I found Dr. Shell's article in last month's journal of great interest. It is wonderful to see increased concern for the facial esthetics of our patients and for this concern to be reflected in the literature. I am concerned, however, with the general conclusion that the esthetic outcomes of orthognathic surgery and functional appliance patients are equally favorable.
In Class II division I patients, the most obvious facial imbalance exists in the mandible, which commonly leads the surgeon to operate on the mandible alone. This is nicely evidenced by the 23 of 32 patients who had mandible-only surgery. The problem is that many Class II patients have some degree of maxillary skeletal hypoplasia. In addition, this hypoplasia is often worsened by early orthodontic attempts at class II correction using premolar extraction or maxillary functional appliances. While treating the lower jaw to an esthetic norm will produce overall esthetic improvement, it will often unmask the deficiency of the maxilla and rob the patient of a better result.
Those patients represented in the article as having a favorable esthetic outcome all possessed great upper lip projection and attractive midfaces before and after intervention. Those described as having an unfavorable esthetic outcome have retracted upper lips, obtuse nasolabial angles and poor midface projections. Patient AG, in fact, shows well how maxillary functional therapy led to esthetic decline, with a complete loss of her upper lip support and projection. Mandible-only surgery would not have provided much improvement either. Her profile would have benefited from maxillary advancement for lip support and occlusal plane leveling and mandibular advancement for lower chin projection.
I am sure that if the surgically treated group had undergone soft tissue cephalometric analysis with treatment planning for the face and the bite, the study's conclusions might have been somewhat different.