CASE REPORT

Advancement genioplasty: An important part of combination surgery in black American patients

Andrew M. Connor, D.D.S., M.S.,* and Farhad Moshiri, D.M.D., M.S.**
Lancaster, Ohio, and St. Louis, MO.

ecent advances in orthognathic surgery have permitted many patients of all races with dentofacial deformities to undergo effective correction. Fonseca and Klein evaluated black American women and concluded that the maxilla and mandible were more protrusive, the middle facial height appeared shorter, and the lower facial height was longer in the black sample than in a comparable white sample. In 1977, Deloach3 performed an interesting study on North American black women ranging in age from 18 to 41 years. The subjects photographs were evaluated by black women of the same age range. This selfassessment demonstrated a significant degree of disfavor for the Class II, extremely bimaxillary protrusive profile, and the Class III type face. Furthermore, in the black subjects, the judges preferred profiles resembling those of white subjects. Thomas7 published a similar study on North American black women aged 18 to 41 years. These subjects included women throughout the United States with all varieties of profiles. They were evaluated by black and white orthodontists by ranking the women from most pleasing to least pleasing. The orthodontists evaluations included lip prominence (Ricketts E line, Steiners S line) and facial profile angles (nasofrontal, nasolabial, and mentolabial). For the pleasing category, both black and white orthodontists selected a straight profile with only slight lip protrusion. In these subjects the upper lip was on, or slightly forward of, the E line with the lower lip on, but forward of, the upper lip. Also, the orthodontists preferred profiles in which the nasofrontal, nasolabial, and mentolabial angles had

similar relationships to each other. For example, the nasofrontal angle of the subjects ranked as pleasing was greater than the mentolabial angle and exceeded the nasolabial angle. The explanation given for selecting the flatter profiles was as follows: Caucasian features are considered to be more attractive than Negroid features in American society.7 Thomas also noted that the least pleasing profiles were the most protrusive ones. However, the white orthodontists comprised the majority in this selection. Lay persons (black and white) agreed with this decision; therefore, Thomas concluded that the least pleasing profile overall is one with severe bimaxillary protrusion. Our findings are also in agreement with that of the literature. The surgical analysis used for these two cases was described in a previous publication. 5 Studies2*4have shown that black Americans more often display a convex profile than white Americans. Therefore, if a cepholometric analysis of black patients indicates combination surgery, the profile can be improved (straighter) if the chin is augmented. The advancement genioplasty is an excellent procedure to establish a more pleasing profile in bimaxillary protrusion patients. CASE REPORTS
CASE 1 (Figs. 1 through 6)

A lZyear-old black male patient was referred for treatment with ClassII malocclusion. Clinical, cephalometric, and model analysesindicated the following:
Horizontal considerations

The review of tbe literature was part of a thesis submitted by the senior author in partial fulfillment of the requirements for the degree of master of science, Department of Orthodontics, Washington University, St. Louis. The two cases presented in this article were treated by the joint efforts of the graduate residents, Department of Orthodontics and Maxillofacial Surgery, Washington University, St. Louis; the junior author was chairman, Department of Orthodontics. *In private practice, Lancaster, Ohio. **Orthodontic Consultant for Ortbognathic Surgery Rogram, Department of Orthodontics, University of Louisville; in private practice, St. Louis, MO.

Maxillary protrusion with excessivemaxillary length ClassII, Division 1 malocclusion with increasedoverjet Flared maxillary incisors Protrusiveupper lip Acute nasolabial angle Short throat length with deficient chin
Vertical considerations

Lip incompetency Excessiveexposure of gingiva on smiling Increased overbite

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Fig. 1, A and B. Case 1, Facial appearance of patient before orthognathic surgery. Fig. 2, A and B. Case 1. Facial appearance of patient after orthognathic surgery.

Transverse considerations Wide maxilla Increased buccal overjet Treatment consisted of presurgical orthodontics inedgewise brackets. Complete volving 0.022 x 0.025inch leveling and alignment of the maxillary and mandibular arches were achieved by extrusion of the posterior segments. At this point in the treatment process, the maxillary first premolars were extracted at the time of the surgical procedure

along with a three-piece LeFort I maxillary ostectomy. The anterior maxilla was set up and back; the posterior maxilla was set up, advanced, and constricted. The mandible was autorotated and an advancement genioplasty was performed. The active orthodontic treatment was continued after the removal of the intermaxillary fixation to achieve the final occlusal result. Retention consisted of a tooth positioner followed by a maxillary removable and mandibular fixed retainer.

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Fig. 3, A and B. Case 1. Skeletal Class II, Division 1 deep bite malocclusion before treatment.

Fig. 4, A and B. Case 1. Occlusion after treatment.

Fig. 5. Case 1. Silhouettes demonstrate facial change.

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W. T.
LeFort I osteotomy Ant. max. up 3mm Ant. max. back 3mm Right post. max. up 3mm Right post. max. advance 3 mm Left post. max. up 2mm Left post. max. advance Post. max. constrict 4m Advancement geniopla

Fig. 6. Case 1. Composite cephalometric up period.

tracings show skeletal stability during postoperative follow-

Fig.

7, A and 8. Case 2. Facial appearance of patient before orthognathic surgery.

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Fig.

8, A and

6. Case

2. Facial

appearance

of patient

after

orthognathic

surgery.

Fig. Fig.

9, A and B. Case 10, A and B. Case

2. Class

III open after

bite malocclusion treatment.

before

treatment.

2. Occlusion

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Fig. 11. Case

2. Silhouettes

show

the effect

of the orthognathic

surgical

approach

on the facial

profile.

M. L. Le Fort I osteotomy max up 6mm max setback 5mm

Fig.

12. Case

2. Composite

cephalometric

tracings

show

presurgical

and pOstsUrgiCal

changes.

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CASE 2 (Figs. 7 through 12)

Am. J. Orthod. Dentofac. Orthop. February 1988

A 17-year-old black female patient was seen initially for treatment of a dentofacial deformity. Clinical, cephalometric, and model analyses indicated the following: Horizontal considerations Bimaxillary protrusion Flared maxillary and mandibular incisors Skeletal and dental Class III with anterior crossbite Excessive maxillary and mandibular length Acute nasolabial angle Long throat length with deficient chin Vertical considerations Excessive facial height Lip incompetency Excessive exposure of gingiva on smiling Open bite Transverse considerations Constricted maxilla with posterior crossbite Presurgical orthodontic treatment involved partial leveling and alignment of the maxillary arch without extractions. The mandibular arch was aligned also and completely leveled without extractions. At this point in the treatment process, a three-piece LeFort I maxillary ostectomy was performed. The posterior maxilla was set up and expanded, the anterior maxilla was set up, the entire maxilla was set back, and the mandible was autorotated and set back by an intraoral vertical ostectomy. An augmentation genioplasty and vertical reduction of the chin finished the surgical procedure. After release of the intermaxillary fixation, the active orthodontic treatment was continued for detailing of the occlusion. A tooth positioner was used as initial retention, replaced eventually by removable retainers.

However, studies3a7have reflected displeasure for this profile from black men and women plus a desire for a flatter, more Caucasian-like profile. Therefore, when
correction of a dentofacial deformity involves combi-

nation orthognathic surgery, advancement genioplasty should be considered to improve the profile. This article comprised case reports of two black American patients, both demonstrating a skeletal discrepancy that required orthognathic surgery for correction. Both cases involved a comprehensive surgical analysis and treatment plan. The treatment included combination surgery with advancement genioplasty.
Moshii F. Orthognathic surgery norms for American black patients. AM J ORTHOD 1985;87:119-34. 2. Cotton WN, Takano WS, Wang WW, Wylie WL. Downs analysis applied to three other ethnic groups. Angle Orthod 1951;21: 213-20. 3. Deloach N. Soft tissue profile of North American blacks, a selfassessment[M.S. thesis]. University of Detroit, 1977.
4. Sushner NI. A photographic study of the soft-tissue profile of the Negro population. AM J ORTHOD 1977;72:373-85. 5. Moshii F, Jung S, Sclaroff A, Marsh J, Gay D. Surgical diagnosis and treatment planning: a visual approach. J Clin Orthod 1982;16:37-59. 6. Fonseca RJ, Klein WD. A cephalometric evaluation of American Negro women. AM J ORTHOD 1978;73:152-60. 7. Thomas R. An evaluation of the soft-tissue facial profile in the North American black woman. AM J ORTHOD 1979;76:84-94. Reprint requests to: Dr. Farhad Moshiri 1265 Graham Rd., Suite C Florissant, MO 63031 REFERENCES 1. Connor AM,

DISCUSSION

The literature6 shows a prevalence of bimaxillary protrusion and a convex profile in American blacks.