SPECIAL ARTICLE

A comparison of outcomes of orthodontic and

surgical-orthodontic treatment of Class 11
malocclusion in adults
William R. Proffit, DDS, PhD, Ceib Phillips, MPH, PhD, and Neofitis Douvartzldis, BDS, MS
Chapel Hill, N.C.

The treatment outcome for skeletal Class II malocclusion was reviewed in 33 nongrowing patients
who were treated with orthodontics alone (by premolar extraction and tooth movement to camouflage
the skeletal problem) and in 57 patients treated for similar problems with surgery and orthodontics
(with mandibular advancement and with tooth movement to reduce rather than increase dental
compensation for the skeletal deformity). Cephalometric and dental cast changes were scored to
quantitate treatment effects. Two approaches were used to detemine the treatment efficacy (the
relative success of treatment): (1) whether the final value for a measurement criterion (such as an
overjet and an ANB angle) fell within the normal range, and (2) the quantitative amount of correction
produced relative to an "ideal" value. In addition, a panel of judges was used to rate esthetic
changes from pretreatment and posttreatment facial slides. Both orthodontic treatment and
surgical-orthodontic treatment improved the malocclusion as judged from dental casts. Surgery
resulted in greater reduction of overjet and g.reater improvement in most cephalometric skeletal,
dental, and soft tissue criteria. Before treatment, the surgical patients had lower esthetic ratings than
the orthodontics-only patients. After treatment, the esthetic ratings for the orthodontic patients were
unchanged. The surgical patients had improve d but not to the pretreatment level of the orthodontics
patients. (AM J ORTHOODENIOFACORTHOP 1992;101:556-65.)

T h e r e are three possible approaches to the significa m growth no longer will occur, camouflage and
treatment of skeletal Class II malocclusion: (1) modi- surgery are the only treatment possibilities. Which of
fication of growth so that the jaw discrepancy is reduced these is the "better" approach is highly controversial,
or eliminated as the mandible grows more than the in part because so little comparative data exist at pres-
maxilla; (2) tooth movement to compensate for the jaw ent. The effects of surgical versus camouflage treatment
discrepancy, i.e., retraction of the upper incisors or can be measured in terms of the clinical outcomes pro-
proclination of the lower incisors. The effect is to cam- duced by the treatment, i.e., the changes in dental oc-
ouflage rather than to correct the skeletal problem; or clusion, cephalometric measures, and esthetic judg-
(3) surgical repositioning of the jaws, which almost ments that occur. These have been discussed in the
always involves mandibular advancement because se- context of case reports by Poulton and WarJ z and by
vere Class II malocclusion is oveinvhelmingly due to McNeiU and ~,Vest4 but have not been reviewed system-
mandibular deficiency.t To the extent that growth mod- atically in groups of patients.
ification is possible, this is the ideal treatment. Ortho- When comparing the alternative treatment proce-
dontic treatment in children and adolescents is based dures, it also is important to evaluate treatment efficacy,
on a combination of growth modification and camou- which is determined by whether and to what extent the
flage. Some favorable growth nearly always is observed treatment met its goals of improving dental relationships
in the younger patients in whom excellent results are and dentofacial esthetics. Although no such comparison
obtained, even when treatment is. done relatively late of treatment efficacy has been previously published, it
in the growth period. seems reasonable to calculate it in terms of the goals
However, for late adolescents and adults in whom of modem orthodontics, which are normal occlusion,
acceptable skeletal and soft tissue proportions, and ac-
ceptable dentofacial esthetics. Additional goals are a
From the Department of Orthodontics, School of DentistD', University ofNor:t h reasonably stable result and good risk-benefit and cost-
Carolina. benefit ratios.
This project ',vas supported by Nltl Grant DE-08708 from the National Institute
of Dental Research. In contrast to the highly developed and straightfor-
8/1/27838 ward methods that orthodontists routinely use to eval-
556
Volume 101 Special article 557
Number 6

Table IA. Pretreatment characteristics o f subjects

Orthodontics only Surgery-orthodontics

n = 33 n = 57

Mean I SD Mean I SD

Age 22.2 6.1 30.5 9.8

Treatment Time (mos) 24.0 -- 30.0 --
Overjet 6.6 3.0 9.0 2.4
ANB 5.1 1.4 5.8 2.0
Mandibular plane angle 34.0 7.0 32.2 7.5

uate dental occlusion and dentofacial proportions, the Table lB. Pretreatment characteristics
evaluation o f dentofacial esthetics is unstandardized. of subjects
The n o r m a l dentofacial proportions established by Orthodontics only Surgical-orthodontics
cephalometric standards correlate with esthetic
judgmentsS( 6 but are not adequate by themselves for Relative frequency (%) Relative frequency (%)
complete e~aluation o f the esthetic c o m p o n e n t of treat- Female 68 73
ment. 7 Experience has s h o w n , however, that groups o f Class II, Divi- 32 29
j u d g e s can consistently score facial photographs, sion 2 mal-
and this approach allows a reasonable evaluation of occlusion
Extractions 91 38
esthetics.8.'~ "Edgewise Ap- 85 100
This article presents data from a retrospective siudy pliance
o f the effects and efficacy of orthodontic (camouflage)
versus surgical-orthodontic treatment o f skeletal Class patients were slightly older and had longer treatment times.
II malocclusion in n o n g r o w i n g patients. They also had greater overjet and somewhat more severe
mandibular deficiency. Of the orthodontics-only patients, five
METHODS were treated with the Begg appliance.
Subjects. Subjects were selected from treatment records Determination of treatment effects. To assess changes in
available at the University of North Carolina. The records to the dental occlusion produced by treatment, the occlusal char-
be analyzed (dental casts, cephalometric radiographs, pho- acteristics included for evaluation in the 1990 N-HANES III
tographs) were taken immediately before treatment and within survey of the United States population were employed, l~ On
1 year of completion of the orthodontic phase of treatment. the pretreatment and posttreatment dental casts, Little's ir-
For the orthodontics-only group, 136 patients were iden- regularity index" was calculated for both the maxillary and
tified whose clinical notes indicated treatment for Class II the mandibular incisors. Overjet was measured as for
malocclusion beginning at age 17 years or older. Of these N-tlANES III. In addition, buccal interdigitation was scored
patients, 52 were rejected because the sequential cephalo- as the horizontal distance from the buccal cusp tip of the
metric radiographs showed jaw growth during treatment, 40 upper second premolar to the contact point between the man-
because analysis of the initial cephalometric film showed that dibular first molar and second premolar. A positive score
they were dental but not skeletal Class II, and 11 because of (maxillary cusp tip anterior to the mandibular contact point)
incomplete or poor quality cephalometric records. Cephalo- indicated the extent of Class 11 interdigitation, a negative score
metric changes were assessed in the remaining 33 patients, indicated the extent of Class III interdigitation (the magnitude
but dental casts were available for only 23 patients. of "Class II windows" or "Class III windows" in the oc-
For the surgical group, 73 patients were identified in clusion). The presence or absence of crossbite was scored,
whom mandibular advancement surgery alone (without max- and intermolar and intercanine widths, as well as overbite
illary, dentoalveolar, or chin surgery) had been accomplished. and open bite, were measured. For each characteristic, treat-
Of these patients, 9 were rejected because jaw growth ment effect was recorded as the change from before to after
occurred during treatment, and 7 because the records were treatment (Table II).
incomplete or of poor quality. All the remaining 57 patients For ccphalometdc evaluation, pretreatment and posttreat-
were used to assess cephalometric changes. Pretreatment and ment cephalometric radiographs were digitized. A coordinate
posttreatment dental casts were available on only 19 patients system was established, with a line through sella rotated 6 ~
since the orthodontic treatment for many patients was per- down anteriorly from the SN line as the horizontal axis, and
formed in their local community and only the surgery was a ,/erlical line through sella perpendicular to it as the vertical
performed at the university. axis. Millimeter changes in landmark positions wcre recorded
Subject characteristics before treatment are summarized as coordinate changes in this reference system; angular mea-
in Table I. The groups were similar. On average the surgical surements also were employed (Fig. 1).
558 Proffit, Phillips, atzd Douvartzidis Am. J. Orthod. Dentofac. Orthop.
June 1992

Nation
Rotated 6 ~ down

\
Reference Line

-t-

Soft tissue
A point
c to NA(mm)

.~ Mx Ine Tip

;oft t i i e u e
| point

PPooonlon
A

~ Mwldib.ler
Angle
Plene

B
i

Fig. 1. A, Landmarks and millimeter measurements used in this study. Note the horizontal reference
line, which approximatesthe true horizontal. B, Angular measurements.

Determhzation of treatment efficacy. For the dental-cast_ range for that measure, an "acceptable" score was given; if
and cephalometric data, two approaches were used to evaluate not, the measure .was "unacceptable." Our values for the
treatment efficacy: (1) Acceptable range achieved. If at the normal range for important measurements are illustrated along
end of treatment the value of a measure fell within the normal with the percentage results in Table 111. (2) Percentage goal
Volume 10l Special article 559
Number 6

Table II. C h a n g e s in t r e a t m e n t

Orthodontics only Surgical-orthodontics

Pretreatment eosllreal/nent Pretreatment Posttreatment
Mean I SD Mean [ SD Pvahte Mean I SD Mean I SO P value

Horizontal position
Point A 70.3 6.4 69.4 6.2 0.001 70.7 6.1 70.7 6.1 0.930
Point B 60.5 8.1 59.7 8.4 0.004 59.1 7.8 63.6 8.0 0.001
Soft tissue A 4.2 4.5 2.5 2.8 0.001 3.7 4.4 3.4 3.3 0.040
Soft tissue B -8.5 6.3 - 10.5 9.0 0.050 - I 1.0 6.3 -5.2 6.1 0.001
P~onion 61.1 9.9 59.7 8.4 0.090 61.0 9.4 65.1 9.4 0.001
Maxillary incisor 72.3 7.8 69.3 7.6 0.001 73.2 8.0 73.0 7.1 0.780
Mandibular incisor 67.3 7.3 66.8 7.4 0.340 65.4 7.1 70. I 6.8 0.001
Vertical position
Point A 54.9 4.1 55.8 3.7 0.004 54.1 3.9 54.9 4.0 0.001
Point B 88.5 6.1 89.5 6.5 0.003 87.9 6.1 92.4 5.8 0.001
Pogonion 105.5 7.2 106.4 7.7 0.001 104.8 7.2 109.0 7.7 0.001
Maxillary. incisor 76.5 4.8 76.5 4.8 0.530 76.8 5.0 77.5 5.3 0.004
Mandibular incisor 71.7 5.3 73.5 5.0 0.001 70.5 4.7 74.9 5.0 0.001
ANB angle 5.1 1.4 4.7 1.0 0.030 5.8 2.0 3.0 3.2 0.001
Mandibula/i plane 34.0 7.0 34.3 7.1 0,190 32.2 7.5 36.2 7.1 0.001
angle
Overjet 6.6 2.9 3.7 90.9 0.001 9.0 2.4 3.0 0.6 0.001
Overbite 3.9 2.2 2.8 1.1 0.020 4.9 2.8' 2.8 I.I 0.001
Buccal interdigita- 3.3 2.2 1.2 1.5 _ 0.001 4.9 2.8 0.7 1.3 0.001
tion (L)
Buccal interdigita- 4.1 2.4 I.l 1.1 0.001 5.9 2.2 1.2 1.1 0.001
tion (R)
Mandibular molar 31.9 3.2 31.8 2.9 0.750 34.3 3.5 32.0 3.3 0.004
width

T a b l e Ill. T r e a t m e n t e f f i c a c y ( p e r c e n t p o s t t r e a t m e n t v a l u e s w i t h i n a c c e p t a b l e r a n g e )
Acceptable Orthodontics
only Surgical orthodontics
range % acceptable % acceptable P value

ANB I to 5 52 81 0.004
Mandibular plane 27 to 37 42 30 0.22
Maxillary incisor
Degrees 16 to 28 30 60 0.007
Millimeters 1 to 7 64 72 0.41
Mandibular incisor
Degrees 19 to 31 48 58 0.39
Millimeters 1 to 7 73 90 0.04
Soft Tissue A-B Difference - 2 to 8 15 33 0.06
Overjet I to 4 74 95 0.06
Overbite 1 to 4 83 80 0.83
Maxillary alignment 0 to 2 52 75 0.12
Mandibular alignment 0 to 2 83 85 0.83
Buccal interdigitation (L) - 2 to 2 78 75 0.80
Buccal interdigitation (R) - 2 to 2 83 75 0.54
Crossbite Absent 100 95 0.28

achieved. The actual change occurring in a measurement dur- Determination of esthetic changes. Facial photographs
ing treatment was expressed as a percentage o f the change were-scored by a panel o f j u d g e s , consisting o f 13 orthodon-
needed to give an ideal posttreatment value (the ideal values tists, 10 orthodontic residents, 7 maxillofacial surgeons, and
are included in Table IV). The closer this was to 100%, the 7 maxillofacial surgery residents. Frontal and profile slidcs
more "successful" the treatment. for 13 surgical and 13 orthodontics-only patients were ran-
560 Proffit, Phillips, and Douvartzidis Am. J. Orthod. Dentofae. Orthop.
June 1992

Table IV. Treatment efficacy (percentage o f goal achieved)

Orthodontics only Surgical orthodontics
% goal achieved % goal achieved
Ideal
value Median Median P value

ANB 3 19 56 0.007
Mand. plane 32 - 1 -22 0.21
Max incisor
Degrees 22 - 24 61 0.004
Millimeters 4 - 47 20 0.007
Mand. incisor
Degrees 22 I - 3 0.67
Millimeters 4 4 15 0.49
Soft Tissue A-B Difference 4 7 50 0.001
Overjet 2 64 87 0.001
Overbite 2 58 66 0.11
Max alignment 0 79 79 0.80
Mand alignment 0 92 80 0.04
Buccal interdig. L 0 81 79 0.82
Buccal interdig. R 0 76 78 0.33

Negative median value ( - ) indicates that at least 50% of the cases were either overcorrected, i.e., treatment caused value to "overshoot" ideal,
or posnreatment value was farther from ideal than initial.

domly selected from those patients whose records contained y coordinate of,the maxillary incisor to 0.7 mm for the
pretreatment and posttreatment frontal and profile slides. y coordinate of point A. To estimate the accuracy o f
These slides were randomized for type of treatment and stage dental cast measurements, a random subset of 10 casts
of treatment when the phot~raphs were taken (i.e., initial or was remeasured. The intraclass correlation was greater
end of treatment). The frontal and profile slides were pre-
than 0.97 for all measurements. This technique, how-
sented simultaneously to the judges, with dual projection; four
ever, does not take into account the possible error in-
pairs were replicated for assessment of intraobserver reli-
ability. The judges were instructed to rate each face on a volved in identifying landmarks on the casts; we believe
visual analog scale of 100 mm length, with "very unattractive such errors to be small.
face" and "very attractive face" as the bipolar endpoints. The Esthetic data. O f the 34 judges, 27 were consistent
scales were digitized, and the distance from the left anchor in their ranking and rating of esthetics. The other 7 had
mark to the judge's mark was calculated for each face. statistically significant differences (p < 0.05) between
Statistical analyses. For the cephalometric and dental cast the replicate slides.
data, the Wileoxon rank sum statistic was used to compare
the treatment groups for the percentage of goal achieved mea- 2. Treatment effects
sures; the chi-square test was used to compare groups for the A major difference in the treatment of the two
acceptable range achieved measures; and an analysis of co-
groups was in the prevalence and pattern of premolar
variance with the initial measure value as the covariate was
extraction. With orthodontic treatment, 92% had ex-
used to compare the final mean values of the treatment groups.
Paired t tests were used to compare the initial and final values tractions, either o f maxillary first premolars alone or
within each treatment group. The level of significance was maxillary and mandibular first premolars. With surgical
set at 0.01 because of the number of comparisons performed. treatment, 38% had extractions, often only in the man-
The rating scores for the esthetic data were analyzed by dibular arch.
a multivariate analysis of variance with the stage of treatment Changes in dental cast and cephalometric measures
as the within subject factor and group of judges, and the type produced by treatment are displayed in Table 1I. After
of treatment as between subject facto.rs. Treatment changes treatment, all of the cephalometric and dental cast mea-
and differences between treatment groups are presented in surements except the vertical position of point A and
graphs. the maxillary incisor and the overbite and buccal in-
terdigitation were significantly different between the
RESULTS orthodontic and the surgical groups. Overjet and
1. Reliability overbite were reduced in both groups, but the reduction
Cepltalontetric and dental cast data. The method was greater in the surgical group. The surgical patients
error and reliability o f cephalometric tracing and dig- started with greater overjet and overbite than the ortho-
itization in our laboratory ranges from 0.2 mm for the dontic patients. They ended with less overjet and similar
Volume 101 (?.~ .'--/
Number 6 ~ article 561

60
9 Orthodontics
50 Surgery
t--
"~ 40
D..
"6
30
(D3

12. 10

< 20% 21-40% 41-60% 61-80% > 80%

Percentage Goal Achieved
ANB Angle

Fig. 2. Graphic representation of precentage goal-achieved data for ANB for the orthodontics-only and
surgical-orthodontic treatment groups. Note that with orthodontic treatment alone, in half tl'ie patients,
less than 20% of the goal was achieved. With surgical-orthodontic treatment, the average result was
a higher percentage achieved, but even with surgery, one-fourth of the patients had less than 20% of
the goal achieved.

overbite. Arch widths were not significantly changed p~itients in the orthodontic and surgical groups whose
by treatment in either group. m~asurements were brought into the acceptable range
In the imaxillary arch, with orthodontic treatment is shown in Table III. Note that the majority of patients
point A was retracted and moved inferiorly, just less in both the orthodontic and surgical groups had ac-
than 1 mm in each direction. With surgical treatment, ceptable overjet, buccal interdigitation, and overbite
the average anteroposterior position of point A was after treatment. The only marginally significant differ-
unchanged, but it moved downward almost as much as ence in dental characteristics was greater reduction of
with orthodontics alone. Similar but slightly greater ovcrjet with surgery (95% acceptable in the surgery
changes occurred at soft tissue point A. The maxillary group, 74% in the orthodontic group). The percent of
incisors were retracted nearly 3 mm in the orthodontic patients with acceptable ANB angles after treatment
group, but were essentially unchanged in the surgical was greater in the surgical group (81%) than in the
group. orthodontic group (52%).
In the mandibular arch, with orthodontic treatment Percent goal achieved. Descriptive statistics for per-
point B also moved posteriorly and inferiorly, i.e., the cent goal achieved are presented in Table IV. A signif-
skeletal Class II became slightly worse. The average icantly greater percentage of the "ideal" goal was
change was less than 1 mm in the A-P plane of space achieved in the surgery group for ANB, the maxillary
and more than 1 mm vertically. With surgical treatment, incisor location, the soft tissue A-B difference, and
point B moved forward and downward, nearly 4.5 mm overjet. There was no difference for several other vari-
in both directions on the average. For both groups, ables, primarily for mandibular incisor position and
changes at soft tissue point B and pogonion were similar mandibular plane angle.
to those at point B. With orthodontic treatment, the Figs. 2 to 4 illustrate the same data graphically for
lower incisor moved forward nearly 2 mm and down overjet, ANB, and buccal interdigitation. Note that for
slightly, i.e., the mandibular dentition moved forward these important variables, some patients in both groups
about 3 mm relative to the chin. With surgical treat- had excellent improvement and some had little im-
ment, the forward and downward movement of the provement, but the percentage of the sample with im-
lower incisor was similar to that of point. B and po- provement was greater with surgical treatment.
gonion, indicating that the relationship of the incisors
to the chin was essentially unchanged. The mandibular 4. Esthetic changes
plane angle increased more than 4 ~ in the surgical A multivariate analysis of variance showed that
group, but only 0.27 ~ in the orthodontic group. there were no significant differences between the oral
surgeons and orthodontists in their rating of the surgical
3. Treatment efficacy
or orthodontic subjects either before or after treatment.
Acceptable range achieved. For each dental cast and Both before and after treatment, the mean esthetic rating
cephalometric measurement value, the percentage of for the orthodontic patients was higher than the mean
 , ~,jj,,Or~r ,,,,~.Dtzm;-s,
,, and Douvartzidis Am. J. Orthod. Dentofac. Orthop.
562 June 1992

9 Orthodontics
[] Surgery

13.
"6
a) 4o

r
a)
o
~ 2o
EL

0
< 20% 21-40% 41-60% 61-80% > 80%

Percentage Goal Achieved

Over jet

Fig. 3. P e r c e n t a g e goal-achieved data for overjet. For this criterion, surgical !reatment w a s more
effective.

60
9 Orthodontics
[] Surgery
u~,50
t-
Q~

EL
"6
(~ 30
o~

~ 2o
U

EL
10

< 20% 21-40% 41-60% 61-80% > 80%

Percentage Goal Achieved
Right Buccal InterdigitaUon

60
I [ ~ Orthodontics
Surgery
u} 5O
r
Q)

13_
"6
3O
o~
t-
o 20
(3

n
10

< 20% 21-40% 41-60% 61-80% > 80%

Percentage Goal Achieved
Left Buccal Interdigitation

Fig. 4. Percentage-goal achieved data for (A) right and (B) left buccal'interdigitation. Surgical and
orthodontic treatment were about equally effective in correcting the buccal occlusal relationships.
 Volume 1 0 l
Number 6
Special article 563

Surg PaL - Pre-Tx

G'}
"0 S u r g Pat. - P o s t - T x
-i
"~ 80

Ortho Only - Pre-Tx

. .....--.~"'"'~. ~ ~ Ortho Only - Post-Tx

e-

~176 .......
.o_ 4o

r-

W 20
r

i .r ~ r I i I i
~ o
2 3 4 5 6 r 8 9 1o 11 12 13
Subject Number
ESTHETIC RATINGS

Fig. 5. Esthetic ratings before and after treatment. Note that the esthetic ratings for the oi'thodontics-
only patients were higher than those for the surgerical patients before treatment. Surgical-orthodontic
treatment produced an improvement in the esthetic rating for most of the patients, particularly those
with the lowest ratings initially; orthodontic treatment had little effect.

rating for the surgical patients (p < 0.001). The es- Because the treatment approaches were so different,
thetic ratings for the individual surgical and orthodontic different treatment effects,would be expected, and these
patients (mean rating for all judges) are shown in a .were observed. With orthodontic camouflage, one
graph in Fig. 5. Within each group, the patients are would expect the upper incisors to be retracted and the
arranged in order of increasing esthetic ratings, i.e., lower incisors to be proclined. In the orthodontic treat-
the least attractive patient in each group is subject 1, ment cases studied here, the clinician's objective in
and the most attractive is subject 13. Note that esthetic nearly every instance was to retract the upper incisors
changes from orthodontic treatment were small and bodily and to minimize forward movement of the lower
were as likely to be negative as positive. Within the teeth; but in many patients the upper incisors tipped
surgical group, improvements in the esthetic rating were lingually more than they were bodily retracted, and
noted for 11 of the 13 patients, and the improvement overjet was corrected as much by. forward movement
was greatest in the patients with the lowest ratings of the lower incisors as by retraction of the upper in-
initially. cisors. Class II elastics were employed in most of the
orthodontic patients. As a side effect of the elastics, a
DISCUSSION
downward rotation of the anterior maxilla, upper and
These results illustrate the different effects of ortho- lower incisors, and chin would be expected, and this
dontic and surgical treatment approaches to skeletal also was observed.
Class II problems in adults. Some caution is required With surgical treatment, the focus was advancement
in generalizing to all skeletal Class II patients: (1) The of the mandible to correct the mandibular deficiency,
patients were selected by clinicians for their treatment, not retraction of maxillary incisors to camouflage it.
rather than being randomly assigned; and (2) over time, Mandibular advancement surgery alone is used for pa-
the number of patients receiving surgical treatment has tients who have normal or short anterior face height
increased, and the number receiving orthodontic cam- initially. Long-face Class II patients receive a combi-
ouflage has declined, as clinical standards have nation of superior repositioning of the maxilla and man-
changed. To some extent, the two factors tend to bal- dibular advancement, and so were not included in this
ance each other. Clinicians now recommend surgical sample. It therefore is not surprising that on the average,
treatment for some patients who probably would have the chin was moved downward as much as forward in
received camouflage orthodontics a decade ago, which the surgical patients studied here.
increased the chances of finding cases of comparable These surgical patients all were treated before 1986,
severity in both groups although no attempt was made and all had conventional maxillomandibular fixation
to match the two groups for severity of initial maloc- (MMF) rather than rigid internal fixation (RIF). With
clusion or skeletal deformity. MMF, the elasticity of the stretched soft tissues pro-
564 r ,,jj,"r^:C't,""
""t,'~ and Dourartzidis Am. J. Orthod. Dentofac. Orthop.
June 1992

duces an effect similar to that of Class II elastics during ularly probable when the lower incisors have been
fixation. This probably explains the downward move- moved too far forward, and the data suggest that this
meat of upper incisors that occurred in the surgical pa- may have occurred in many of the camouflage patients.
tients. For many of the surgical patients, the lower in- A major factor in stability after mandibular advance-
cisors were retracted during the presurgical orthodon- ment is patient selection: stability is enhanced by ro-
tics, and this probably masked the forward movement tating the mandible at surgery so that the mandibular
of lower teeth that is known to occur during MMF. t'- plane angle increases. ~3 Our sample included no sur-
At the end of treatment, the surgical group differed gical patients with the "wrong way" rotation of the
from the orthodontic group in two major ways: the mandible that is associated with relapse. At this point,
surgical patients had a more ideal skeletal relationship, there are no data to suggest that with competent treat-
with the mandible further forward and a more protrusive ment, stability is a major difference between surgical
profile, and they had maxillary and mandibular incisors and orthodontic patients.
in more ideal positions relative to their respective bony The risks and costs of the two treatment approaches
bases. In both groups, the buccal interdigitation of the must be balanced against the benefits when a treatment
teeth and the overbite were nearly ideal, and although decision is being made for an individual patient. The
overjet was greater in the orthodontic group, it was greatest risk of mandibular advancement surgery is de-
within the normal range. Therefore, as expected, the creased sensation in the lower lip after surgery. About
orthodontic treatment corrected the occlusion by dis- 50% of patients who undergo mandibular ramus oste-
placing the teeth to camouflage the skeletal discrepancy. otomy report some decrease in sensation, ~4 but ahnost
The surgical patients experienced greater esthetic im- never is this severe enough that the patient regrets hav-
provemen t than the orthodontic patients, but the ing undergone the treatment, t5 The greatest risk of
result was to bring the surgical patients up to tlie orthodontic camouflage is severe resorption of the max-
level at which the orthodontic patients Started illary incisor roots. Kaley et al. 16have recently reported
treatment. that the risk of severe resorption is 20 times greater
T h e important clinical questions would b e whether than usual when the maxillary incisor roots are torqued
the camouflage was successful in terms of being es- against the lingual cortical plate, a movement that is
thetically acceptable, and whether the greater improve- particularly associated with maximum retraction of pro-
ment produced by surgery was worth the greater cost truding incisors in patients with Class 11 malocclusions.
and risk of surgery. In that regard, the difference in the There is no doubt that surgical-orthodontic treatment is
esthetic ratings of these patients before treatment is considerably more costly than orthodontics alone, be-
important. Although some of the orthodontics-only cause of the surgical and hospitalization costs.
cases go back into the early 1970s, it is clear that the From the results of this study and our analysis of
clinicians selected patients for orthodontic treatment the other factors involved, we suggest that camouflage
who had reasonable facial esthetics, and that they were treatment is most effective in patients who have rea-
successful in correcting the occlusion without produc- sonably good facial esthetics initially. The data suggest
ing detrimental effects esthetically. The patients se- that orthodontic treatment alone can be accomplished
lected for surgical treatment had poorer facial esthetics without detriment to facial esthetics in these patients.
initially. It therefore appears that the clinicians favored The more severe the mandibular deficiency and the
surgery for patients with low esthetic rankings before greater the overjet (and the poorer the facial esthetics),
treatment, who might be handicapped by psychosocial the more likely it is that the patient would benefit
discrimination related to their appearance. Better facial enough from surgery to make it worthwhile. These sug-
esthetics often are observed in patients with Class II, gestions should be interpreted with the potential biases
Division 2 malocclusion than Class II, Division 1, and inherent in such a retrospective observational study in
it is not coincidence that 40% of the camouflage patients mind. Although the outcome comparisons are likely
in this study had Class II, Division 2 malocclusion confounded by the selection of treatment by clinician
initially. decision, it is highly unlikely that in the current clinical
Long-term follow-up of the patients in this sample atmosphere a randomized clinical trial would be judged
is not yet available. From other studies, it is known ethical. A comparison of the relative efficacy of these
that there are relapse tendencies after both orthodontic two treatment approaches will probably require the ac-
and surgical treatment, which can be controlled by care- cumulation of information from observational studies
ful technique during treatment and by o r t h o d o n t i d Y e - such as this one.
tention. Relapse after orthodontic treatment is partic- We thank Debora"Price for technical assistance.
Volume I01 Special article 565
Number 6

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1. Proffit WR, Phillips C, Dann C. Who seeks surgical-orthodontic dibular incisor alignment. AM J ORntOD 1975;68:554-63.
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Reprint request to:
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Dr. William R. Proffit
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of Orthodontics, 1988.

AAO MEETING CALENDAR

1993--Toronto, Canada, May 15 to 19, Metropolitan Toronto Convention Center
1994--Orlando, Fla., May 1 to 4, Orange County Convention and Civic Center
1995--San Francisco, Calif., May 7 to 10, Moscone Convention Center
(International Orthodontic Congress)
1996--Denver, Colo., May 12 to 16, Colorado Convention Center
1997--Philadelphia, Pa., May 3 to 7, Philadelphia Convention Center
1998--Dallas, Texas, May 16 to 20, Dallas Convention Center
1999--San Diego, Calif., May 15 to 19, San Diego Convention Center