before orthodontics to cover an area e. Transverse narrowing or widening of the exposed by gingival recession. However, if bone mandibular arch resorption is evident or if pockets exist, every effort f. Asymmetric vertical height of the mandibular should be made to restore the teeth and supporting ramus, condyle, or body. periodontium to optimum health. After deformity treatment, the periodontium should be reassessed,2. Maxillary: and guided bone regeneration techniques can be used to address any remaining pockets. Oral hygiene a. Anteroposterior deficiency, producing a class III should be thoroughly maintained throughout the malocclusion treatment period.39,44728 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
    • FUNCTIONAL AND AESTHETIC ENDPOINTS / Elsalanty et alPRESURGICAL ORTHODONTIC TREATMENT be more easily achieved by the planned surgical procedure. However, it is advisable to perform asT he goal of presurgical orthodontic procedures is to prepare the teeth for the skeletal changes thatwill occur during surgery, with no regard for the much presurgical orthodontic finishing as possible to lessen the amount needed after surgery and thus enhance postsurgical stability.presurgical dental occlusion. In fact, presurgicalorthodontic typically reverses any camouflage ordental compensation that may exist to optimize the FUNCTIONAL SURGICAL ENDPOINTSskeletal movement that can be achieved duringsurgery. This would cause the deformity to looktemporarily worse during the presurgical treatment S keletal modification carried out during surgery aims at influencing the facial soft tissue outline to achieve attractive facial features while maintaining a stableperiod. The extent and duration of preparatory functional occlusion. The degree of skeletal correctionorthodontic treatment is case-dependant, varying is limited by the ability of the soft tissues to adapt tofrom a few days up to 18 months. skeletal changes. When satisfactory bone stability is One aim of presurgical orthodontic treatment is ensured, postsurgical orthodontics can be started.to restore the proper curvature of the occlusal plane Postsurgical orthodontic treatment aims at(curve of Spee). Patients with facial deformities reaching the best possible dental occlusion withoutcommonly have accentuated or reversed curve, compromising the stability of skeletal changesnecessitating vertical height adjustment. In general, achieved during surgery. The goal is to ensuresurgery is the best way to induce vertical facial coordination of the centric relation, in which thechanges; however, the relative vertical and horizon- condyles are anatomically seated in their anatomictal position of the incisors should be established positions, and centric occlusion, in which the teeth fitbefore surgery. To establish the desired vertical or bite best together, which is also called maximumposition of the incisors within an acceptable curve intercuspation.of Spee, some presurgical leveling may be required Functional treatment guidelines include establish-by selective extrusion and intrusion of teeth. ing stable normal occlusion with consistent centric Intuitively, we can see that extrusion would be relation of the TMJ and centric occlusion. Normalmore appropriate in cases where facial height needs occlusion is defined by proper dental intercuspation,to be increased and vice versa. If segmental surgery is proper incisor overlap, with elimination of overjet,planned for a severe deformity, the teeth should be reverse overjet, open bite, or overbite. Discrepancyleveled within each segment so that arch alignment is between centric relation and centric occlusion is a ‘‘redachieved after surgical segmentation.44 In any case, alert’’ that should be monitored throughout thefinalizing the alignment should be delayed to the treatment period, especially during the postsurgicalpostsurgical phase. Although intrusion must be orthodontic treatment. Starting the orthodontic toothperformed before or during surgery, extrusion is movements before full stability of bone segments is abetter achieved after surgery.44 major cause of such a complication. Another aim of preparatory orthodontics is Another functional marker of treatment successadjusting the horizontal incisor position that will is the restoration of appropriate longitudinal andguide the anteroposterior positioning of the jaws horizontal curvature of the occlusal plane (curve ofduring surgery. Dental extraction can be necessary to Spee and curve of Wilson), proper dental align-create spaces that can be partially used for adjusting ment, and elimination of dental crowding andthe incisor position while leaving enough room for interdental spaces. Additional postsurgical dentalthe planned interdental osteotomies. alignment and leveling may be necessary to achieve Arch alignment, incisor position, and vertical the final result.leveling of the teeth should be compatible with theplanned surgical positioning of the jaw bones. AESTHETIC ENDPOINTSExtrusion or intrusion of teeth to restore verticalleveling should be decided on the basis of thepatient’s facial height. It should be noted thatorthodontic treatment will have to be continued T he ultimate measure of success lies in achieving the predicted facial appearance that the patient anticipated and agreed to. Although normative softafter surgery; therefore, it is a waste of both time and tissue and skeletal values are helpful as guidelines,energy to try to achieve perfect dental relations they should not be regarded as concrete targets. Inbefore surgery. Furthermore, it is inefficient to fact, if we applied the ‘‘ideal’’ soft tissue proportionsattempt to orthodontically achieve changes that can to a large number of individuals who are considered 729 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
    • THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007to have beautiful or attractive facial profiles, we The rule of thirds (Fig 2) states that the verticalwould find that most of them have significantly facial height is divided into equal thirds by fourdifferent proportions. This makes deviation from the horizontal lines at the hairline, the glabella, the base‘‘ideal’’ the rule rather than the exception, which of the nose, and the menton. In adults, the philtrummeans that the endpoint of treatment should be height should constitute one third of the lower facialindividually defined for each patient. The patient height. The commissure height is typically 2 to 3 mmshould fully understand and be comfortable with this longer than the philtrum in adults but is shorter inconcept before treatment starts. adolescents. During growth, the upper lip may lag People have been trying to define beauty for as behind the lower lip in vertical height but catches uplong as art and sculpture have existed. Renaissance around adolescence. When the head is in neutralartists identified several anthropometric rules that position, the nostrils should be barely visible. Thedefine the ideal facial relationships as based upon columella should be parallel to the alae of the nose,classical Greek canons.45 Later, the classical artistic regardless of the direction of view.definition of beauty was transferred from art to The rule of fifths states that the anterior profile ofmedical practice. However, testing these parameters the face can be divided vertically into five regionshas proven that they cannot consistently be applied that are almost equal. The lines of division are acrossto define aesthetic endpoints for a specific race.45 It the lateral and medial canthus on both sides (Fig 3).makes no sense, therefore, to try to achieve the same Vertical lines from the inner canthus, the pupil, andcriteria across racial lines.46 the outer canthus should consequently coincide with Some guiding criteria for facial harmony have the ala of the nose, the oral commissure, and thebeen proposed, including the rule of thirds, the rule mandibular gonial angle. Therefore, the nasal widthof fifths, and smile parameters. These and other should be equal or slightly larger than the inter-criteria were adopted over the years in the attempt to canthal width, whereas the oral width should bequantify the elements of facial beautyVfacial sym- equal to the interpupillary distance.metry, balance between hard and soft tissues, and The most relevant dental landmark for the patientharmony in facial featuresVso that these ‘‘abstract’’ may be incisor position and inclination. Changes inelements could be measured, analyzed, and com- this landmark will greatly influence the amount ofpared. Although the patient’s situation can be incisor display during rest, which should be within 3 todefined using such guidelines, the goal of treatment 4 mm. During social smiling, the upper incisors shouldshould not be to bring each individual measurement be completely displayed with a rim of gingival toback to its ‘‘normal’’ value. Instead, the treatment produce an attractive, youthful smile. Even if moreendpoint for a specific patient is reached when gingival show occurs during smiling, this does notoptimal facial projection that is balanced, symmet- require correction as long as the display at rest isrical, harmonious, and stable has been achieved. within 3 to 4 mm.39 With age, the labial thicknessFig 2 Rule of thirds: vertical facial height is divided into equal thirds by four horizontal lines at hairline, glabella, base ofnose, and menton. In adults, philtrum height should constitute one third of lower facial height.730 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
    • FUNCTIONAL AND AESTHETIC ENDPOINTS / Elsalanty et al outcome; therefore, it should be foremost in the treatment plan. Parameters such as Cupid’s bow outline, philtrum height, lip thickness, buccal corri- dors, smile arc, and symmetry of the dental display and nasolabial folds during smile have gained well- deserved attention in recent years. In addition to the classical incisor display and gingival show, these parameters have dramatic influence on the personality of the face. Criteria for an esthetic smile have been previously identified.39,47Y51 Intuitively, we can see it is the facial features that will ultimately define the beauty and attractiveness of the face and not its outline or dimensional ratios. It is interesting how very fine changes in nasal profile, symmetry of the nasolabial folds, commissure height, depth of the labiomental sulcus, lip-chin-throat angle, chin projection, and chin-neck angle can dramatically change the facial outlook. Adequate prominence of specific points of the face, more so than others, defines its overall projection, and theseFig 3 Rule of fifths: face can be divided vertically into fiveequal regions. Lines of division are across lateral and include the chin, the temples, tip of the nose, andmedial canthus on each side. Vertical lines from inner supraorbital ridges (Fig 4). Therefore, treatmentcanthus, pupil, and outer canthus should consequently results can be greatly enhanced if some ‘‘fine-tuning’’coincide with ala of nose, oral commissure, and mandib- of these features is considered. This may includeular gonial angle. genioplasty, which can be performed as a part of the jaw surgery, malar augmentation, lip augmentation, submental liposuction, fat injection, or rhinoplasty.decreases, increasing the length of the upper lip, and The result is a visually pleasing, attractive face, not athe gingival show will typically decrease. matrix of calculated lines and angles. One of the most prominent factors that deter-mines the attractiveness of the face is the smile. It is CONCLUSIONalso one of the most variable factors and is difficult tocontrol. The achievement of an aesthetic smile is veryimportant for patient satisfaction with the treatment F unctional endpoints aligned with societal norms typically provide a ‘‘normal’’ face that is notFig 4 Not all areas of the face are of equal importance in determining facial projection. Most important points are chin,temples, tip of nose, and supraorbital ridges. 731 Copyright @ 2007 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
    • THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007necessarily beautiful. Orthognathic surgery can human bone morphogenetic protein-2. Int J Oral Maxillofac Surg 2002;31:287Y295dramatically change the look and proportions of 19. Rachmiel A, Aizenbud D, Peled M. Enhancement of bonethe face even without changing functional occlusion. formation by bone morphogenetic protein-2 during alveolarBy adding an aesthetic concept to the surgical plan, distraction: an experimental study in sheep. J Periodontolwe can achieve a face with stable occlusion and a 2004;75:1524Y1531 20. Cheung LK, Zheng LW. Effect of recombinant human bonebeautiful look each time. Additional soft tissue morphogenetic protein-2 on mandibular distraction at differ-procedures may be required to give final balance ent rates in an experimental model. J Craniofac Surg 2006;17:and harmony to the face. 100Y110 21. Ozec Y, Ozturk M, Kylyc E, et al. 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