J Oral Maxillofac Surg

53:579-587, 1995

Orthodontic Camouflage Versus

Orthognathic Surgery in the Treatment of
Mandibular DeficiencY
PAUL M. THOMAS, DMD, MS*
The Class I1 relationship is the most prevalent subclassification of malocclusion.1 Recognizing the limitations of this description, epidemiologists have formulated indices and scales for use in public health studies.
The results of these surveys suggest that 15% to 20%
of the teenage population have an overjet of 6 mm or
greater. Although such studies do not directly address
this issue, it is likely that many of these individuals
have an abnormality in jaw size or position as a contributing factor. ~
Motivations for seeking correction of this imbalance
generally include a mixture of functional and psychosocial concerns, including self-image as influenced
by dental and facial esthetics. It has been suggested
that Class II malocclusion may lead to dental attrition
and periodontal trauma as well as problems with
speech and chewing. Despite conflicting and contradictory evidence, some clinicians still consider Class II
malocclusion a contributing factor in temporomandibular disorders. 3'4 In a psychosocial context, research
has shown that malocclusion affects employability,
interpersonal relationships, and, accordingly, selfimage. 5

of favorable growth and dentoalveolar manipulation

can lead to reasonable results in the appropriate patient. 6
There are two treatment options for postpubertal individuals seeking correction; orthodontic camouflage
and surgical advancement of the mandible in conjunction with orthodontics. Camouflage, or orthodontic
compensation of Class II malocclusion, is one of the
more common treatment strategies used in clinical
practice. The maxillary anterior teeth are retracted and
their counterparts in the lower arch proclined in an
attempt to reduce overjet and establish a Class I canine
relationship. The extraction of teeth, typically first premolars, is necessary in one or both arches to eliminate
crowding and provide room for compensation. Surgical
treatment involves preoperative orthodontics to properly position the teeth in the respective jaw and an
operative procedure to correct mandibular position,
followed by finishing orthodontics for occlusal detailing. The focus of this discussion will be on these two
approaches.
Although there would appear to be ample justification for correcting Class II malocclusions; previous
experience suggests that there are flaws in the process
of selecting treatment options. There is generally little
disagreement when considering patients at the extremes of the classification. Mild Class II problems can
be orthodontically corrected and severe discrepancies
require orthognathic surgery. Problems seem to occur
when the patient falls in a "grey zone" and might be
treated by either option. Needless to say, both orthodontic camouflage and surgery have been used inappropriately in the past. A review of patients seen from
1984 to 1987 in the University of North Carolina Dentofacial Program indicated 20% of those seen had previous orthodontic treatment and were dissatisfied with
the outcome. 7 The majority of these patients had undergone camouflage treatment for Class II malocclusions.
Likewise, mandibular advancements performed to correct moderate overjet have sometimes exposed the individual to greater morbidity, while producing negligible facial change. A primary goal of this article is to
identify factors that influence both the decision-making

Treatment Alternatives
Four options exist for those individuals seeking correction of increased overjet. Patient concerns and clinical findings are key factors in narrowing the choice.
Treatment should not be considered if the outcome is
unlikely to meet patient expectations, or if local factors
such as dental or periodontal health indicate a prosthetic alternative. Growth guidance may be suggested
for the prepubertal patient having a favorable growth
pattern. Although there is mounting evidence that the
skeletal impact is negligible clinically, a combination

* In private practice.
Address correspondence to Dr Thomas: 5501 Fortune's Ridge Dr,
Suite H, Durham, NC 27713-9355.
1995 American Association of Oral and Maxillofacial Surgeons
0278-2391/95/5305-001553.00/0

579

580

ORTHODONTIC CAMOUFLAGE VS ORTHOGNATHIC SURGERY

process and assessment of outcome. Recognition of

these factors should help with the selection of a treatment option that addresses patient concerns while considering a favorable cost (risk) versus benefit ratio.
Because this discussion and the companion article have
been written in the context of point/counterpoint, emphasis will be placed on the efficacy of orthodontic
camouflage.

The Decision-Making Process

DIAGNOSIS AND PLANNING

The treatment planning process is well-known to

most contemporary clinicians and generally follows a
method suggested by Ackerman and Proffit more than
20 years ago. Using a scheme of Venn diagrams to
expand on the traditional Angle classification, they
identified five major characteristics of malocclusion
that were descriptive in three dimensions. 8 They also
adapted Lawrence Weed's problem-oriented medical
diagnosis for use in an orthodontic context. 9 Following
this method, data collection includes patient interview,
clinical examination, radiographic studies, standardized photographs or slides, and dental models. This
information is analyzed to produce a list of findings
that may be prioritized in the context of patient concerns according to severity. Treatment alternatives,
orthodontic camouflage, and surgery in this case are
developed with consideration for the ability of each to
address patient concerns with maximum efficiency and
minimum morbidity. This process may include treatment simulation using computer imaging and model
surgery or orthodontic setup. Accepting the limitations
of such simulation, it remains the best means available
to explore options and communicate potential outcome
to the patient and family.
REVIEWING THE OPTIONS

A key part of the preliminary decision-making process involves an unbiased explanation of the alternatives and the associated cost and risk versus benefit
with each. Intellectual honesty is paramount during
both the initial encounter and the subsequent discussion of alternatives. Because it is natural for clinicians
to seek solutions in the context of training and experience, care must be taken to avoid inappropriate influence on patient perceptions and attitudes. This may be
especially difficult for the orthodontist presented with
a patient who is initially expecting limited orthodontic
treatment only to discover there is a significant underlying skeletal imbalance. If there is some uncertainty
regarding alternatives at the initial visit, diagnostic records should be suggested and definitive answers deferred. A sensitive, carefully structured, global discus-

sion can be used to introduce concepts without

committing to a course of action.
If surgery has been discussed at the initial visit and
is a viable option, it is ideal to have the surgeon present
for the subsequent treatment explanation or to arrange
for a timely follow-up consultation. Because treatment
strategies are significantly different for each option,
the individual contemplating treatment must be given
enough information to make an informed decision before starting clinical care. When appropriate, outcome
probabilities should be discussed based on the scientific literature and personal experience. Questions such
as "what would you do?" should be answered carefully by restating the advantages, disadvantages, and
probable outcome with the option in question. Treatment simulations are valuable communication adjuncts, but should be used carefully to avoid creating
unrealistic expectations.
FINANCIAL CONCERNS

The cost of care is frequently a concern, and must

be fully discussed before treatment. This is especially
true given the escalating hospital costs and diminishing
insurance coverage for orthognathic surgery. Poor
communication may result in the orthodontist unilaterally preparing a patient for surgery only to learn thirdparty coverage has changed or is nonexistent. Because
the goals of orthodontic preparation for surgery are
generally the opposite of camouflage, this may leave
the individual with an orthodontic result that has exaggerated the malocclusion.

Factors Affecting Outcome

The evaluation of treatment outcome can be elusive,
but is typically done using a combination of subjective
and objective criteria. Although there are objective
analyses to scrutinize functional change as well as the
accuracy and stability of the outcome, the assessment
of facial attractiveness and body image tends to be less
structured. In addition to feedback from the clinicians
involved, other psychosocial factors such as self-perception and peer reaction shape patient's attitudes.
It is not unusual to see diversity of opinion. A clinician may determine the morphologic and functional
result to be excellent, only to have it perceived as less
than satisfactory by the patient. Likewise an individual
may be thrilled with a result considered only fair by
the treating orthodontist and surgeon. Differences in
perception between surgeons, orthodontists, and laypeople have been shown to exist, and further complicate the issue. In a study of facial improvement, Dunlevy et alm found that surgeons tended to favor more
prominent chins and larger anterior-posterior change
when compared with panels composed of the laypeople
and orthodontists. This bias may affect individual pa-

PAUL M. THOMAS

tient evaluation and is likely to be an influence in

research involving outcome assessment.
PSYCHOSOCIAL FACTORS AND ESTHETIC CONCERNS

There is considerable research indicating that dental

and facial esthetic concerns are major motivating factors
for those seeking treatment) H2 The type of treatment
selected (surgery or orthodontic camoflage) is related
more to body image or self-perception than morphometric discrepancy. Bell et al ~3 found that patients who opt
for surgery tend to view themselves as being at the
extremes of the profile classification. Paradoxically, objective analysis could not distinguish between their malocclusion and that of patients selecting orthodontic camouflage. These findings were further supported in a
study of facial attractiveness involving females who
have Class II malocclusions. ~4Those selecting a surgical
option tested as having more indicators of global psychologic stress and problems with self-esteem. As in
Bell's study, conventional cephalometric analyses could
not discriminate between patients opting for surgery
versus those selecting orthodontic camouflage. The bottom line would seem to be that the psychosocial factors
of self-perception and body image are of significance
in selecting a course of treatment.
FUNCTIONAL AND MORPHOMETRIC FACTORS

Although morphometric analysis is a poor indicator

of which patient will select surgery versus orthodontic
camouflage, it does provide useful insight into the likelihood of correction with each option. Previous efforts
at establishing numerical guidelines have been directed
primarily at defining the limits for application of a
given treatment option. For example, the "envelope
of discrepany" described by Proffit and Ackerman 15
graphically illustrates their best estimate of the maximum change possible with growth guidance, orthodontic camouflage, and orthognathic surgery. The description is limited to the sagittal and vertical dimension
changes in incisor position, without concern for other
modifying factors. Although this concept is useful to
describe the extremes, it lacks the detail necessary for
decision-making in borderline patients. Additional recommendations have been made for patients with Class
II malocclusions beyond the adolescent growth spurt.
Based on an evaluation of treatment outcome, Proffit
et a116 suggested that orthodontic correction becomes
unlikely in a situation with the following characteristics: an overjet beyond 10 mm; a facial height greater
than 125 nun; a mandibular body length less than 70
ram; and pogonion being located more than 18 mm
behind a nasion perpendicular.
Given these guidelines, a stereotype of the acceptable orthodontic camouflage patient begins to emerge.
The posterior occlusal discrepancy should not be

58"1

greater than the width of a premolar because overjet

correction is usually achieved through retraction of the
upper anterior teeth after premolar extraction. The odds
of successful treatment are further improved if the molar relationship is less than full Class II. This allows for
the loss of some maxillary posterior anchorage without
jeopardizing incisor retraction. A short facial height
with increased overbite is beneficial. Because molar
extrusion is common during mechanotherapy, the accompanying bite opening is less likely to risk loss
of anterior contact and diminish chin projection from
clockwise rotation (Fig 1).
Nonextraction treatment of the lower arch is generally
desirable, when possible. If there is mild to moderate
crowding, with upright incisors and good periodontal
support, the lower arch can be expanded and the incisors
proclined during leveling and alignment. This further reduces the amount of maxillary incisor retraction needed
to correct the overjet. On the other hand, an accentuated
curve of Spee, skeletal asymmetry with midline deviation, pre-existing incisor proclination, and severe crowding all indicate the need for extraction. This increases the
likelihood of lower incisor retraction, which accordingly
reduces the probability of overjet correction.
Facial esthetic outcome is influenced by the proportional relationships of the nose, lips, and chin, as well
as the chin to neck contour. Lip retraction increases
the dominance of the nose and chin as soft tissue facial
features. It follows that the pretreatment facial proportions must be considered in selecting the appropriate
treatment option. The amount of lip support lost with
incisor retraction is a function of tissue tonus, thickness, lip competence, and incisor torque (Figs 2A-2G).
Given the proper soft tissue relationships, incisor
retraction may have a negligible effect on lip support.
If chin prominence is a concern, advancement genioplasty offers a less costly, less risky, alternative to
enhance facial esthetics. Augmentation can be done
under deep sedation on an outpatient basis to further
control expense. The esthetic outcome may be equally
acceptable in the eyes of the patient, while avoiding
the expense and potential morbidity of a more comprehensive operative procedure (Figs 2H and 2I).
To summarize, the desireable camouflage candidate
would meet the following criteria: an end-to-end posterior occlusion; an average or short facial height, with
some increase in overbite; mild to moderate mandibular crowding without excessive curve of Spee or incisor
compensation; periodontal support that will allow
expansion and proclination of the lower anterior teeth
without risk of compromise; and soft tissue relationships that are reasonably proportional and likely to
respond favorably to tooth movement.

Advancing the Case for Camouflage

It has been suggested that the actual choice of treatment in borderline cases may be largely a function

582

ORTHODONTIC CAMOUFLAGE VS ORTHOGNATHIC SURGERY

FIGURE 1. A, Normal facial proportions are evident in this frontal view of the patient. The slightly high smile line is a function of the lip
elevating over procumbent incisors during animation. B, In this profile view an acute nasolabial angle suggests that a component of maxillary
protrusion contributes to the Class II malocclusion. C, D, E, The maxillary and mandibular arches are well-formed with no crowding to suggest
the need for extraction. The full Class II malocclusion, with l0 mm of oveljet, will require extraction for camouflage, however, and is at the
limit of orthodontic correction.

o f which specialist the patient happens to contact. 17 Although somewhat tongue-in-cheek, this statement, in reality, m a y be disturbingly accurate. W i l m o t et al analyzed
a series of dentofacial patients' motivations for orthodontic or surgical treatment and examined the association
of these motivations with the severity of the skeletal
malocclusion. Patients in this study, especially those with
Class II relationships, were more motivated for orthodontic treatment than surgery. This is not surprising because
most individuals would prefer the least invasive treatment

that might address their concerns. In keeping with the

findings previously mentioned, there was tittle relationship between the cephalometric variables and motivations
for treatment. These findings, coupled with other research
on psychosocial and morphometric factors, offer some
guidelines that m a y be useful in a clinical setting. Epidemiologic, functional and economic information adds further support for the proposition that camouflage should
be given seriou~ consideration in a majority of postpubertal Class II patients.

PAUL M. THOMAS

583

FIGURE 1 (Cont'd). F, The cephalometric schematic confirms

horizontal maxillary excess and proclined maxillary incisors, in addition to an ample soft tissue chin contour. G, A computer-assisted
treatment simulation suggests that orthodontic camouflage will produce a satisfactory esthetic result. The plan demonstrated involves
extraction of the maxillary first premolars followed by maximum
anchorage retraction of the anterior teeth.

EPIDEMIOLOGY

Proffit et al have suggested that successful orthodontic

camouflage becomes much less likely when the oveqet
is greater than 10 mm. Public health surveys of teenage
malocclusion indicate only 1.6% of those examined
would fall into this category.~ If the criteria for increased
facial height are used, some extrapolation from the public
health data is necessary. Increased facial height (vertical
growth pattern) is often accompanied by diminished
overbite or openbite and clockwise rotation of the mandible. Because no cephalometric data are included in the
public health information, overbite statistics must be substituted. Only 5.2% of the youths surveyed had edge to
edge or openbite relationships of the anterior teeth. The

percentage increases to 16.2 in African American teens.

Because the openbite is frequently combined with bialveolar protrusion in these individuals, correction with
extraction and orthodontics is generally successful. Using
the criteria suggested by Proffit et al, epidemiologic studies indicate the group of patients with Class II malocclusions requiring surgery on a morphologic basis is relatively small.
FUNCTIONAL IMPROVEMENT

The desire for functional improvement is often cited

as the justification for seeking surgical correction) 2
Advocates suggest that improved biomechanics and
masticatory efficiency result from surgical correction.

584

ORTHODONTIC CAMOUFLAGE VS ORTHOGNATHIC SURGERY

FIGURE 2. A, This frontal view suggests relatively normal transverse and vertical facial proportions. B, Mandibular deficiency is
evident on the profile view. Maxillary lip support is within normal
limits. C, D, E, The crowding in the lower dental arch suggests that
extraction may be necessary. Expansion is likely to procline the
incisors beyond the limits of good periodontal support. The occlusal
relationships and overjet are actually less severe than seen in the
patient in Figure 1 due to forward drift of the posterior mandibular
teeth. Correction, however, would require extraction in both arches,
with the likelihood of lower incisor retraction and residual overjet.
F, The cephalometric tracing shows components of both maxillary
protrusion and mandibular deficiency. The maxillary incisors are
already slightly upright and further retraction is best avoided.

PAUL M. THOMAS

585

FIGURE 2 (Cont'd). G, Treatment simulation confirms the undesireable profile changes that would result from orthodontic camouflage.
The nasolabial angle is markedly obtuse and there is inadequate chin projection. H, An advancement genioplasty helps with profile appearance
in the orthodontic camouflage simulation, but the lips are still undersupported. This may be an acceptable alternative, depending on the patient's
concerns and motivation for seeking treatment. L This computer-assisted treatment simulation demonstrates the result from extraction of the
lower first premolars, space closure, and surgical advancement of the mandible. The soft tissue relationships have better balance in the noselip-chin region.

586

ORTHODONTIC CAMOUFLAGE VS ORTHOGNATHICSURGERY

Much of the research in this area has involved bite

force measurement because it is relatively easy to record and analyze. ~8 Unfortunately, bite force does not
correlate with chewing efficiency and has little to do
with improved masticatory function) 9 For all the rhetoric regarding function, there is limited research involving changes in masticatory efficiency after orthognathic surgery. The existing studies deal with
prognathic patients and report no significant improvement in postoperative efficiency.2 In fact, in one report, the number of occlusal contacts decreased with
treatment, as did efficiency when compared with pretreatment and untreated prognathic controls. 2~ Although Class II malocclusion is a much more common
finding, this author is unaware of any research reporting changes in masticatory efficiency after treatment. Suggestions of improvement are subjective at
best or anecdotal in nature.
ECONOMIC FACTORS
Given the rhetoric surrounding the issue of healthcare delivery reform, the cost of treatment is a major
concern for both patient and provider alike. In 1987,
Dolan et a122reported the mean hospital cost (exclusive
of anesthesia professional fees) associated with a mandibular sagittal split osteotomy as being $3,086 with
a range from $1,997 to $4,561. These figures are for
a university hospital in central North Carolina and regional costs are likely to vary widely. Because the
study was conducted with data from patients treated
in 1985, inflation also must be considered for these
figures to be useful. The investigators cited the 1985
escalation of healthcare expenditures as about 9%, but
cautioned that this was the lowest annual increment
since 1965. Based on Consummer Price Index data
from the Bureau of Labor Statistics, hospital-related
charges have increased 150.4% in the 11-year period
from 1982 to 1993. 23 Using this 13.6% per year increment, the 1994 hospital charges for the same institution
could be in excess of $10,000 exclusive of all professional fees.
A recent survey indicated that the charges for a mandibular sagittal split osteotomy ranged from $1,500 to
$11,000, with an average fee of about $4,400. 24 The
assistant surgeon's fee also must be considered and is
usually about 20% to 25% of the surgeon's bill. These
figures are consistent with average fees from this author's locale. Orthodontic fees range from $3,000 to
$5,000 and anesthesiologist's fees from $600 to $900. 25
This brings the potential total expense for mandibular
advancement in a hospital setting to ($21,000). Greater
overhead expense is likely to make this figure considerably higher in selected locations. Using the same
sphere of reference, the surgical option is at least three
to four times the cost of orthodontic camouflage. Certainly this underscores the need for careful consider-

ation of the perceived benefit from orthognathic surg e r y versus the cost and risk.

Summary and Conclusions

Clearly, there are postpubertal patients with Class
II malocclusions for whom orthognathic surgery combined with orthodontics is the " b e s t " option, but epidemiologic information suggests they are a relatively
small percentage of the potential patient pool. The majority of patients fall into either an orthodontic treatment group or a borderline category. Many of these can
be treated successfully with orthodontic camouflage.
Research has shown psychosocial factors play a major
role in determining the patient's selection of a treatment option. This emphasizes the need for careful attention to global psychologic factors, with special emphasis on patient concerns regarding body image.
Morphometric criteria have been offered describing
appropriate candidates for orthodontic camouflage.
These are supported by a combination of research and
clinical experience. Patients who do not fit these criteria should not automatically be considered candidates
for surgery. Psychosocial research suggests a percentage of these individuals place less importance on facial
change and are content to improve dental esthetics and
function to the degree possible.
To assist in the decision-making process, patients
should be given the best information available regarding potential outcome. Currently this may involve
treatment simulation using a combination of computer
images and dental models. Caution has been suggested,
given the variability associated with predicting soft
tissue change. 26 There are additional legal concerns
regarding the implied guarantee of treatment outcome. 22'27 Correspondingly, the influence of this technology must be kept in perspective. Recent research
on the decision-making process found computer imaging to be an important factor in only 24% of the
patients studied. 28 However, the value of this technology for communication was underscored when these
same individuals ranked computer simulation as the
best information source when considering all diagnostic records.
The future of orthognathic surgery is uncertain,
given the current climate surrounding health care in
general. Coverage is being specifically excluded as
many patients change to low option policies or managed care plans. For those still having coverage, the
process of gaining prior approval has become increasingly stringent and slow. For those without coverage,
there is a trend toward developing "package deals"
to make care more affordable. It would appear that
although the demand for treatment will continue, the
orthognathic surgery option may become less feasible
and orthodontic camouflage more frequent. It continues to be imperative that we discuss treatment options

PAUL M. THOMAS

with our patients in an honest and forthright manner

to t h e b e s t o f o u r a b i l i t y . T h e i n f o r m a t i o n s h o u l d b e
free from personal bias and should incorporate the advantages and disadvantages of various options, including risk and economic information. Only then will our
patients be able to make a truly informed decision.

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