Advancement genioplasty: An important part of combination surgery in black American patients By Andrew M. Connor, D.D.S., M.S.,* and Farhad Moshiri, D.M.D., M.S. Lancaster, Ohio, and St. Louis, MO.

1. CASE REPORT
Advancement genioplasty: An important part of
combination surgery in black American patients
Andrew M. Connor, D.D.S., M.S.,* and Farhad Moshiri, D.M.D., M.S.**
Lancaster, Ohio, and St. Louis, MO.
R
ecent advances in orthognathic surgery
have permitted many patients of all races with dento-
similar relationships to each other. For example, the
nasofrontal angle of the subjects ranked as pleasing was
facial deformities to undergo effective correction. greater than the mentolabial angle and exceeded the
Fonseca and Klein’ evaluated black American nasolabial angle. The explanation given for selecting
women and concluded that the maxilla and mandible the flatter profiles was as follows: “Caucasian features
were more protrusive, the middle facial height appeared are considered to be more attractive than Negroid fea-
shorter, and the lower facial height was longer in the tures in American society.“7
black sample than in a comparable white sample. Thomas also noted that the least pleasing profiles
In 1977, Deloach3 performed an interesting study were the most protrusive ones. However, the white
on North American black women ranging in age from orthodontists comprised the majority in this selection.
18 to 41 years. The subjects’ photographs were eval- Lay persons (black and white) agreed with this deci-
uated by black women of the same age range. This self- sion; therefore, Thomas concluded that the least pleas-
assessment demonstrated a significant degree of dis- ing profile overall is one with severe bimaxillary
favor for the Class II, extremely bimaxillary protrusive protrusion. Our findings are also in agreement with
profile, and the Class III type face. Furthermore, in the that of the literature. The surgical analysis used for
black subjects, the judges preferred profiles resembling these two cases was described in a previous publi-
those of white subjects. cation. 5
Thomas7 published a similar study on North Amer- Studies2*4have shown that black Americans more
ican black women aged 18 to 41 years. These subjects often display a convex profile than white Americans.
included women throughout the United States with all Therefore, if a cepholometric analysis’ of black patients
varieties of profiles. They were evaluated by black and indicates combination surgery, the profile can be im-
white orthodontists by ranking the women from “most proved (straighter) if the chin is augmented. The ad-
pleasing” to “least pleasing.” The orthodontists’ eval- vancement genioplasty is an excellent procedure to es-
uations included lip prominence (Rickett’s “E” line, tablish a more pleasing profile in bimaxillary protrusion
Steiner’s “S” line) and facial profile angles (nasofrontal, patients.
nasolabial, and mentolabial). For the pleasing category,
both black and white orthodontists selected a straight CASE REPORTS
profile with only slight lip protrusion. In these subjects CASE 1 (Figs. 1 through 6)
the upper lip was on, or slightly forward of, the “E” A lZyear-old black male patient was referred for treat-
line with the lower lip on, but forward of, the upper ment with ClassII malocclusion. Clinical, cephalometric, and
lip. Also, the orthodontists preferred profiles in which model analysesindicated the following:
the nasofrontal, nasolabial, and mentolabial angles had Horizontal considerations
Maxillary protrusion with excessivemaxillary length
ClassII, Division 1 malocclusion with increasedoverjet
The review of tbe literature was part of a thesis submitted by the senior author
Flared maxillary incisors
in partial fulfillment of the requirements for the degree of master of science, Protrusiveupper lip
Department of Orthodontics, Washington University, St. Louis. The two cases Acute nasolabial angle
presented in this article were treated by the joint efforts of the graduate residents, Short throat length with deficient chin
Department of Orthodontics and Maxillofacial Surgery, Washington University,
Vertical considerations
St. Louis; the junior author was chairman, Department of Orthodontics.
*In private practice, Lancaster, Ohio. Lip incompetency
**Orthodontic Consultant for Ortbognathic Surgery Rogram, Department of Excessiveexposure of gingiva on smiling
Orthodontics, University of Louisville; in private practice, St. Louis, MO. Increased overbite
92

2. Volume 93
Number 2
Case report 93
Fig. 1, A and B. Case 1, Facial appearance of patient before orthognathic surgery.
Fig. 2, A and B. Case 1. Facial appearance of patient after orthognathic surgery.
Transverse considerations along with a three-piece LeFort I maxillary ostectomy. The
Wide maxilla anterior maxilla was set up and back; the posterior maxilla
Increased buccal overjet was set up, advanced, and constricted. The mandible was
Treatment consisted of presurgical orthodontics in- autorotated and an advancement genioplasty was performed.
volving 0.022 x 0.025inch edgewise brackets. Complete The active orthodontic treatment was continued after the
leveling and alignment of the maxillary and mandibular removal of the intermaxillary fixation to achieve the final
arches were achieved by extrusion of the posterior segments. occlusal result. Retention consisted of a tooth positioner
At this point in the treatment process, the maxillary first followed by a maxillary removable and mandibular fixed
premolars were extracted at the time of the surgical procedure retainer.

3. Am. .I. Orthod. Dentofac. Orthop.
94 Connor and Moshiri February 1988
Fig. 3, A and B. Case 1. Skeletal Class II, Division 1 deep bite Fig. 4, A and B. Case 1. Occlusion after treatment.
malocclusion before treatment.
Fig. 5. Case 1. Silhouettes demonstrate facial change.

4. Volume 93 Case report 95
Number 2
W. T.
LeFort I osteotomy
Ant. max. up 3mm
Ant. max. back 3mm
Right post. max. up 3mm
Right post. max. advance 3 mm
Left post. max. up 2mm
Left post. max. advance
Post. max. constrict 4m
Advancement geniopla
Fig. 6. Case 1. Composite cephalometric tracings show skeletal stability during postoperative follow-
up period.
Fig. 7, A and 8. Case 2. Facial appearance of patient before orthognathic surgery.

5. Am. J. Orthod. Dentofac. Orthop.
96 Connor and Moshiri
February 1988
Fig. 8, A and 6. Case 2. Facial appearance of patient after orthognathic surgery.
Fig. 9, A and B. Case 2. Class III open bite malocclusion before treatment.
Fig. 10, A and B. Case 2. Occlusion after treatment.

6. Volume 93
Case report 97
Number 2
Fig. 11. Case 2. Silhouettes show the effect of the orthognathic surgical approach on the facial profile.
M. L.
Le Fort I osteotomy
max up 6mm
max setback 5mm
Fig. 12. Case 2. Composite cephalometric tracings show presurgical and pOstsUrgiCal changes.

7. Am. J. Orthod. Dentofac. Orthop.
98 Connor and Moshiri
February 1988
CASE 2 (Figs. 7 through 12) However, studies3a7have reflected displeasure for this
A 17-year-old black female patient was seen initially for profile from black men and women plus a desire for a
treatment of a dentofacial deformity. Clinical, cephalometric, flatter, more Caucasian-like profile. Therefore, when
and model analyses indicated the following: correction of a dentofacial deformity involves combi-
Horizontal considerations nation orthognathic surgery, advancement genioplasty
Bimaxillary protrusion should be considered to improve the profile.
Flared maxillary and mandibular incisors This article comprised case reports of two black
Skeletal and dental Class III with anterior crossbite American patients, both demonstrating a skeletal dis-
Excessive maxillary and mandibular length crepancy that required orthognathic surgery for correc-
Acute nasolabial angle
tion. Both cases involved a comprehensive surgical
Long throat length with deficient chin
Vertical considerations analysis and treatment plan. The treatment included
Excessive facial height combination surgery with advancement genioplasty.
Lip incompetency
Excessive exposure of gingiva on smiling REFERENCES
Open bite 1. Connor AM, Moshii F. Orthognathic surgery norms for American
Transverse considerations black patients. AM J ORTHOD 1985;87:119-34.
2. Cotton WN, Takano WS, Wang WW, Wylie WL. Downs analysis
Constricted maxilla with posterior crossbite
applied to three other ethnic groups. Angle Orthod 1951;21:
Presurgical orthodontic treatment involved partial level- 213-20.
ing and alignment of the maxillary arch without extractions. 3. Deloach N. Soft tissue profile of North American blacks, a self-
The mandibular arch was aligned also and completely leveled assessment[M.S. thesis]. University of Detroit, 1977.
without extractions. At this point in the treatment process, a 4. Sushner NI. A photographic study of the soft-tissue profile of the
three-piece LeFort I maxillary ostectomy was performed. The Negro population. AM J ORTHOD 1977;72:373-85.
posterior maxilla was set up and expanded, the anterior max- 5. Moshii F, Jung S, Sclaroff A, Marsh J, Gay D. Surgical diagnosis
illa was set up, the entire maxilla was set back, and the and treatment planning: a visual approach. J Clin Orthod
mandible was autorotated and set back by an intraoral vertical 1982;16:37-59.
6. Fonseca RJ, Klein WD. A cephalometric evaluation of American
ostectomy. An augmentation genioplasty and vertical reduc-
Negro women. AM J ORTHOD 1978;73:152-60.
tion of the chin finished the surgical procedure. After release
7. Thomas R. An evaluation of the soft-tissue facial profile in the
of the intermaxillary fixation, the active orthodontic treatment North American black woman. AM J ORTHOD 1979;76:84-94.
was continued for detailing of the occlusion. A tooth posi-
tioner was used as initial retention, replaced eventually by Reprint requests to:
Dr. Farhad Moshiri
removable retainers.
1265 Graham Rd., Suite C
Florissant, MO 63031
DISCUSSION
The literature6 shows a prevalence of bimaxillary
protrusion and a convex profile in American blacks.