Case Report: Advancement genioplasty


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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.

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Case Report: Advancement genioplasty

  1. 1. CASE REPORTAdvancement genioplasty: An important part ofcombination 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 selectingwomen and concluded that the maxilla and mandible the flatter profiles was as follows: “Caucasian featureswere 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.“7black 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 whiteon 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 bimaxillaryfavor for the Class II, extremely bimaxillary protrusive protrusion. Our findings are also in agreement withprofile, and the Class III type face. Furthermore, in the that of the literature. The surgical analysis used forblack 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 moreican 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 patientsvarieties 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 protrusionSteiner’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 REPORTSprofile 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, andlip. 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 increasedoverjetThe review of tbe literature was part of a thesis submitted by the senior author Flared maxillary incisorsin partial fulfillment of the requirements for the degree of master of science, Protrusiveupper lipDepartment of Orthodontics, Washington University, St. Louis. The two cases Acute nasolabial anglepresented in this article were treated by the joint efforts of the graduate residents, Short throat length with deficient chinDepartment of Orthodontics and Maxillofacial Surgery, Washington University, Vertical considerationsSt. 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 smilingOrthodontics, University of Louisville; in private practice, St. Louis, MO. Increased overbite92
  2. 2. Volume 93Number 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. TheWide maxilla anterior maxilla was set up and back; the posterior maxillaIncreased 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 theleveling and alignment of the maxillary and mandibular removal of the intermaxillary fixation to achieve the finalarches were achieved by extrusion of the posterior segments. occlusal result. Retention consisted of a tooth positionerAt this point in the treatment process, the maxillary first followed by a maxillary removable and mandibular fixedpremolars were extracted at the time of the surgical procedure retainer.
  3. 3. Am. .I. Orthod. Dentofac. Orthop.94 Connor and Moshiri February 1988Fig. 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. 4. Volume 93 Case report 95Number 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. 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. 6. Volume 93 Case report 97Number 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. 7. Am. J. Orthod. Dentofac. Orthop.98 Connor and Moshiri February 1988CASE 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 atreatment of a dentofacial deformity. Clinical, cephalometric, flatter, more Caucasian-like profile. Therefore, whenand model analyses indicated the following: correction of a dentofacial deformity involves combi-Horizontal considerations nation orthognathic surgery, advancement genioplastyBimaxillary protrusion should be considered to improve the profile.Flared maxillary and mandibular incisors This article comprised case reports of two blackSkeletal 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 surgicalLong throat length with deficient chinVertical considerations analysis and treatment plan. The treatment includedExcessive facial height combination surgery with advancement genioplasty.Lip incompetencyExcessive exposure of gingiva on smiling REFERENCESOpen bite 1. Connor AM, Moshii F. Orthognathic surgery norms for AmericanTransverse considerations black patients. AM J ORTHOD 1985;87:119-34. 2. Cotton WN, Takano WS, Wang WW, Wylie WL. Downs analysisConstricted maxilla with posterior crossbite applied to three other ethnic groups. Angle Orthod 1951;21: Presurgical orthodontic treatment involved partial level- 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 thethree-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 diagnosisilla was set up, the entire maxilla was set back, and the and treatment planning: a visual approach. J Clin Orthodmandible was autorotated and set back by an intraoral vertical 1982;16:37-59. 6. Fonseca RJ, Klein WD. A cephalometric evaluation of Americanostectomy. 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 theof 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 Moshiriremovable retainers. 1265 Graham Rd., Suite C Florissant, MO 63031DISCUSSION The literature6 shows a prevalence of bimaxillaryprotrusion and a convex profile in American blacks.