LINI

J Oral Maxillofac Surg

51:730-740,1993

Occlusal Plane Alteration in

Orthognathic Surgery
LARRY M. WOLFORD, DDS,* PETER D. CHEMELLO, DDS,t
AND FRANK W. HILLIARD, DDS:f:

This article discusses correction of functional and esthetic deformities by surgically

increasing or decreasing the occlusal plane angulation. Clockwise rotation, or
increase of the occlusal plane angulation, is a well-accepted technique in or-
thognathic surgery. However, counterclockwise rotation (decrease of the occlusal
plane angulation), has not been a well-accepted treatment approach. The func-
tional and esthetic characteristics of the low occlusal plane and the high occlusal
plane facial types are presented, specific surgical approaches to alteration of the
occlusal plane are described, and the long-term stability of results with both
clockwise and counterclockwise rotations of the occlusal plane are discussed.
Cases illustrating the application of these surgical approaches are presented.

Management of patients with musculoskeletal de-
formities of the jaws where double-jaw surgery is nec-
essary to establish optimal functional and esthetic re-
lationships requires accurate diagnoses and proper
treatment planning. Variations in the mandibular plane
angulation are related to specific morphologic differ-
ences of the craniofacial structures and clinical ap-
pearance of patients. Wolford et all have clearly dem-
onstrated this in reference to mandibular deficiency
patients. Orientation of the cranial base is significantly
different in patients with low mandibular plane angle
skeletal morphology as compared with those with high
mandibular plane angle skeletal morphology. Thus, the
sella nasion plane and/or Frankfort horizontal (FH)
plane may have very different orientations in each facial
type and to each other within the same facial type, thus
making it difficult to obtain an accurate diagnosis based
on these cephalometric cranial-base references. Cor-
relation of clinical evaluation data with the cephalo-
metric analysis is necessary to provide an accurate and
* Clinical Professor of Oral and Maxillofacial Surgery, Baylor Col-
lege of Dentistry, Dallas, TX; in private practice, Baylor University
Medical Center, Dallas, TX.
t Former Fellow in Oral and Maxillofacial Surgery, Baylor Uni-
versity Medical Center, Dallas, TX; Clinical Associate, Department
of Surgery, Section of Oral and Maxillofacial Surgery, University of
Chicago, Chicago, IL; in private practice, Arlington Heights, IL.
* In private practice in orthodontics, Arlington, TX.
Address correspondence and reprint requests to Dr Wolford: 3409
Worth St, Suite 400, Dallas, TX 75246.
© 1993 American Association of Oral and Maxillofacial Surgeons
0278-2391/93/5107-0003$3.00/0
comprehensive diagnosis to aid in the development of
an optimal treatment plan. However, sometimes the
clinical and cephalometric data do not correlate be-
cause of an abnormal orientation of the FH. Correcting
the FH plane to correlate to the clinical evaluation will
significantly improve the diagnostic and treatment
planning aspects of patient management.
Although usually ignored, the angular relationship
of the occlusal plane and FH (occlusal plane angle,
with a normal value of 8° ± 4°)2 is very important in
both diagnosis and treatment planning. From a surgical
basis, clockwise rotation, or increase of the occlusal
plane angle (lOP) of the maxillomandibular complex
in double-jaw surgery, has been strongly advocated,
particularly in open-bite cases, regardless of the steep-
ness of the presurgical mandibular plane and occlusal
plane angulation."? However, counterclockwise rota-
tion, or decrease of the occlusal plane angle (DOP) of
the maxillomandibular complex, has not been sup-
ported as an acceptable treatment modality.v' and
misconceptions have developed that this is an unstable
procedure. The senior author (L.M.W.) has been using
counterclockwise rotation of the maxilla and mandible
as a treatment method to correct specific types of de-
formities for over 14 years. With the development of
rigid fixation and improvement in surgical techniques,
the DOP rotation has proven to be a very stable pro-
cedure in properly selected cases.
This paper will discuss two important aspects that
can have significant influence on the functional and
esthetic results for patients, but are commonly ignored
in traditional diagnosis and management ofdeformities

730
WOLFORD, CHEMELLO, AND HILLIARD
requiring double-jaw surgery. These are (1) selective
alteration of the FH plane on the cephalometric tracing
so that the numerical cephalometric values agree with
the clinical impression of the patient's deformity. This
"corrected" FH (CFH) is then used as a diagnostic and
treatment planning reference; and (2) selective surgical
alteration of the occlusal plane angle to acquire optimal
functional and esthetic relationships.
Corrected Frankfort Horizontal
Sometimes numeric cephalometric values for the
maxillary and mandibular depths may not correlate
with the diagnostic clinical impression when related to
the anatomically "based FH reference plane. For ex-
ample, a patient may clinically demonstrate a relatively
normal anteroposterior (A-P) position of the maxilla
and significant mandibular deficiency, but numeric ce-
phalometric values for the maxillary depth, related to
anatomically based FH, can be significantly higher than
normal, and mandibular depth can be relatively normal
(Fig 1). Clearly, in this example, the small anatomic
cephalometric values do not correlate with the clinical
impression. The basic reasons for the lack ofcorrelation
between the cephalometric and clinical analyses are
that cephalometrically I) infraorbitale may be located
higher or lower than normal; 2) porion may be located
higher or lower than normal; and 3) nasion may be
located more anterior or posterior than normal.
FH
CFH
FIGURE I. In this illustrative case, the cephalometric analysis using
anatomic FH indicates maxillary protrusion and a normal A-P po-
sition of the mandible (small numbers), which does not correlate
with the clinical impression of the patient. Correcting FH until the
numerical values correlate with the clinical impression (large numbers)
will allow normal cephalometric interrelationships to be used for
diagnosis and treatment planning.
731
If infraorbitale, porion, and/or nasion are abnor-
mally positioned, the numeric values of maxillary and
mandibular depth may be different than expected based
on the clinical examination. In addition, locating an-
atomic porion can be difficult. If porion is difficult to
identify, but the condyle can be located on the cephal-
ometric radiograph, selecting a point 2 to 3 mm below
the top of the condyle can serve as porion. This is help-
ful in some cases, but in others the required reorien-
tation of the FH plane to correlate to the clinical eval-
uation may be unrelated to porion or condylar position.
In application of this alteration technique, infraorbitale
is usually maintained as the base reference point and
the vertical position of porion is altered until the max-
illary and/or mandibular depth correlate numerically
to the clinical evaluation. In Fig I, the posterior aspect
of FH was lowered until the CFH correlated with the
clinical examination of the patient.
The advantage of establishing a CFH, when indi-
cated, is that this will allow the development of the
orthodontic and surgical treatment objectives using
normal cephalometric interrelationships. The decision
concerning correction of the FH, and particularly any
decision to surgically alter the occlusal plane angle,
should be made before orthodontics and surgery, be-
cause alteration of these structures may significantly
affect presurgical orthodontic goals and mechanics.
Selective Alteration of the Occlusal Plane
Although improved function is the primary goal of
orthognathic surgery, esthetics are affected by the re-
positioning of the teeth with orthodontics as well as by
the choice ofsurgical procedures and spatial alterations
ofthe maxilla and mandible. Traditional management
with double-jaw surgery has relied either on autoro-
tation ofthe mandible to determine an acceptable angle
for the occlusal plane, or the angle ofthe occlusal plane
is increased relative to the FH to "improve" stability.l"
This method may achieve an acceptable interrelation-
ship of the teeth, but it may not provide the optimal
functional and esthetic relationships between muscu-
loskeletal structures and the dentition. A common
practice in double-jaw surgery for open-bite cases is to
move the posterior maxilla superiorly to close the open
bite. When the occlusal plane is already steep, often
the angulation ofthe occlusal plane is further increased.
As the occlusal plane approaches the inclination ofthe
articular eminence, not only can esthetics be adversely
affected, but several undesirable functional alterations
may occur, which include 1) loss of cuspid-rise occlu-
sion; 2) loss of incisal guidance; and 3) development
ofworking and nonworking side posterior dental func-
tional interferences.
Those who believe in the necessity of protected oc-
clusal mechanisms, such as cuspid-rise occlusion and
incisal guidance, may have significant concerns over
732
FIGURE 2. Case 1. A. A 25-year-old woman desired correction ofhersignificant dentofacial deformity. B. Anteroposterior deficiency of the
maxillary andmandibular dentoalveolus isevident, aswell asa prominent nose andchin. C. D, Theocclusion shows a class IIend-on relationship
with allfour first premolars missing dueto previous orthodontic treatment.
the application of these traditional philosophies of in-
creasing the occlusal plane angulation. Selective alter-
ation of the occlusal plane angulation to create a more
normal interrelation to structures at the cranial base
can enhance the functional and esthetic results for
many patients. The three most important lateral ceph-
alometric interrelationships that can be selectively
changed in double-jaw surgery are I) the vertical po-
sition of the maxillary incisor; 2) the A-P position of
the anterior maxilla and maxillary incisor; and 3) the
angulation of the occlusal plane. The establishment of
these three interrelationships will dictate the new po-
sition of the maxilla and mandible. Surgical alteration
of the occlusal plane will change the angulation of the
maxillary and mandibular incisors as they relate to the
basal bone structures, as well as the A-P and vertical
positions of the maxilla, mandible, and chin.
Low OCCLUSAL PLANE FACIAL TYPE
The basic characteristics often observed in the low
occlusal plane (LOP) facial type (Figs 2, 3A) are as
follows: 1) low occlusal plane angle (less than 4°); 2)
low mandibular plane angle; 3) well-defined mandib-
ular angles; 4) strong chin relative to the mandibular
alveolus (A-P macrogenia); 5) decreased angulation of
the maxillary incisors as in a class II division 2 mal-
occlusion, but there also may be overangulated incisors;
6) decreased angulation of the lower incisors; 7) class
II malocclusion, but can be class I or III; 8) accentuated
curve of occlusion (curve ofSpee) in the mandible and
sometimes a reverse curve in the maxilla; and 9) an-
terior deep overbite.
SURGICAL INCREASE OF OCCLUSAL
PLANE ANGULATION
It can be advantageous in some of these LOP cases
to rotate the occlusal plane in a clockwise direction"
into the normal angulation range (8° ± 4°). This ro-
tation may have significantly beneficial effects on the
functional and esthetic results and in establishing the
presurgical orthodontic goals.
OCCLUSAL PLANE ALTERATION IN ORTHOGNATHIC SURGERY
As the occlusal plane angle increases (rotates clock-
wise), specific changes will occur. To illustrate these
changes (Fig 4A), the incisal edge of the maxillary in-
cisor will be used as the center of rotation. The changes
include I) increased occlusal plane angle; 2) increased
mandibular plane angle; 3) decreased maxillary incisor
angle relative to the nasion A point; 4) increased man-
dibular incisor angle relative to the nasion B point (NB);
5) rotation of the chin posteriorly in relation to the A-
P position of the lower incisor tips; 6) decreased pos-
terior facial height; and 7) advancement ofthe peri nasal
supportive bone structures.
The direction of movement should be predictable
and stable because all the muscles of mastication will
remain basically the same or shorten vertically. Relative
to alteration of the occlusal plane, the anatomic center
of rotation also effects esthetic change. For example,
if rotation is around the incisal edge of the central in-
cisor, the perinasal area will be advanced as the maxilla
rotates forward in that area. If rotation is around point
A, the perinasal area will not be affected as significantly,
but the upper incisor edge will rotate posteriorly and
the inferior aspect of the upper lip will also move pos-
teriorly. Pure vertical or A-P movements of the max-
illomandibular complex will not affect the occlusal
plane or incisor angulation, but may affect the esthetic
outcome.
HIGH OCCLUSAL PLANE FACIAL TYPE
Common characteristics of this facial type (Figs 5,
6A) may include the following: l) high occlusal plane
(HOP) angulation (greater than 12°); 2) high mandib-
ular plane angulation; 3) anterior vertical maxillary
excess and/or posterior vertical maxillary deficiency;
4) increased height of the anterior mandible and/or
decreased height ofthe posterior mandible; 5) decreased
projection of the chin (A-P microgenia); 6) A-P man-
dibular deficiency; 7) decreased angulation of maxillary
incisors, although overangulation can also occur; 8)
increased angulation of mandibular incisors; 9) class
II malocclusion, but can also occur with class I or III;
WOLFORD, CHEMELLO, AND HILLIARD 733

A B
DC

~
DC
6 25YRS
STO

C DC
----PRE T X
- - 6 6 MO POST OP

FIGURE 3. Case I . A, Deficiency of the maxilla and mandible in

case no. I is evident. Th e occlusal plane angle is 0°. The chin and
nose are relatively prominent. B. Surgical treatment objective dem-
onstrates the proposed movements of increasing the occlusal plane
angulation to 9° and advancement of the maxillary and mandibular
incisors 7 rnrn. With the clockwise rotat ion of the maxillomandibular
complex , the chin advances only 5 mm and the maxilla at the os-
teotom y level will advance 8 mrn . C. Superimposition of the pre-
treatment and 66-month follow-up shows the changes in the occlusal
plane angulation and the effects on esthetics.

10) anterior open bite, often accompanied by an ac-
centuated curve ofSpee in the upper arch; II) in more
pronounced cases, loss of incisal guidance, cuspid-rise
occlusion, and presence of working and nonworking
side interferences in the molar areas as the occlusal
plane angle approaches the inclination of the articular
eminence; and 12) moderate to severe obstructive sleep
apnea symptoms as a result of the tongue base being
displaced posteriorly and constricting the oropharyn-
geal airway in the more severe cases.
SURGICAL DECREASE OF OCCLUSAL
PLANE ANGULATION
Changes that occur with counterclockwise rotation
of the maxillomandibular complex (using the maxillary
incisor edge as the center of rotation for illustrative
purposes) are seen in Figure 4B. Changes that generally
occur include I) decreased occlusal plane angle; 2) de-
creased mandibular plane angle; 3) increased maxillary
incisor angulation; 4) decreased mandibular incisor
734 OCCLUSAL PLANE ALTERATION IN ORTHOGNATHIC SURGERY

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,,
...... _-- ...
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---,
FIGURE 4. A. Illustrative tracing demonstrates denio-osseous changes that occur with an increase in occlusal plane angulation in an LOP
facial type with a class I occlusion. Changing the occlusal plane angle from 0° (dotted line) to a normal of 8° (solid line) alters incisor angulation,
A·P projection of the chin, and spacial positions of the maxilla and mandible. The black area with white arrows in the ramus represents bone
that must be removed on the lingual side of the ramus above the medial horizontal osteotomy. Since the distal segment will rotate superiorly,
the black area indicated at the vertical buccal osteotomy area necessitates bone removal to get the proximal and distal segments to fit together.
B. This illustrative tracing represents an occlusal plane angle change in high occlusal plane facial type with a class I occlusion, from 16° (dotted
line) to a normal of 8° (solid line). Changes occur in the upper and lower incisor angulation, chin projection, and in a spacial position of the
maxillary and mandibular components. C. Occlusal plane alteration from an LOP of 0° to a high occlusal plane of 16° illustrates the significant
spacial changes of the maxillomandibular complex.

angulation; 5) increased chin projection in relation to
the lower incisor edges; 6) increased prominence ofthe
mandibular angles may occur; 7) improved incisal
guidance and cuspid-rise occlusion; 8) increased pos-
terior facial height; and 9) posterior movement of the
perinasal area relative to the maxillary incisor edge.
The center of rotation is also very important in es-
tablishing esthetic relationships. If the center of rotation
is at the maxillary incisor edge, the perinasal and sub-
nasale areas and the nasal tip will move posteriorly. If
rotation is around point A or higher, the perinasal areas
will be less affected, as will the nose, but the maxillary
incisor edges will come forward, increasing the A-P
support to the upper lip and increasing the chin pro-
jection. When decreasing the occlusal plane angle and
advancing the mandible, the A-P dimension of the
oropharyngeal airway will increase approximately 40%
of the mandibular advancement measured at the genial
tubercles.' The significant differencesin the orientation
of the dento-osseous structures with lOP and OOP
movements are seen in Fig 4C.
Presurgical Orthodontic Goals
It is most important to determine the amount of
alteration of the occlusal plane to be accomplished
during surgery so that appropriate presurgical ortho-
dontic goals can be established. Alterations in incisal
angulation will occur as the occlusal plane angle
changes. In the LOP facial type, it may be desirable
during the presurgical orthodontics to increase max-
illary incisor angulation (above normal) so that as the
occlusal plane angle is increased, maxillary incisor an-
gulation will decrease an equal amount toward normal.
It may also be desirable to decrease the mandibular
incisor angulation below normal so that, as the occlusal

FIGURE 5. A. This 25-year-old woman complained ofsevere dentofacial deformity and significant sleep apnea symptoms. B. Severe retrusion
of the mandible and elongated lower third face are noted. Notice her head posture, which is in pan created by her sleep apnea symptoms with
her head tilted up to help project her chin and open her oropharyngeal airway. C. D. Patient has a class II end-on occlusal relationship. Patient
had four bicuspids extracted and previous orthodontic treatment.
WOLFORD, CHEMELLO, AND HILLIARD 735

B JK

Cl:> SI D

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FlGURE 6. Case 2. A. Cephalometrically, this patient has mild retrusion of th e maxilla, but severe retrusion ofthe mandible with a mandibular
depth of74°, with A·P microgenia and occlusal plane angulation of 30°. Note the severe restricted oropharyngeal airway of only I mm. The
upper incisors are decreased in angul ation. B. The surgical treatment objective demonstrates that the anterior maxilla is to be moved superiorly
4 mm and"the posterior aspect of the maxilla inferiorly 3 mm. The mandible is to be advanced 16 mm at the sagittal split area with a IO-mm
chin augmentation so that pogonion will advance approximately 34 mm. C. The patient was evaluated 28 months postsurgery, showing good
stability of results. A significant improvement was also achieved in the oropharyngeal airway. D. Superimposition of the preoperative and 28-
month postoperative tracings demonstrate th e significant changes accomplished .

plane is increased, the mandibular incisor angulation Temporomandibular Joint Consideration

will increase toward normal.
In an HOP facial type, decreasing angulation of the
maxillary incisors (below normal) during the presurg-
ical orthodontic phase may be indicated. Thus, when
the occlusal plane angle is surgically decreased, max-
illary incisor angulation will increase an equal amount
toward normal. The presurgical orthodontic goal may
also include overangulation ofthe mandibular incisors
so that, as the occlusal plane angle is surgically de-
creased, the incisor angulation will decrease an equal
amount.
If the maxilla is segmentalized in either the LOP or
HOP facial type patient, the presurgical orthodontic
goal relative to maxillary incisor angulation may not
be as critical as it is when occlusal plane alteration is
performed with a one-piece maxilla. In particular, if
the maxilla is sectioned between the lateral incisors
and the canines, there is much more latitude, not only
to alter the occlusal plane, but also to selectively es-
tablish an optimal maxillary incisor angulation, adjust
for any anterior tooth size discrepancy between the
maxil1ary and mandibular teeth, and correct transverse
arch differences. Determining presurgical orthodontic
goals has significant influence on whether extractions
will be done, whether accentuated curves of occlusion
or reverse curves of occlusion are to be leveled ortho-
dontically or surgically, and whether interarch me-
chanical procedures are necessary to achieve optimal
presurgical positions of the dental units. For premolar
extraction cases in the LOP facial type, it is usually
easier to orthodontically move the anterior teeth pos-
teriorly, but it is more difficult to move the posterior
teeth forward. Conversely, in the HOP facial type, it
is more difficult to orthodontically move the anterior
teeth posteriorly, but it is easier to move the posterior
teeth forward.
It is important to note the health and condition of
the temporomandibular joint (TMJ) prior to this type
of surgery. Any evidence of presurgical pathology must
be thoroughly evaluated and properly managed. Pa-
tients with internal derangements, arthritic conditions,
or resorptive processes (eg, idiopathic condylar resorp-
tion, rheumatoid arthritis, psoriatic arthritis) may have
dysfunctional and/or unstable TMJs, requiring special
management including consideration of simultaneous
TMJ surgery, or as a separate procedure prior to the
orthognathic surgical procedures. Patients who have
had appliance therapy to "recapture the disc" may have
unstable joints for the DOP rotational movement and,
unless the TMJs are specifically addressed, the discs
may become displaced postsurgery and a class II open
bite may develop.
Surgical Technique
Surgical sequencing may be different for the two ba-
sic morphologic facial types. An accurate presurgical
prediction tracing and precise model surgery will sim-
plify surgery and enhance the accuracy and stability of
the treatment outcome.
SURGICAL INCREASE OF OCCLUSAL
PLANE ANGULATION
When increasing the occlusal plane angle it is usually
easier to reposition the maxilla first, creating a posterior
open bite, but maintaining a predetermined incisor re-
lationship, be it class I, II, or III. Although we prefer
to set the mandible first, using rigid fixation, accurate
presurgical model surgery is much more difficult in
such cases, usually creating a large anterior open bite.
736 OCCLUSAL PLANE ALTERATION IN ORTHOGNATHIC SURGERY
Therefore, setting the maxilla first is easier for most
surgeons. An intermediate splint will improve surgical
accuracy. A maxillary step-osteotomy," or other sur-
gical design of the surgeon's choice, is used to mobilize
and reposition the maxilla. The posterior aspect of the
maxilla is usually moved superiorly a greater amount
than the anterior maxilla (Figs 3B and 4A) or the an-
terior maxilla is brought inferiorly a greater amount
than the posterior maxilla as predetermined on the
surgical treatment objective or prediction tracing and
by model surgery.
The intermediate splint is used to stabilize the max-
illa or mandible in the new, predetermined position
while rigid fixation is applied. The surgeon must be
aware of and eliminate potential interferences in the
maxillary region of the pterygoid plates, tuberosity, and
perpendicular plate of the palatine bone. When the
mandibular ramus osteotomies are completed and the
mandible is set into its new position, the posterior as-
pect of the mandible and the teeth also must be raised
superiorly to fit into occlusion with the maxillary teeth.
The proximal mandibular segments will then rotate
upward and forward. With autorotation of the proximal
segment, even with moderate advancement at the
mandibular incisal edge, the mandibular segments may
end up being managed similar to a mandibular setback
in the sagittal split area, requiring removal of bone in
the vertical buccal osteotomy area. Bone also must be
removed from the medial aspect of the proximal seg-
ment directly above the level of the medial horizontal
cut6•10 (Fig 7). This bone is consistently an area of in-
terference if it is not removed. Rigid fixation is used
to stabilize the mandibular segments in the new posi-
tion. Care must be taken not to overlook the joints;
excessive stress on the TMJ and articular discs should
be minimized.
SURGICAL DECREASE OF OCCLUSAL
PLANE ANGULATION
When the occlusal plane angulation is decreased, it
is usually easier to set the mandible into its new position
FIGURE 7. When increasing
the occlusal plane angulation,
bone must be removed from the
proximal segment, above the
medial cut, or a major bone in-
terference will occur with an in-
ability to get the proximal and
distal segments passively to-
gether.
first with rigid fixation, using an intermediate splint to
create a posterior open bite. The maxillary surgery then
becomes much simpler, requiring completion of the
osteotomies and mobilization and placement of the
segment(s) into occlusion with the mandible, with or
without a final splint. Rigid fixation is applied and nat-
ural or synthetic bone is placed in the osteotomy areas,
if necessary. The maxilla can be repositioned first, but
it may require creating a large anterior open bite and
a significant downward and posterior rotation of the
mandible to create room to downgraft the posterior
maxilla, if that is a treatment requirement.
In some of these cases, the height of the ramus may
increase. However, since most patients requiring this
type of movement are skeletal class II cases, the ramus
portion of the distal segment moves forward as it 'moves
inferiorly, in front ofthe pterygoid-masseteric sling and
along the descending inferior slope of the inferior bor-
der of the mandible. Thus, no impingement on the
muscle sling occurs in most of these cases. It is very
difficult to lengthen muscles 11 and, if attempted, the
results may be fraught with significant relapse of bony
segments. If the posterior inferior aspect of the distal
segment in the sagittal split area impinges on the pter-
ygoid-masseteric muscular sling (as in a class III HOP,
mandibular prognathic open bite), it may be necessary
to reflect the medial pterygoid muscle from the medial
aspect of the proximal segment and slit the muscular
sling so that the posterior-inferior aspect of the distal
segment can rotate down through the sling. The area
that moves inferior to the pterygoid-masseteric sling
will eventually remodel up to the height of the mus-
culature. If the sagittal split occurs posteriorly and
through the inferior-posterior aspect of the angle, it is
possible for part of the medial pterygoid muscle to re-
main attached to the distal segment. If this is suspected,
a "J"-stripper periosteal elevator may be needed to re-
lease the medial pterygoid muscle from the distal seg-
ment.
With counterclockwise rotation, large anterior open
bites are essentially closed with the mandibular pro-
cedure. In cases where large counterclockwise move-
ments are indicated, mandibular ramus sagittal split
osteotomies can usually be done; however, inverted-
"L" osteotomies also can be used. With either proce-
dure, rigid stabilization can usually be applied, elimi-
nating the need for postsurgical maxillomandibular
fixation. Specific modifications of the sagittal split os-
teotomy may be helpful in facilitating maximum bony
interface when these are extremely large move-
ments. 1O, 12 Suprahyoid myotomies are rarely indicated
or necessary for stable results. In fact, maintaining the
attachment of the geniohyoid musculature will maxi-
mize the increase of the oropharyngeal space, which
may be very important in patients with obstructive
sleep apnea.' When decreasing the occlusal plane,
WOLFORD, CHEMELLO, AND HILLIARD
sometimes the posterior aspect ofthe maxilla will need
to be downgrafted. In these cases, it is imperative that
four bone plates be used with at least two screws above
and two screws below the osteotomy in each bone plate.
The bone defects must then be grafted with bone or,
preferably, porous block hydroxylapatite.v'?
In some cases, (eg, rheumatoid arthritis, idiopathic
condylar resorption, previous fractured and displaced
condyles, etc) the TMJ may require reconstruction,
which can be done at the same time as the orthognathic
surgery (ie, disc repositioning, temporal fascia grafts,
etc). Materials that can be used to reconstruct the TMJ,
lengthen the ramus, and counterclockwise rotate the
maxillomandibular complex include a sternoclavicular
graft, a costochondral graft, or a total joint prosthesis.
Stability of Results
The stability of results, particularly with counter-
clockwise rotation ofthe maxillomandibular complex,
has often been highly questioned. There has been very
little documentation in the literature relative to sta-
bility, particularly for double-jaw surgery. Although the
senior author has used this technique successfully for
over 14 years, the development of rigid fixation tech-
niques and improved surgical designs has significantly
improved the stability of results. In a recent study by
Chemello et al, 14 stability of the results were evaluated
in patients with surgically increased or decreased oc-
clusal plane angulation and healthy TMJs in whom
rigid fixation techniques were used. Lateral cephalo-
metric radiographs were used, including the immediate
presurgical (T I ) , immediate postsurgical (T 2) , and
longest follow-up evaluation (T 3) , to make the deter-
minations of stability at specific anatomic areas.
INCREASED OCCLUSAL PLANE ANGULATION
Fourteen patients (10 females and four males) with
an average age of 31 years (range, 15 to 53 years) un-
derwent double-jaw surgery for increase ofthe occlusal
plane angulation. The mean follow-up period was 23
months, but none was lessthan 12 months. The surgical
FIGURE 8. Case J. A-D. The functional and esthetic results achieved with the clockwise rotation and advancement of the maxilla and
mandible are apparent. No nasal or chin surgery was performed.
737
change of the occlusal plane angle was 5.6° (SO 2.8°)
with a postsurgical change of -0.6° (SO 1.50, 10.7%).
The surgical change in maxillary depth was 2.9° (SO
I. r) with a postsurgical change of -0.4° (SO 1.0°,
13.8%). The mandibular depth was essentially un-
changed surgically and in the long term did not change
position. The surgical change of the maxillary incisor
angulation was -10.2 ° (SO 2. r), with a postsurgical
change of 1.0° (SO 3.3°; 9.8%). The horizontal surgical
change from point A was 3.3 mm (SO 1.9 mm), with
a postsurgical change of-0.6 mm (SO 1.2 mm; 18.2%).
The horizontal surgical change from point B was -0.2
mm (SO 3.9 mm) with a minimal postsurgical change
of -0.1 mm (SO 1.7 mm). Pogonion likewise had a
small surgical change of -2.0 mm (SO 4.8 mm) with
a postsurgical change of 0.5 mm (SO 1.7 mm).
OECREASED OCCLUSAL PLANE ANGULATION
Twenty-seven patients (22 females and five males),
with a mean age of 30 years (range, 15 to 44 years)
underwent double-jaw surgery for decrease of the oc-
clusal plane. The mean follow-up period was 21
months, but none was lessthan 12 months. The average
surgical change in the occlusal plane angulation was
-8.8° (SO 3.3°). Postsurgical change was 0.2° (SO
1.3°; 2.3%). Maxillary depth had a very minimal sur-
gical change of only 1.1° (SO 2.2°) and a postsurgical
change of -0.5° (SO 1.0°). The average mandibular
depth, however, had a surgical change of 4.1° (SO 3.2°),
with a postsurgical change of0.1 ° (SO 1.2°), or a post-
surgical increase in mandibular depth of 2.4%. The
horizontal surgical change at point B was 7.7 mm (SO
5.8 mm) and the postsurgical change was 0.3 mm (SO
2.2 mm), or a further increase of point B projection of
3.9%. The horizontal surgical change of pogonion was
10.4 mm (SO 6.2 mm), with a postsurgical change of
0.5 mm (SO 2.7 mm), for a further forward movement
of pogonion of 4.8%. The slight increase in mandibular
depth and horizontal change in point B and pogonion
are most likely related to splint removal and settling
of the occlusion. These results demonstrate predictable
stability with this procedure when properly performed.
738 OCCLUSAL PLANE ALTERATION IN ORTHOGNATHIC SURGERY

FIGURE 9. Case 2. A-D. Patient is seen posttreatment with establishment of good facial symmetry and balance and a good functional occlusal
relationship. Her sleep apnea symptoms were completely eliminated.

The results of this study indicate that clockwise and
counterclockwise rotation of the maxillomandibular
complex, with alteration of the occlusal plane, is a stable
and predictable procedure. In fact, counterclockwise
rotation, overall, is somewhat more stable than clock-
wise rotation. This is probably due to the fact that with
counterclockwise rotation the bone plates and porous
block hydroxylapatite implants were able to provide
direct vertical support to the lateral and posterior max-
illary walls. When increasing the occlusal plane angle
with the clockwiserotation, bone is excised at the lateral
and posterior aspect of the maxilla and, because of the
morphologic characteristics ofthe maxilla, there is less
bony interface posteriorly. Therefore, the mobilized
portion of the maxilla may tend to telescope into the
maxillary sinus.
The adaptability of these techniques is demonstrated
in the following case presesentations.
Report of Cases
CASE 1
phalometrically, the patient demonstrated A-P maxillary de-
ficiency (maxillary depth 86°), and A-P mandibular defi-
ciency (mandibular depth 85°). Occlusal plane angulation
was low at 0°, maxillary incisor angulation was 30°, and
mandibular incisor angulation was 150. The lower incisor to
the NB line was I mm and pogonion to NB was 6 mm,
demonstrating a significant imbalance between the lower in-
cisor position and chin projection to NB.
The treatment plan included the following:
I. Presurgical orthodontics to align and level the maxillary
and mandibular arches.
2. Surgery (Fig 3B): 1) multiple piece Le Fort I osteotomy
to advance the maxilla 8 mm at the level of the oste-
otomy and 7 mm at the incisor edge. The posterior
maxilla was moved superiorly 6 mm, but the anterior
remained at the original vertical level. 2) Bilateral man-
dibular ramus osteotomies to advance the mandible in '
a clockwise direction so that the incisor edges came
forward 7 mm and pogonion came forward 5 mm. The
ramus portion of the distal segment moved superiorly
5 mm as seen in the surgical treatment objective tracing
(Fig 3B) noted by the oblique lines at the medial oste-
otomy level. The occlusal plane was changed from 0°
to 9°.

A 26-year-old woman (Figs 2, 3A) had previous ortho-
dontic treatment, including extraction of four premolars, and
presented with a residual class II end-on occlusion. Deficien-
cies in dentoalveolar projection of both the maxilla and
mandible was evident in the lateral view. The nose and chin
were prominent relative to the lip supporting structures. Ce-
No chin or external nasal surgery was performed. The pa-
tient is seen posttreatment in Fig 8, showing significant im-
provement in functional and esthetic facial balance. The pa-
tient is now 5 years 6 months' postsurgery and remains very
stable, with no detectable changes in jaw position since the
immediate postsurgical radiograph.

FIGURE 10. Case 3. A. This 38-year-old woman had a significant facial deformity and moderate sleep apnea symptoms. She has a transverse
facial asymmetry. B. Profile demonstrates the vertical excess and elongated lower third of the face and the significant retruded mandible. C. D.
She has a class II occlusion and significant crowding in the maxillary and mandibular arch.
WOLFORD, CHEMELLO, AND HILLIARD 739

o o

FIGURE II. Case 3. A. Cephalornctrically, a CFH was used so that normal cephalometric values could be used for diagnosis and treatment
planning. The vertical maxillary excess and A-P mandibular deficiency are noted. B. Following four premolar extractions and presurgical
orthodontics, the final.surgical treatment objective was achieved with the anterior portion of the segmentalized maxilla moving superiorly 4
inm . The posterior maxilla will be downgrafted 2 mm on the left side. The mandible will be advanced 15 mm and a 6-mm chin augmentation
placed, so that pogonion will advance 23 mm. C. Follow-up at 54 months shows excellent stability, with no significant changes since the
postsurgical cephalometric radiograph. D. Superimposition of the pretreatment and 54-month postoperative tracings demonstrates the significant
changes made.

CASE 2 At 28 months' postsurgery, the patient has maintained ex-

A 25-year-old woman (Figs. 5, 6A) had orthodontic treat-
ment 10 years prior with extraction of four first premolars
to correct an anterior open bite and mandibular deficiency.
The patient had recently been rebanded in anticipation of
surgery and had a class II end-on occlusion, but cephalo-
metrically had significant facial imbalance. Maxillary depth
was 88° and mandibular depth was 74° , indicating a signif-
icant A-P mandibular deficiency. The maxillary incisor an-
gulation was 5° and lower incisor angulation was 34°. Oc-
clusal plane angulation was 30°. The oropharyngeal airway
was I mm. The patient had severe sleep apnea. The maxillary
tooth-to-lip relationship was 7 mm .
Treatment included the following:
I. Presurgical orthodontics to align and level the maxillary
and mandibular arches.
2. Surgery (Fig 6B): I) multiple maxillary osteotomies to
move the anterior maxilla superiorly approximately 4
mm, downgraft the posterior maxilla 3 mm, and achieve
proper angulation of the maxillary incisors; 2) bilateral
mandibular ramus osteotomies for advancement ofthe
mandible approximately 16 mm ; and 3) augmentation
genioplasty of 10 mm with porous block hydroxylap-
atite. It is important to understand that the bony po-
gonion will advance significantly more than the ad-
vancement at the sagittal split area because of the
counter-clockwise rotation of the complex .
cellent stability ofjaw position, with no opening of the bite,
good esthetics, and good jaw function without pain (Figs 6C,
6D, 9). The occlusal plane angle had been decreased 20°
(Figs 9A, 9C).
CASE 3
This 38-year-old woman (Figs 10, IIA) had a significant
musculoskeletal deformity of the lower jaw structures with
facial asymmetry and transverse tipping of the occlusal plane.
The cephalometric maxillary depth was 97° and mandibular
depth was 83 0. This obviously did not agree with the clinical
evaluation, so a CFH reference plane was established. The
CFH placed the jaw structures into a more appropriate re-
lationship with maxillary depth relative to the CFH of 90°
and mandibular depth of76° . The occlusal plane angulation
was 27°. The oropharyngeal airway was 2 mm, and the patient
had moderate sleep apnea symptoms. Treatment included
the following:
I. Extract four first premolars.
2. Presurgical orthodontics: 1) alignment and leveling of
the upper arch, decreasing the angulation of the incisors;
and 2) alignment and leveling ofthe lower arch, leaving
the incisors overangulated.
3. Surgery (Fig l l B): I) multiple maxillary osteotomies
to move the anterior maxilla superiorly 4.5 mm on the
right and 2.5 mm on the left, and to move the maxilla
posteriorly 4 mm at the osteotomy level. The left pos-
terior maxilla was downgrafted 2 mm and the right side

FIGURE 12. Case 3. A-D. The patient is seen posttreatment with establishment of good facial balance and symmetry, and good functional
occlusion. The oropharyngeal airway has improved significantly with elimination of sleep apnea symptoms.
740
o mm. 2) Mandibular advancement of 15 mm; and 3)
a 6-mm chin augmentation using porous block hy-
droxylapatite.
The patient's posttreatment functional and esthetic results
are seen in Figures l l C, liD, 12. When evaluated 4 years,
6 months' postsurgery, there was good stability of the results,
with relatively normal facial architecture and balance. The
occlusal plane angle was decreased 16° (Figs IIA, 1I C). The
oropharyngeal airway had opened to 10 mm, well within the
normal limits. Jaw function was normal. Pogonion came for-
ward 23 mm with the surgery.
These three cases demonstrate the applicability of
alteration of the occlusal plane in achieving optimal
functional and esthetic results in patients presenting
with abnormal variations ofocclusal plane angulation.
The documented stability of the results indicate that
this treatment approach should be considered when
double-jaw surgery is indicated for correction of den-
tofacial deformities.
Acknowledgment
The orthodontics in Figure 8 were provided by Dr John Valant,
Baylor College of Dentistry, Dallas, TX. Orthodontics in Figure 9
were provided by Dr John Callahan, Sr, Fayetteville, NY. Ortho-
dontics in Figure 12 were provided by Dr Joe Crain, Fort Worth,
TX.
References
I. Wolford LM, Walker G, Schendel SA, et al: Mandibular defi-
ciency syndrome. Part I. Clinical delineation and therapeutic
significance. Oral Surg Oral Med Oral PathoI45:329, 1978
J Oral Maxillofac Surg
51;740-741,1993
Discussion
Occlusal Plane Alteration
in Orthognathic Surgery
Bruce N. Epker, DDS, PhD
Fort Worth. TX
In the authors' quest to improve our treatment of den to-
facial deformities from both a functional and esthetic stand-
point, they have suggested that we add arbitrary alteration
of the occlusal plane to our current regimen as a deliberate
part of treatment. Their hypothesis is that such alteration of
the occlusal plane is important in orthognathic surgery to
optimize functional and esthetic results. Unfortunately, there
is no test of this hypothesis nor data to suggest that either
masticatory function or facial esthetics is improved with ar-
bitrary occlusal plane adjustment.
There are a number of actual and conceptual problems
with this article. The authors repeatedly emphasize that
"counterclockwise rotation or decrease of the occlusal plane
angle of the maxillomandibular complex has not been sup-
ported as acceptable treatment modality . . . ." Apparently,
they do not appreciate that this is precisely what occurs with
isolated superior repositioning of the maxilla, which does
DISCUSSION
2. Ricketts RM: Cephalometric analysis' synthesis. Angle Orthod
31:141,1961
3. Epker BN, Wolford LM: Dentofacial Deformities: Surgical Or-
thodontic Correction. St Louis, MO, Mosby, 1980
4. Proffit WR, Bell WH: Open bite, in Bell WH, Proffit WR, White
RP (eds): Surgical Correction of Dentofacial Deformities.
Philadelphia, PA, Saunders, 1980, Chapter 13, p 1058
5. Epker BN, Fish LC: Dentofacial Deformities: Integrated Ortho-
dontics and Surgical Correction. St Louis, MO, Mosby, 1986
6. McCollum AGH, Reyneke JP, Wolford LM: An alternative for
the correction of the class II low mandibular plane angle pa-
tient. Oral Surg Oral Med Oral PathoI67:231, 1989
7. Kortebein M, Wolford LM: Changes in posterior airway space
with counter-clockwise rotation of the maxiIIomandibular
complex. Abstract presented at the AAOMS Annual Meeting,
Chicago, IL, September 25-29,1991
8. Wolford LM, Wardrop RW, Hartog JM: Coralline porous hy-
droxyapatite as a bone graft substitute in orthognathic surgery.
J Oral Maxillofac Surg 45: 1034, 1987
9. Bennett MA, Wolford LM: The maxillary step osteotomy mod-
ification and Steinmann pin stabilization. J Oral Maxillofac
Surg 43:307, 1985
10. Wolford LM, Bennett MA, Rafferty CG: Modification of the
mandibular ramus sagittal split osteotomy. Oral Surg Oral
Med Oral PathoI64:146, 1987
II. Yellich GM, McNamara JA Jr, Ungerleiden JC: Muscular and
mandibular adaptation after lengthening, detachment, and
reattachment of the masseter muscle. J Oral Surg 39:656, 1981
12. Wolford LM, Davis WML: The mandibular inferior border split:
A modification in the sagittal split osteotomy. J Oral Maxil-
lofac Surg 48:92, 1990
13. Wardrop RW, Wolford LM: Maxillary stability following down-
graft and/or advancement procedure with stabilization using
rigid fixation and porous block hydroxyapatite implants. J
Oral Maxillofac Surg 47:336, 1989
14. Chemello P, Wolford LM, Buschang P: Occlusal plane alteration
in orthognathic surgery: Long-term stability of results. Am J
Orthod (in press)
effect a counterclockwise rotation and decrease in occlusal
plane angle, and has been documented repeatedly as the most
stable operation in orthognathic surgery!They next state that
"misconceptions have been developed that this [counter-
clockwise rotation of the occlusal plane] is an unstable pro-
cedure" and I am at a loss to find any line of logic in this
statement. What has been criticized as unstable is the coun-
terclockwise rotation of the distal mandible with attempted
lengthening of the ramus to close an open bite with isolated
mandibular advancement. Although the primary treatment
approach has not been to deliberately alter the occlusal plane
for any functional purpose, oral and maxillofacial surgeons
have been routinely autorotating occlusal planes for decades,
either increasing the plane angle in isolated inferior reposi-
tioning of the maxilla or two-jaw surgery, or decreasing it in
isolated superior repositioning of the maxilla and/or in many
cases a simultaneous two-jaw surgery. If one is going to ad-
vocate alteration of the occlusal plane as the primary treat-
ment to improve function, then this concept must be incor-
porated into the known functional relationships between the
maxillomandibular skeleton, dentition, condyle, articular
eminence, fossa, and disc. The anatomic, anthropometric,
orthodontic, and basic bone literature is replete with docu-