considerations for orthognathic surgery during growth, part 1 - mandibular deformities

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Qestions often arise regarding the appropriatetiming for orthognathic surgery in growingpatients and the possible effects of such

surgery on subsequent facial growth. Approximately98% of facial growth is usually complete in girls by age15, and in boys by, approximately, age 17 or 18.1,2

Some growing patients with dentofacial deformitiesexhibit proportionate growth between the maxilla andmandible, but others exhibit disproportionate growthwith progressive worsening of the deformity. The sur-gical procedures required to correct these deformitiesmay affect subsequent facial growth and dentofacialdevelopment. Thus, both surgical procedures andgrowth factors may affect the quality of the outcome.

Facial appearance is a fundamental factor in deter-mining interpersonal relationships.3,4 Thus, earlyorthognathic surgery may hold important psychosocialimplications for some patients. Teenagers with signifi-

From the Baylor University Medical Center and the Department of Oral andMaxillofacial Surgery, Baylor College of Dentistry, Texas A&M UniversitySystem, Dallas.aClinical Professor of Oral and Maxillofacial Surgery and in Private Practice.bFormer Fellow in Oral and Maxillofacial Surgery and currently in Private Prac-tice, Chicago, Ill.cFellow in Oral and Maxillofacial Surgery.Reprint requests to: Larry M. Wolford, 3409 Worth St, Suite 400, SammonsTower, Dallas, TX 75246.Submitted, February 2000; revised and accepted, May 2000.Copyright © 2001 by the American Association of Orthodontists.0889-5406/2001/$35.00 + 0 8/1/111401doi:10.1067/mod.2001.111401

CLINICAL REVIEW

Considerations for orthognathic surgery duringgrowth, Part 1: Mandibular deformitiesLarry M. Wolford, DMD,a Spiro C. Karras, DDS,b and Pushkar Mehra, DMDc

Dallas, Tex

Management of the growing patient with mandibular dentofacial deformities presents a unique and challengingproblem for orthodontists and surgeons. The surgical procedures required for correction of the deformity mayaffect postsurgical growth and dentofacial development. Further, facial growth may continue postoperativelyand negate the benefits of surgery performed, resulting in treatment outcomes that are less than ideal. Fromindividual patient characteristics, the type of deformity, and the indications for early surgical intervention, it ispossible to effectively treat many cases during growth. A thorough understanding of facial growth patterns isessential, and each case needs to be evaluated individually. Surgery is often undertaken with the expectationthat additional treatment, including more surgery, may be required after the completion of growth. The materialpresented here is based on the available research and the senior author’s clinical experience of more than 25years in the correction of mandibular deformities in the growing patient. Advantages and disadvantages ofspecific surgical techniques for correction of common mandibular deformities and pertinent age and surgicalconsiderations are discussed. The material should be viewed as a general outline that provides broadguidelines for management of these patients. The management of maxillary deformities will be discussed inPart 2 of this article. (Am J Orthod Dentofacial Orthop 2001;119:95-101)

cant dentofacial deformities are often perceived as beingless attractive by their peers, and differences of behaviortoward attractive and unattractive people have been welldocumented.5,6 Choosing nonsurgical compromisedtreatment or delaying orthognathic surgery until growthis complete could be damaging to the patient’s self-image. Delaying treatment until adulthood can exacer-bate problems related to pain, speech, airway, anatomy,occlusion, esthetics, temporomandibular joint (TMJ)function, masticatory function, and psychosocial factors.

This 2-part article discusses the more commondentofacial deformities, the surgical techniques applic-able for each, and the earliest age at which these surg-eries can be performed with predictable results. Part 1deals with surgical treatment of mandibular deformitiesin growing patients, and Part 2 will focus on surgicalcorrection of maxillary deformities and double-jawsurgery in growing patients. There are, of course,exceptions to these general guidelines based on indi-vidual patient characteristics, hormonal or other factorsaffecting growth, the presenting deformity, co-existingdisease, other local or systemic factors, and the ortho-dontist’s and surgeon’s clinical abilities.

The TMJs are the foundation for orthognathicsurgery. If the TMJs are not stable and healthy, orthog-nathic surgical results may be unstable, with increasedTMJ dysfunction and pain as a result.7 The TMJs mustbe appropriately evaluated before surgery. The mostcommon TMJ disorder seen in orthognathic surgery

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96 Wolford, Karras, and Mehra American Journal of Orthodontics and Dentofacial OrthopedicsFebruary 2001

patients is the displaced articular disk. Significant prob-lems can occur when orthognathic surgery is performedin the presence of untreated disk displacement.7,8

Before surgery, 36% of patients had some pain or dis-comfort, but 2 years after mandibular advancement,88% of the patients had pain with increased intensity.After surgery, condylar resorption occurred in 30% ofthe patients, which resulted in redevelopment of a jawdeformity and malocclusion.8 Other TMJ pathologicconditions that may affect treatment outcomes includecondylar hyperplasia, condylar hypoplasia, idiopathiccondylar resorption, osteochondroma, reactive arthritis,rheumatoid arthritis, psoriatic arthritis, systemic lupuserythematosus, scleroderma, and ankylosing spondyli-tis. TMJ pathology must be assessed and properly man-aged to provide healthy, stable TMJs for a sound foun-dation and the achievement of predictable results.

The tongue is an important factor in jaw growth anddevelopment. Microglossia can cause underdevelop-ment of the jaws with lingual collapse of the dentoalve-olar structures. Macroglossia can result in overdevelop-ment of the jaws, especially the dentoalveolus. Theetiology of macroglossia may be congenital (eg, mus-cular hypertrophy, lymphangioma, or glandular hyper-plasia) or acquired (eg, cyst, tumor, acromegaly, oramyloidosis). The most common cause of macroglossiais muscular hypertrophy.

The tongue usually reaches its approximate adultsize when a child reaches the age of 8 years.9 An eval-uation of the tongue should include clinical, radi-ographic, and functional assessments relative to inter-ference with speech, mastication, airway, and treatmentstability. Surgical reduction of the tongue can improvethe stability and predictability of surgical outcomes incases of absolute macroglossia. Wolford et al10 previ-ously described the diagnosis of macroglossia and theindications for reduction glossectomy.

Determination of growth rate and vector can bechallenging. Because the jaws grow in all 3 dimen-sions, growth disturbances can also occur in more than1 dimension. A good understanding of facial growthtendencies of the specific anatomical facial types (eg,brachycephalic, normocephalic, or dolicocephalic)gives the clinician important information about subse-quent growth. Evaluation of the patient’s medical andfamily history, as well as serial clinical and radi-ographic examinations, are helpful to identify growthimbalances in jaw structures. Comparison of serial lat-eral and anteroposterior cephalograms, and cephalo-metric tomograms that include the TMJ and posteriormandible can be extremely helpful in assessment ofjaw growth. Specialized radiography (eg, computedtomography [CT] scans, magnetic resonance imaging

[MRI], or nuclear scintigraphy) are indicated in cer-tain cases, especially for identification of TMJ pathol-ogy. Hand-wrist films may be useful in determiningthe growth potential in some patients but are of littlebenefit in skeletal Class III patients with condylarhyperplasia. Serial dental models help in monitoringocclusal and dental changes.

MANDIBULAR DEFORMITIESMandibular hypoplasia

Mandibular hypoplasia is defined as retruded man-dibular position resulting in a Class II skeletal relation-ship with either a normal or a deficient mandibulargrowth rate.

Normal growth rate. In patients with normalmandibular growth, the mandible grows from aretruded position relative to the normally positionedmaxilla, or it may be smaller. With normal rates ofmaxillary and mandibular growth, the same Class IIskeletal and occlusal relationship is maintainedthroughout growth.11 This deformity can be correctedsurgically during growth, with predictably stableresults, by using the mandibular ramus osteotomiesdiscussed below. With healthy TMJs and proper use ofthese techniques, the rate of growth is essentially unal-tered by surgery, and harmonious postoperative maxil-lary and mandibular growth can be expected withmaintenance of the surgical result.12-14

Deficient growth rate. Patients experiencing defi-cient mandibular growth are initially seen with pro-gressively worsening mandibular retrusion and Class IImalocclusion, as normal maxillary growth outpaces thedeficient mandibular growth. If the deformity is cor-rected surgically during growth, a Class II skeletal andocclusal relationship can be expected to recur, as themaxilla continues to grow normally and the mandiblemaintains its deficient growth rate.15 However, surgeryduring growth may be indicated in cases of severedeformities that adversely affect function (eg, malnu-trition resulting from masticatory dysfunction, airwaycompromise, or speech disorders) or psychosocialdevelopment. Under these circumstances, surgery dur-ing growth may improve the quality of life, but thepatient and parents must be made aware that additionalsurgery will probably be necessary. Patients with defi-cient mandibular growth may have an associated TMJpathology that requires surgical correction to achieve astable outcome. Any of the ramus osteotomies dis-cussed below could be used in deficient growth cases.

Treatment modalities

With any of the following surgical procedures, thepreoperative rate of growth can be maintained after

American Journal of Orthodontics and Dentofacial Orthopedics Wolford, Karras, and Mehra 97Volume 119, Number 2

surgery. These techniques should neither stimulate norhinder mandibular growth, provided that the TMJs arehealthy, the growth centers of the condylar heads arenot damaged, and the articular disks are not displacedas a result of surgery. The vector of facial and mandibu-lar growth, however, may be altered by a change in theorientation of the proximal segment, and thus thecondyle.16 With any of the following techniques, ifthe proximal segment is rotated forward, an increasedvertical growth vector will be seen after the operation.Likewise, rotation of the proximal segment backwardwill result in a more horizontal growth vector post-surgically. Compared with nonrigid fixation, the useof rigid fixation with all of the following techniqueswill improve immediate and long-term stability.17

Sagittal split ramus osteotomy. The sagittal split ramusosteotomy (SSRO)(Fig 1) is more difficult to perform onyounger patients because of greater bony elasticity, thethinness of the cortical bone, the presence of uneruptedmolar teeth, and the relatively shorter posterior verticalmandibular body height, as compared with adults. It doeshave the advantages of easy application of rigid fixation aswell as better positional control of the proximal segment.

SSRO is best reserved for patients over the age of 12years—that is, after the eruption of the permanent secondmolars, so that damage to these teeth during surgery canbe avoided. Although the senior author (L.W.) has suc-cessfully performed this procedure on patients as youngas 8,12,13 we recommend waiting until at least age 12.

Inverted “L” osteotomy. The inverted “L” osteotomy(ILO) (Fig 2) can be used to advance the mandible and ver-tically lengthen the ramus, but it may require bone or syn-thetic bone grafting to control the positional orientation ofthe proximal segment and to fill the bony voids betweensegments. The use of rigid fixation is recommended.

Vertical ramus osteotomy. The vertical ramusosteotomy (VRO) (Fig 3) can be used to advance the

mandible and vertically lengthen the ramus with appro-priate bone or synthetic bone grafting as indicated tocontrol the positional orientation of the proximal seg-ment and fill bony voids. The amount of mandibularadvancement and vertical lengthening possible withthis technique is limited by the temporalis muscleattachment and interference of the coronoid processeson the zygomatic arch. Thus, for larger movements acoronoidectomy may be needed, or the clinician mayneed to revert to other surgical options.

The ILO and VRO can be performed on patients ofvirtually any age because the design of the osteotomiesavoids developing teeth. However, care must be takento avoid damage to developing teeth during applicationof rigid fixation.

Fig 1. The SSRO procedure can be used to (A and B)advance the mandible or reposition it backward.

Fig 2. The ILO procedure can be used to advance themandible or reposition it backward.When used to advancethe mandible, the gap created between proximal and distalsegments requires grafting with bone or synthetic bone.

Fig 3. The VRO procedure can be used to advance themandible or reposition it backward. The coronoidprocess limits the extent of movement. When used toadvance the mandible, the gap created between proxi-mal and distal segments requires grafting with bone orsynthetic bone.


Mandibular hyperplasia

Mandibular hyperplasia is defined as a protrusivemandibular position resulting in Class III skeletal andocclusal relationships. This condition may be ini-tially seen with normal or accelerated mandibulargrowth rates.

When the clinician treats mandibular hyperplasia,the patient’s tongue size and its position must be care-fully evaluated before surgery. The most commontongue-related factors affecting surgical results aremacroglossia and habitual tongue placement. When themandible is surgically moved posteriorly, the volumeof the oral cavity decreases. An enlarged tongue or anabnormal tongue-posturing habit may create postsurgi-cal relapse by causing forward posturing of the condylein the fossa, forward protrusion of the mandibular den-toalveolus, or shifting between segments that are wirefixated. The use of a reduction glossectomy may beindicated in specific cases.10

Normal growth rate. In patients with normalmandibular growth rates, the mandible initiates itsgrowth from a forward position relative to the maxilla,or it is anatomically larger. With normal rates of max-illary and mandibular growth, the same Class III jawrelationship is maintained throughout growth. Thisdeformity can be corrected with various ramusosteotomies during growth with predictable and stableresults. With these techniques, the rate of growthshould be unaltered by surgery and harmonious post-operative maxillary and mandibular growth can beexpected, with maintenance of the surgical result.

Accelerated growth rate. In patients with acceleratedmandibular growth, the deformity usually begins as a

skeletal Class III relationship that becomes progressivelymore severe, or it begins as a Class I relationship anddevelops into a progressively worsening Class III rela-tionship. The accelerated mandibular growth outpacesthe normal maxillary growth. Note that maxillary growthdeficiency with normal or accelerated mandibular growthcan create the same Class III jaw relationship, and it mustbe ruled out because the type and timing of treatment forthat condition is different. Typically, the increase in themandibular growth rate almost always occurs in thecondyles (condylar hyperplasia) and can cause elonga-tion of the condylar neck and mandibular body, whichleads to development of dental compensations. The con-dition often begins during the pubertal growth spurt, butit may precede or succeed it, and the growth may con-tinue far beyond the normal growth period into the mid-dle and even the late 20s. Growth can be accelerated uni-laterally or bilaterally and can be in a horizontal orvertical vector (9:1 ratio). Other TMJ pathologies thatcan cause unilateral excessive growth include osteochon-droma and fibrous dysplasia. Treatment considerationsdiscussed here pertain to condylar hyperplasia.

There are essentially 3 options regarding the timingof surgery relative to growth (with option 3 being theauthors’ preferred method of management).

Option 1 is to defer surgery until growth is com-plete. This may require delaying surgery until patientsare in their middle to late 20s. Consequently, they mayhave functional problems (mastication, speech),esthetic disfigurement, pain, and psychosocial stigmasassociated with a severe facial deformity.18,19 Addi-tionally, the magnitude of the deformity, if allowed tobecome fully manifested by this delay in treatment,may preclude an ideal result later. The hyperplasticcondylar growth may result in severe deformation ofthe mandible. Compensatory changes will occur in themaxilla, dentoalveolar structures, and associated softtissue structures, compromising the outcome and mak-ing the result less than ideal. This is particularly true incases of unilateral involvement, which can lead tosevere asymmetric deformities and can also result inTMJ internal derangement and dysfunction.

Option 2 is to perform surgery to posteriorly posi-tion the mandible during growth, with overcorrectionof the mandible. The accelerated growth can beexpected to continue after surgery, and additionalsurgery will be necessary if the overcorrection is insuf-ficient or excessive. Early intervention may benefit thepatient, however, relative to function, esthetics, andpsychosocial concerns. If this alternative is chosen, theoperation should be performed after the majority ofmaxillary growth is complete (girls, 14 years; boys, 17years) to facilitate the estimation of overcorrection.

Fig 4. High condylectomy procedure (dotted line) witharticular disk repositioning provides a predictablemethod to stop mandibular growth, as well as good post-surgical TMJ function.


Option 3 is to surgically eliminate further mandibulargrowth with a high condylectomy (Fig 4) and to simulta-neously correct the jaw deformity.20 Alternatively, thehigh condylectomy can be performed as stage 1 surgery,followed by orthognathic surgery at a later time. The highcondylectomy removes the active growth center(s), andthus prevents further mandibular growth. If orthognathicand TMJ surgery are performed concomitantly, the SSROis the procedure of choice because it maintains maximalsoft tissue attachments and thus vascularity to the proxi-mal segment. The ILO and VRO require increased strip-ping of periosteum and may lead to vascular compromiseof the proximal segment, in addition to causing difficul-ties with positional control of the condyle.


With any of the following mandibular ramus proce-dures, the preoperative rate of growth can be expectedto be maintained after surgery. Mandibular growthshould not be affected by any of these techniques, pro-vided that the condylar head is not damaged duringsurgery. The vector of facial growth, however, may bealtered by a change in the orientation of the proximalsegment and thus the condyle. The use of rigid fixationwill improve long-term stability.

Sagittal split ramus osteotomy. The SSRO (Fig 1)is more difficult to perform on younger patientsbecause of the greater bony elasticity, the decreasedthickness of the cortical plates, the presence ofunerupted molar teeth, and the relatively shorter pos-terior vertical mandibular body height in youngerpatients. It is the preferred technique when highcondylectomy is performed simultaneously to stopexcessive mandibular growth, because maximum vas-cularity to the proximal segment is maintained. Rigidfixation provides optimal long-term stability. Althoughthe SSRO is more difficult to perform than the ILO orVRO, it is the preferred technique because it allows forgood control of the condylar position.

SSRO is best reserved for patients over the age of12—that is, after the eruption of the permanent secondmolars, so that damage to these teeth during surgerycan be avoided.

Inverted “L” osteotomy and vertical ramusosteotomy. The ILO (Fig 2) and VRO (Fig 3) can beused effectively to correct mandibular prognathism.The amount of mandibular set-back possible with theVRO is limited by the temporalis muscle and the coro-noid process, unless a coronoidectomy is performed.The application of rigid fixation can be technically dif-ficult for both types of osteotomies, particularly froman intraoral approach. Without fixation, condylar posi-tion control may be inexact and can result in difficulties

with postsurgical occlusion.The ILO and VRO can be performed on patients of

virtually any age. Rigid fixation must be applied cau-tiously to avoid injury to developing teeth.

High condylectomy. Surgically removing the supe-rior 3 to 5 mm of the condylar head (Fig 4) will pre-dictably stop anteroposterior and vertical growth of themandible by removing the active growth center incondylar hyperplasia.20,21 Appositional mandibulargrowth and dentoalveolar growth will not be affected.TMJ function after surgery can be expected to remainnormal if the condylar head is appropriately recontouredand the articular disk is repositioned and stabilized in anormal anatomical relationship between the condylarhead and articular fossa. The Mitek bone anchor (Mitek,Westwood, Mass) helps stabilize the repositioned disk tothe condylar head. Its use has significantly improved thepredictability of disk repositioning surgery.

Except in select cases, this procedure should gener-ally be deferred until age 14 in girls and age 16 inboys—that is, when normal maxillary and mandibulargrowth are closer to completion. Since no furtheranteroposterior growth of the mandible can beexpected after this procedure, continued maxillarygrowth usually results in a downward and backwardgrowth vector for the maxillomandibular complex, butthe occlusion should remain stable. In unilateral cases,the unoperated contralateral condyle will maintain nor-mal growth and could cause shifting of the mandibletoward the operated side. The severity of the deformity,however, may warrant earlier surgery in some cases.

ANTERIOR MANDIBULAR DENTOALVEOLARDEFORMITIES

Anterior mandibular dentoalveolar deformities havebeen defined as excessive, deficient, or asymmetric growthof the dentoalveolar structures. The condition may be due

Fig 5. Anterior mandibular subapical osteotomy allowsrepositioning of the dentoalveolus.


to overdevelopment or underdevelopment of alveolarbone, dental ankylosis, anodontia, premature tooth loss,macroglossia, microglossia, habitual factors, or genetics.

The mandibular growth rate should not be affectedby correction of these deformities unless adjacent teethare damaged, which may result in dento-osseous anky-losis, a condition that will impair subsequent verticalalveolar growth.


Anterior mandibular subapical osteotomy. The ante-rior mandibular subapical osteotomy (Fig 5) involves 2vertical interdental osteotomies joined inferiorly by ahorizontal osteotomy 4 to 5 mm below the tooth apices.The segment is placed in the desired position and stabi-lized, ideally with rigid fixation.22 Preoperative ortho-dontic treatment may be required to create adequatespace between the roots of the teeth to safely completethe interdental osteotomies. To avoid damage to the rootsof developing teeth, which could result in ankylosis andalveolar growth impairment, this procedure should bedeferred until eruption of adjacent teeth in this region isessentially complete (ie, when the patient is over age 12).

MANDIBULAR BODY DEFORMITIES

Mandibular body deformities are defined as excessive,deficient, or asymmetric development of the mandibularbody. Correction of these deformities during growthshould have no effect on subsequent mandibular growth,unless adjacent teeth are ankylosed or the developing teethare damaged, leading to dento-osseous ankylosis, whichwill result in impaired vertical alveolar growth.


Mandibular body osteotomy. A mandibular bodyprocedure (Fig 6) involves 1 or more osteotomies,extending the full vertical height of the mandibular body.

These osteotomies are often performed between adjacentteeth. Rigid fixation and precise surgery will produce themost predictable results. Care must be taken to maintainthe integrity of the inferior alveolar and mental neurovas-cular structures. It is recommended that this procedure bedeferred until after the age of 12 years to minimize therisk of injury to the developing dental structures.

CHIN DEFORMITIES

Deformities of the chin include excessive (macroge-nia) or deficient (microgenia) development. Chin defor-mities can occur in all 3 planes of space and can thereforeaffect the height, width, and anteroposterior dimensionsof the anterior mandible. The treatment for macrogeniamay involve osseous recontouring or spatial reorientationof the chin with osteotomy techniques. Microgenia maylikewise be treated by altering chin position withosteotomies or with a graft, using bone, synthetic bonesubstitutes, or alloplastic implants. In younger patients inthe mixed dentition there is an inherent risk of damage todeveloping teeth and to the mental nerves that closelyapproximate the inferior border of the mandible. Aug-mentation genioplasty with alloplastic implants that donot cause resorption of underlying bone can be performedat an earlier age, provided the implant can be stabilizedwithout risk of injury to underlying dental structures.


Osseous genioplasty. Various techniques are availablefor altering the dimensions of the chin by osteotomies (Fig7, A), including sliding horizontal osteotomy and the tenonand mortise technique.23,24 Bone segments may be fixedwith wires, bone screws, or bone plates, and may requirebone or synthetic bone grafting, as in the case of verticallengthening. These procedures have no significant effecton subsequent facial growth, with the exception of affect-ing appositional bone growth at pogonion, or if developing

Fig 6. Mandibular body osteotomy (A) allows positionalalteration in the body area. (B) Rigid fixation of seg-ments is recommended.

Fig 7. Osseous genioplasty can be used to (A) augmentor reduce chin prominence. (B) Alloplastic implants canalso be used to augment chin.

A B BA


dental structures are injured, which may lead to dentoalve-olar ankylosis and decreased vertical alveolar growth. Thepatient must be at a level of dento-osseous development(ie, 12 years old or older), that will minimize the risk ofdamage to underlying teeth and neurovascular structures.

Augmentation genioplasty with alloplasts. Alloplasts(Fig 7, B) that are proved not to cause bone resorption(porous block hydroxyapatite,25 and HTR26) can beplaced in patients as early as age 8 or 9 to the early teens,provided they can be fixed to the bone without damageto underlying dental or neurovascular structures. Appo-sitional growth at pogonion will be eliminated afterplacement of these implants. Certain alloplastic materi-als, (Proplast-Teflon [Vitek, Houston, Texas], Silastic[Dow Corning, Midland, Mo], and acrylic), have beendocumented to cause resorption of underlying bone, andtheir use is discouraged.25 Although certain alloplasticimplants can be placed when the patient is 10 years oldor younger, it is best to wait until the patient is at least 12to minimize the risk of damage to underlying teeth andneurovascular structures.

CONCLUSIONS

Pediatric and adolescent patients with dentofacialdeformities may, at times, require surgical treatmentduring active growth because of functional, esthetic,and psychosocial factors. A good understanding offacial growth, available treatment options, and theeffects of surgery on postoperative growth patterns willhelp the clinician improve treatment outcomes forthese patients. Serial clinical, dental model, and radi-ographic analyses are important in predicting growthrates and patterns for individual patients.

The material presented in this article is based onavailable research information and extensive personalclinical experience. It is not meant to be absolute—instead, it should serve as a guide to formulate a spe-cific treatment plan for each individual growing patientwith respect to the appropriate type and timing of cor-rective surgical procedures on the mandible.

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16. Epker BN, O’Ryan F. Effects of early surgical advancement ofthe mandible on subsequent growth, part II: biomechanical con-siderations. In: The effect of surgical intervention on craniofa-cial growth. McNamara JA, Carlson DS, Ribbens KA, editors.Ann Arbor: University of Michigan; 1982. p. 207-29.

17. Satrom KD, Sinclair PM, Wolford LM. The stability of doublejaw surgery: a comparison of rigid versus wire fixation. Am JOrthod Dentofacial Orthop 1991;99:550-63.

18. Bruce RA, Haywood JR. Condylar hyperplasia and mandibularasymmetry: a review. J Oral Surg 1968;26:281-2.

19. Beirne OR, Leake DL. Technetium 99m pyrophosphate uptake ina case of unilateral condylar hyperplasia. J Oral Surg 1980;38:385-6.

20. Wolford LM, LeBanc J. Condylectomy to arrest disproportionatemandibular growth. Proceedings of the American Cleft PalateAssociation Annual Meeting; 1986 May 16-19; New York, NY.Chapel Hill (NC):American Cleft Palate Association;1986.

21. Obwegeser HL, Makek MS. Hemimandibular hyperplasia— hemi-mandibular elongation. J Craniomaxillofac Surg 1986;14:183-5.

22. Wolford LM, Moenning JE. Diagnosis and treatment planning formandibular subapical osteotomies with new surgical modifications.Oral Surg Oral Med Oral Path Oral Radiol Endod 1989;68:541-50.

23. Wessberg GA, Wolford LM, Epker BN. Interpositional genio-plasty for the short face syndrome. J Oral Surg 1980;38:584-90.

24. Wolford LM, Bates JD. Surgical modification for the correctionof chin deformities. Oral Surg Oral Med Oral Path Oral RadiolEndod 1988;66:279-86.

25. Moenning JE, Wolford LM. Chin augmentation with variousalloplastic materials: a comparative study. Int J Adult OrthodOrthognath Surg 1989;4:175-87.

26. Karras SC, Wolford LM. Augmentation genioplasty with hard tis-sue replacement implants. J Oral Maxillofac Surg 1998; 56:549-52.

considerations for orthognathic surgery during growth, part 1 - mandibular deformities

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