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Surgical management of the growing patientremains controversial. The published literaturehas little to say on the appropriate timing of var-

ious maxillary surgical procedures in growing patientsor the effects of surgery on postoperative maxillarygrowth. Growing patients can present to the clinicianwith maxillary dentofacial deformities that requirecombined surgical and orthodontic correction.

An understanding of normal facial growth is invalu-able in properly managing growing patients with max-illary deformities. Around 12 years of age, most trans-verse maxillary growth is complete.1 Anteroposterior(AP) growth of the maxilla is basically complete byabout the age of 14 years.2-8 Normal vertical maxillarygrowth, however, continues into adulthood.2,6,8 Serialclinical, radiographic, and dental model analyses arevery helpful in determining the rate and direction offacial growth. Accurate diagnosis, proper treatmentplanning, and appropriate age sequencing of proce-dures are important steps in achieving quality out-

comes for orthognathic surgery in growing patients.Coexisting mandibular deformities, dental ankylosis,and temporomandibular joint (TMJ) pathosis must alsobe assessed and properly managed.

This article, Part 2, outlines our recommendationsfor combined surgical-orthodontic management of thegrowing patient with dentofacial deformities. In Part 1,we reviewed management of patients with mandibulardeformities. In this part we present common maxillarydentofacial deformities and considerations for surgicalmanagement of these deformities in the growingpatient who has normal mandibular growth and nodental ankylosis or TMJ pathosis. We will also presentrecommendations for correction of combined maxillo-mandibular deformities with double-jaw surgery ingrowing patients.

MAXILLARY DEFORMITIESMaxillary hypoplasia

Maxillary hypoplasia is defined as deficient maxil-lary development in the AP, transverse, and/or verticaldimensions. Because the cause of this deformity isdeficient maxillary growth, normal growth cannot beexpected after surgery. Correction of AP or verticaldeficiencies during growth will result in recurrence of the Class III skeletal relationship as the mandiblecontinues to grow normally. Earlier surgery may beindicated if significant functional, esthetic, and psy-chosocial impairments exist. When treating these casesduring growth, the surgeon may choose to overcorrectthe maxilla and allow the growing mandible to develop

From the Baylor University Medical Center and the Department of Oral andMaxillofacial Surgery, Baylor College of Dentistry, Texas A & M UniversitySystem, Dallas, Tex.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 Street, 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 8/1/111400doi:10.1067/mod.2001.111400

CLINICAL REVIEW

Considerations for orthognathic surgery duringgrowth, Part 2: Maxillary deformitiesLarry M. Wolford, DMD,a Spiro C. Karras, DDS,b and Pushkar Mehra, DMDc

Dallas, Tex

The growing patient can present to the clinician with significant dentofacial deformities that require surgicalcorrection. In some cases, certain functional, esthetic, and psychosocial factors may necessitate earlysurgical intervention. Although there is extensive literature on the effects and stability of orthognathic surgicalcorrection of maxillary deformities in adults, the same is not true for the pediatric and adolescent growingpatient. Not much is known about the predictability of orthognathic surgical procedures performed duringgrowth or the effects such procedures have on subsequent facial growth. There is always the possibility thatsecondary corrective procedures may be required after the initial corrective surgery. This article presentsrecommendations based on available research and personal clinical experience in surgical correction ofmaxillary deformities in growing patients. The common maxillary dentofacial deformities, age considerations,and surgical alternatives and sequencing are presented. The treatment of mandibular deformities isaddressed in Part 1 of this article. (Am J Orthod Dentofacial Orthop 2001;119:102-5)

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American Journal of Orthodontics and Dentofacial Orthopedics Wolford, Karras, and Mehra 103Volume 119, Number 2

into it. If surgery is performed during growth, thepatient and parents must be informed that futuresurgery will probably be necessary.

Treatment modalities

Le Fort I maxillary osteotomy. The Le Fort Iosteotomy (Fig 1), when performed during growth,effectively inhibits further anterior growth of the max-illa.9,10 Vertical maxillary growth, however, can be

expected to continue postoperatively at the same rate asbefore surgery.10-13 The use of rigid fixation and appro-priate grafting with either porous block hydroxyapatite(Interpore 200; Interpore International, Irvine, Calif) orautogenous bone will maximize the quality of the sur-gical outcome for all types of maxillary osteotomies.

Horseshoe maxillary osteotomy (dentoalveolarosteotomy). With the horseshoe maxillary osteotomyprocedure (Fig 2), the nasal septum remains attached tothe stable palate, and only the dentoalveolar structuresare mobilized.14 Thus, some AP maxillary growth maybe expected to occur postoperatively. The overallgrowth rate, however, will remain deficient and resultin the redevelopment of a skeletal Class III deformity.No studies are available on growth after maxillary den-toalveolar osteotomies for this type of deformity. Themaxillary dentoalveolar osteotomy is technically muchmore difficult to perform in this patient type.

For both of the techniques described here, the mostpredictable outcome can be expected if performed near toor after the completion of mandibular growth (approxi-mately age 15 for girls; age 17 or 18 for boys). Serial lat-eral cephalograms are helpful in documenting cessationof mandibular growth. Severe functional or psychosocialfactors may indicate earlier treatment. Either procedurecan be performed before the patient reaches age 10, pro-vided sufficient space exists above the apices of thedeveloping permanent teeth to place the osteotomies andapply rigid fixation. Although vertical maxillary growthis generally unaffected by this procedure, damage todeveloping tooth roots may result in dento-osseous anky-losis and localized dentoalveolar growth impairment.

Fig 1. Le Fort I osteotomy with segmentalization allowsrepositioning of the maxilla in all 3 planes of space. A, Max-illary step osteotomy modification. B, Rigid fixation andgrafting areas of bone gaps with autogenous or syntheticbone grafts (shown as positions a, b, and c), is the most pre-dictable method for stabilization of the Le Fort I osteotomy.

A

B

Fig 2. Horseshoe osteotomy maintains attachment ofhorizontal palate to vomer and lateral nasal walls. Onlythe dentoalveolus is mobilized.

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

Surgically assisted rapid palatal expansion. Surgi-cally assisted rapid palatal expansion usually involvesLe Fort I osteotomies without mobilization of the max-illa. It is a useful procedure in cases where the defi-ciency exists in the transverse dimension only. Thereare no studies available regarding growth after this pro-cedure. In fact, this procedure may be contraindicatedin most growing patients because the midpalatinesuture has not normally closed, thus, the less invasivenonsurgical orthodontic/orthopedic expansion is possi-ble. Moreover, postoperative AP maxillary growth maybe inhibited by this procedure if the nasal septum isseparated from the palatal bone.

This procedure is rarely indicated in patients who areless than 15 years of age, but it can technically be doneafter complete root development and full eruption of theteeth adjacent to the vertical interdental osteotomy.

Maxillary protrusion

Maxillary protrusion is defined as excessive APgrowth of the maxilla, resulting in a Class II skeletalrelationship. No studies exist on facial growth aftersurgery in growing patients. Postsurgical growth maybe dependent on the procedure selected to correct thedeformity, as discussed next.

Treatment modalities

Le Fort I maxillary osteotomy. The Le Fort Iosteotomy (Fig 1), when performed during growth,effectively inhibits further anterior growth of the max-illa, while allowing vertical maxillary growth to con-tinue at the same rate.9-13 With normal mandibular andvertical maxillary growth present, a Class III skeletaland occlusal relationship may develop after surgery.

Horseshoe maxillary osteotomy (dentoalveolarosteotomy). With the horseshoe maxillary osteotomy(Fig 2), the nasal septum remains attached to the hardpalate; therefore, AP maxillary growth may not be inhib-ited as it is with the Le Fort I osteotomy.14 Although nopostsurgical growth studies have been performed on thistype of patient, this may be the technique of choice formaxillary repositioning in the growing patient with APmaxillary hyperplasia. It may offer the best potential forcontinued AP maxillary growth after surgery.

It is recommended that neither procedure be per-formed before the age of 15 in girls and 17 to 18 inboys, particularly if normal or deficient vertical maxil-lary growth is present. The effects of these procedureson subsequent growth for this deformity have not beenstudied. However, better postsurgical growth may beexpected with the horseshoe osteotomy. Patients withcoexisting vertical maxillary excess can be treated at anearlier age with either technique (see section on vertical

maxillary hyperplasia). In cases with severe functionalor psychosocial problems, the procedures can be per-formed when the patient is 8 or 9 years old, providedsufficient space exists above the apices of the develop-ing permanent teeth to place the osteotomies and fixatethe maxilla in its new position. Damage to developingtooth roots may result in dento-osseous ankylosis andlocalized dentoalveolar growth impairment.

Vertical maxillary hyperplasia

Also known as vertical maxillary excess, verticalmaxillary hyperplasia is defined as an excessive verticalgrowth of the maxilla and may or may not include ananterior open bite deformity. This deformity can be cor-rected during growth with predictable results. Verticalmaxillary growth can be expected to continue postoper-atively at the same rate as before surgery.10-14 While themaxilla continues to grow downward after surgery andthe mandible continues to grow at a normal rate, thepostoperative occlusal result should be maintained. Thevector of facial growth will continue to be downwardand backward. AP maxillary growth cannot be expectedafter surgery if a Le Fort I osteotomy is used, but it maybe preserved with a horseshoe osteotomy.

Treatment modalities

Le Fort I maxillary osteotomy. Although the Le FortI maxillary osteotomy (Fig 1) inhibits further anteriorgrowth of the maxilla,9,10 patients with vertical maxil-lary hyperplasia can expect postoperative vertical max-illary growth to continue at the same rate as beforesurgery. In patients with normal mandibular growth,the occlusion should remain stable.10-13

Horseshoe maxillary osteotomy (dentoalveolarosteotomy). AP maxillary growth may not be inhibitedas significantly with the horseshoe osteotomy tech-nique (Fig 2) compared with the Le Fort I osteotomy.Vertical maxillary growth remains unaffected and con-tinues at the same rate as before surgery.10-13

The most predictable results will be obtained ifsurgery is performed after age 14 in girls and age 16 inboys. If done at an earlier age (12 years in girls and 14years in boys), there is a possibility of the excessive ver-tical maxillary growth rate recreating a vertical maxil-lary excess after surgery, although to a lesser extent thanwould occur if surgery was not performed. The occlu-sion will usually remain stable. Mogavero et al10

demonstrated harmonious growth between the jawstructures when surgery was performed at a youngerage. The horseshoe osteotomy, by keeping the nasalseptum attached to the horizontal palatal plate, mayallow some AP maxillary growth. However, this has notbeen clinically studied with rigid fixation. Either maxil-

American Journal of Orthodontics and Dentofacial Orthopedics Wolford, Karras, and Mehra 105Volume 119, Number 2

lary procedure can be performed before the patientreaches age 10, provided sufficient space exists abovethe apices of the developing permanent teeth to placethe osteotomies and apply fixation. Damage to develop-ing tooth roots may result in dento-osseous ankylosis,and localized dentoalveolar growth impairment.

Double-jaw orthognathic surgery

Maxillary and mandibular procedures can some-times be combined and performed during growth withpredictable growth after surgery. Orthognathic surgeryfor the correction of vertical maxillary hyperplasia canbe performed with corrective mandibular surgery forretrognathia or prognathism, if the preoperative rate ofmandibular growth is normal, and the TMJs arehealthy.10 The Le Fort I osteotomy will inhibit furtherAP maxillary growth while allowing vertical maxillarygrowth to continue.

In cases involving mandibular prognathism sec-ondary to active condylar hyperplasia, surgery involv-ing high condylectomy will arrest the pathologicgrowth and can be combined with maxillary andmandibular osteotomies with predictable results,regardless of the rate of maxillary growth.14 The highcondylectomies should be performed first, and thearticular disk should be repositioned over the remain-ing condylar head. This is followed by routine double-jaw surgery, as planned preoperatively. When properlyperformed, the high condylectomies prevent further APgrowth of the mandible. In the presence of verticalmaxillary excess, the vector of facial growth will bedownward and backward. Surgical treatment of othercombinations of deformities may not be predictableand should be performed after cessation of growth.

CONCLUSIONS

The type of facial deformity present and the specificgrowth vectors of the patient will affect the surgical out-come and must be carefully assessed before surgery. Thepatient and family must understand the expected results,potential risks, and possible complications that can occuras a result of early surgical intervention. Factors such asthe presence of disproportionate mandibular growth(excessive or deficient) and coexisting TMJ pathosis cansignificantly affect postsurgical growth and treatment out-comes and must be identified and treated appropriately.

Some basic considerations that must be kept in mindwhile contemplating surgical correction of maxillarydentofacial deformities in the growing patient include:

1. Early surgical correction may be beneficial insome patients for functional, esthetic, and psy-chosocial reasons.

2. The TMJs must be functionally healthy and stablefor predictable surgical results.

3. The Le Fort I osteotomy eliminates further APgrowth of the maxilla.

4. Surgical correction of vertical maxillary hyperpla-sia with normal mandibular growth can be pre-dictably performed during growth. Postsurgically,the vector of facial growth will be in a downwardand backward direction.

5. Double-jaw surgery may be predictably performedin selected instances for specific jaw deformities.

The material presented in this article should serveas a guide for management of maxillary dentofacialdeformities in the growing patient who requires cor-rective orthognathic surgery. These recommendationsare in no way meant to be hard and fast rules; eachpatient should be diagnosed and treated individuallywith a tailored orthodontic and surgical treatment plan.

REFERENCES

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2. Savara BS, Singh IJ. Norms of size and annual increments ofseven anatomical measures of maxillae in boys from three to six-teen years of age. Angle Orthod 1968;38:104-20.

3. Sillman JH. Dimensional changes of the dental arches: longitu-dinal study from birth to twenty-five years. Am J Orthod 1964;50:824-42.

4. Björk A. Facial growth in man studied with the aid of metallicimplants. Acta Odontol Scand 1955;13:9-34.

5. Scott JH. The analysis of facial growth from fetal life to adult-hood. Angle Orthod 1963;33:110-3.

6. Singh IJ, Savara BS. Norms of size and annual increments ofseven anatomical measures of maxillae in girls from three to sev-enteen years of age. Angle Orthod 1968;36:312-24.

7. Björk A, Skieller V. Facial development and tooth eruptions: animplant study at the age of puberty. Am J Orthod 1972;62:339-83.

8. O’Reilly MT. A longitudinal growth study: maxillary length atpuberty in females. Angle Orthod 1979;49:234-58.

9. Friehofer HP. Results of osteotomies of the facial skeleton inadolesence. J Maxillofac Surg 1977;5:267-97.

10. Mogavero FJ, Buschang PH, Wolford LM. Orthognathic surgeryeffects on maxillary growth in patients with vertical maxillaryexcess. Am J Orthod Dentofacial Orthop 1997;111:288-96.

11. Epker BN, Schendel SA, Washburn M. Effects of early surgicalsuperior repositioning of the maxilla on subsequent growth: III, bio-mechanical considerations. In: McNamara JA, Carlson DS, RibbensKA, editors. The effect of surgical intervention on craniofacialgrowth. Ann Arbor: University of Michigan; 1982. p. 231-50.

12. Washburn MC, Schendel SA, Epker BN. Superior repositioningof the maxilla during growth. J Oral Maxillofac Surg 1982;40:142-9.

13. Vig KW, Turvey TA. Surgical correction of vertical maxillaryexcess during adolescence. Int J Adult Orthodon OrthognathSurg 1989;4:110-28.

14. Epker BN, Wolford LM. Dentofacial deformities: surgical-orthodontic correction. St. Louis: CV Mosby; 1980.