CLINICAL REVIEW C

Considerations for orthognathic surgery during

growth, Part 2: Maxillary deformities
Larry 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 surgical
correction. In some cases, certain functional, esthetic, and psychosocial factors may necessitate early
surgical intervention. Although there is extensive literature on the effects and stability of orthognathic surgical
correction of maxillary deformities in adults, the same is not true for the pediatric and adolescent growing
patient. Not much is known about the predictability of orthognathic surgical procedures performed during
growth or the effects such procedures have on subsequent facial growth. There is always the possibility that
secondary corrective procedures may be required after the initial corrective surgery. This article presents
recommendations based on available research and personal clinical experience in surgical correction of
maxillary deformities in growing patients. The common maxillary dentofacial deformities, age considerations,
and surgical alternatives and sequencing are presented. The treatment of mandibular deformities is
addressed in Part 1 of this article. (Am J Orthod Dentofacial Orthop 2001;119:102-5)

S
urgical management of the growing patient
remains controversial. The published literature
has little to say on the appropriate timing of var-
ious maxillary surgical procedures in growing patients
or the effects of surgery on postoperative maxillary
growth. Growing patients can present to the clinician
with maxillary dentofacial deformities that require
combined 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 by
about the age of 14 years.2-8 Normal vertical maxillary
growth, however, continues into adulthood.2,6,8 Serial
clinical, radiographic, and dental model analyses are
very helpful in determining the rate and direction of
facial growth. Accurate diagnosis, proper treatment
planning, and appropriate age sequencing of proce-
dures are important steps in achieving quality out-
From the Baylor University Medical Center and the Department of Oral and
Maxillofacial Surgery, Baylor College of Dentistry, Texas A & M University
System, 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.
comes for orthognathic surgery in growing patients.
Coexisting mandibular deformities, dental ankylosis,
and temporomandibular joint (TMJ) pathosis must also
be assessed and properly managed.
This article, Part 2, outlines our recommendations
for combined surgical-orthodontic management of the
growing patient with dentofacial deformities. In Part 1,
we reviewed management of patients with mandibular
deformities. In this part we present common maxillary
dentofacial deformities and considerations for surgical
management of these deformities in the growing
patient who has normal mandibular growth and no
dental ankylosis or TMJ pathosis. We will also present
recommendations for correction of combined maxillo-
mandibular deformities with double-jaw surgery in
growing patients.
MAXILLARY DEFORMITIES
Maxillary hypoplasia
Maxillary hypoplasia is defined as deficient maxil-
lary development in the AP, transverse, and/or vertical
dimensions. Because the cause of this deformity is
deficient maxillary growth, normal growth cannot be
expected after surgery. Correction of AP or vertical
deficiencies during growth will result in recurrence
of the Class III skeletal relationship as the mandible

Reprint requests to: Larry M. Wolford, 3409 Worth Street, Suite 400, Sammons continues to grow normally. Earlier surgery may be
Tower, Dallas, TX 75246. indicated if significant functional, esthetic, and psy-
Submitted, February 2000; revised and accepted, May 2000. chosocial impairments exist. When treating these cases
Copyright © 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/1/111400 during growth, the surgeon may choose to overcorrect
doi:10.1067/mod.2001.111400 the maxilla and allow the growing mandible to develop
102
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 119, Number 2
A Fig 2. Horseshoe osteotomy maintains attachment of
B in the redevelopment of a skeletal Class III deformity.
Fig 1. Le Fort I osteotomy with segmentalization allows
repositioning of the maxilla in all 3 planes of space. A, Max-
illary step osteotomy modification. B, Rigid fixation and
grafting areas of bone gaps with autogenous or synthetic
bone grafts (shown as positions a, b, and c), is the most pre-
dictable method for stabilization of the Le Fort I osteotomy.
into it. If surgery is performed during growth, the
patient and parents must be informed that future
surgery will probably be necessary.
Treatment modalities
Le Fort I maxillary osteotomy. The Le Fort I
osteotomy (Fig 1), when performed during growth,
effectively inhibits further anterior growth of the max-
illa.9,10 Vertical maxillary growth, however, can be
Wolford, Karras, and Mehra 103
horizontal palate to vomer and lateral nasal walls. Only
the dentoalveolus is mobilized.
expected to continue postoperatively at the same rate as
before surgery.10-13 The use of rigid fixation and appro-
priate grafting with either porous block hydroxyapatite
(Interpore 200; Interpore International, Irvine, Calif) or
autogenous bone will maximize the quality of the sur-
gical outcome for all types of maxillary osteotomies.
Horseshoe maxillary osteotomy (dentoalveolar
osteotomy). With the horseshoe maxillary osteotomy
procedure (Fig 2), the nasal septum remains attached to
the stable palate, and only the dentoalveolar structures
are mobilized.14 Thus, some AP maxillary growth may
be expected to occur postoperatively. The overall
growth rate, however, will remain deficient and result
No studies are available on growth after maxillary den-
toalveolar osteotomies for this type of deformity. The
maxillary dentoalveolar osteotomy is technically much
more difficult to perform in this patient type.
For both of the techniques described here, the most
predictable outcome can be expected if performed near to
or 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 cessation
of mandibular growth. Severe functional or psychosocial
factors may indicate earlier treatment. Either procedure
can be performed before the patient reaches age 10, pro-
vided sufficient space exists above the apices of the
developing permanent teeth to place the osteotomies and
apply rigid fixation. Although vertical maxillary growth
is generally unaffected by this procedure, damage to
developing tooth roots may result in dento-osseous anky-
losis and localized dentoalveolar growth impairment.
104 Wolford, Karras, and Mehra
Surgically assisted rapid palatal expansion. Surgi-
cally assisted rapid palatal expansion usually involves
Le 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. There
are no studies available regarding growth after this pro-
cedure. In fact, this procedure may be contraindicated
in most growing patients because the midpalatine
suture has not normally closed, thus, the less invasive
nonsurgical orthodontic/orthopedic expansion is possi-
ble. Moreover, postoperative AP maxillary growth may
be inhibited by this procedure if the nasal septum is
separated from the palatal bone.
This procedure is rarely indicated in patients who are
less than 15 years of age, but it can technically be done
after complete root development and full eruption of the
teeth adjacent to the vertical interdental osteotomy.
Maxillary protrusion
Maxillary protrusion is defined as excessive AP
growth of the maxilla, resulting in a Class II skeletal
relationship. No studies exist on facial growth after
surgery in growing patients. Postsurgical growth may
be dependent on the procedure selected to correct the
deformity, as discussed next.
Treatment modalities
Le Fort I maxillary osteotomy. The Le Fort I
osteotomy (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 and
vertical maxillary growth present, a Class III skeletal
and occlusal relationship may develop after surgery.
Horseshoe maxillary osteotomy (dentoalveolar
osteotomy). With the horseshoe maxillary osteotomy
(Fig 2), the nasal septum remains attached to the hard
palate; therefore, AP maxillary growth may not be inhib-
ited as it is with the Le Fort I osteotomy.14 Although no
postsurgical growth studies have been performed on this
type of patient, this may be the technique of choice for
maxillary repositioning in the growing patient with AP
maxillary hyperplasia. It may offer the best potential for
continued 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 in
boys, particularly if normal or deficient vertical maxil-
lary growth is present. The effects of these procedures
on subsequent growth for this deformity have not been
studied. However, better postsurgical growth may be
expected with the horseshoe osteotomy. Patients with
coexisting vertical maxillary excess can be treated at an
earlier age with either technique (see section on vertical
American Journal of Orthodontics and Dentofacial Orthopedics
February 2001
maxillary hyperplasia). In cases with severe functional
or psychosocial problems, the procedures can be per-
formed when the patient is 8 or 9 years old, provided
sufficient space exists above the apices of the develop-
ing permanent teeth to place the osteotomies and fixate
the maxilla in its new position. Damage to developing
tooth roots may result in dento-osseous ankylosis and
localized dentoalveolar growth impairment.
Vertical maxillary hyperplasia
Also known as vertical maxillary excess, vertical
maxillary hyperplasia is defined as an excessive vertical
growth of the maxilla and may or may not include an
anterior open bite deformity. This deformity can be cor-
rected during growth with predictable results. Vertical
maxillary growth can be expected to continue postoper-
atively at the same rate as before surgery.10-14 While the
maxilla continues to grow downward after surgery and
the mandible continues to grow at a normal rate, the
postoperative occlusal result should be maintained. The
vector of facial growth will continue to be downward
and backward. AP maxillary growth cannot be expected
after surgery if a Le Fort I osteotomy is used, but it may
be preserved with a horseshoe osteotomy.
Treatment modalities
Le Fort I maxillary osteotomy. Although the Le Fort
I maxillary osteotomy (Fig 1) inhibits further anterior
growth 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 before
surgery. In patients with normal mandibular growth,
the occlusion should remain stable.10-13
Horseshoe maxillary osteotomy (dentoalveolar
osteotomy). AP maxillary growth may not be inhibited
as 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 if
surgery is performed after age 14 in girls and age 16 in
boys. If done at an earlier age (12 years in girls and 14
years 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 than
would occur if surgery was not performed. The occlu-
sion will usually remain stable. Mogavero et al10
demonstrated harmonious growth between the jaw
structures when surgery was performed at a younger
age. The horseshoe osteotomy, by keeping the nasal
septum attached to the horizontal palatal plate, may
allow some AP maxillary growth. However, this has not
been clinically studied with rigid fixation. Either maxil-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 119, Number 2
lary procedure can be performed before the patient
reaches age 10, provided sufficient space exists above
the apices of the developing permanent teeth to place
the 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 with
predictable growth after surgery. Orthognathic surgery
for the correction of vertical maxillary hyperplasia can
be performed with corrective mandibular surgery for
retrognathia or prognathism, if the preoperative rate of
mandibular growth is normal, and the TMJs are
healthy.10 The Le Fort I osteotomy will inhibit further
AP maxillary growth while allowing vertical maxillary
growth to continue.
In cases involving mandibular prognathism sec-
ondary to active condylar hyperplasia, surgery involv-
ing high condylectomy will arrest the pathologic
growth and can be combined with maxillary and
mandibular osteotomies with predictable results,
regardless of the rate of maxillary growth.14 The high
condylectomies should be performed first, and the
articular disk should be repositioned over the remain-
ing condylar head. This is followed by routine double-
jaw surgery, as planned preoperatively. When properly
performed, the high condylectomies prevent further AP
growth of the mandible. In the presence of vertical
maxillary excess, the vector of facial growth will be
downward and backward. Surgical treatment of other
combinations of deformities may not be predictable
and should be performed after cessation of growth.
CONCLUSIONS
The type of facial deformity present and the specific
growth vectors of the patient will affect the surgical out-
come and must be carefully assessed before surgery. The
patient and family must understand the expected results,
potential risks, and possible complications that can occur
as a result of early surgical intervention. Factors such as
the presence of disproportionate mandibular growth
(excessive or deficient) and coexisting TMJ pathosis can
significantly affect postsurgical growth and treatment out-
comes and must be identified and treated appropriately.
Some basic considerations that must be kept in mind
while contemplating surgical correction of maxillary
dentofacial deformities in the growing patient include:
1. Early surgical correction may be beneficial in
some patients for functional, esthetic, and psy-
chosocial reasons.
Wolford, Karras, and Mehra 105
2. The TMJs must be functionally healthy and stable
for predictable surgical results.
3. The Le Fort I osteotomy eliminates further AP
growth 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 downward
and backward direction.
5. Double-jaw surgery may be predictably performed
in selected instances for specific jaw deformities.
The material presented in this article should serve
as a guide for management of maxillary dentofacial
deformities in the growing patient who requires cor-
rective orthognathic surgery. These recommendations
are in no way meant to be hard and fast rules; each
patient should be diagnosed and treated individually
with a tailored orthodontic and surgical treatment plan.
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