The long face syndrome: vertical maxillary excess

There is a clinically recognizable facial morphology, the long face syndrome, which has been incompletely described in the literature. On the basis of the clinical summary in thirty-one adults with this syndrome, an analysis of esthetics, skeletal morphology, and occlusion was undertaken. Herein we report on these findings, which confirm that this basic dentofacial deformity is associated with excessive vertical growth of the maxilla. Dental open and closed bite are two variants of the syndrome. An increased mandibular ramus height is associated with the closed-bite group.

Surgical-orthodontic expansion of the maxilla

Selected maxillary osteotomies are safe and dependable adjuncts to treatment of bilateral and unilateral maxillary deficiency. Maxillary expansion in fifteen adults was accomplished by separating the maxillary basal bone from the nasal, zygomaticomaxillary, and pterygomaxillary buttresses.

Characterization of the 56-kDa subunit of yeast trehalose-6-phosphate synthase and cloning of its gene reveal its identity with the product of CIF1, a regulator of carbon catabolite inactivation

Trehalose-6-phosphate synthase is the key enzyme for biosynthesis of trehalose, the major soluble carbohydrate in resting cells of yeast. This enzyme was purified from a strain of Saccharomyces cerevisiae lacking vacuolar proteases. It was found to be a multimeric protein of 630 kDa. Monoclonal antibodies were raised against its smallest subunit (56 kDa) and used for screening a yeast cDNA library. This yielded an immunopositive cDNA clone of 1.7 kb, containing an open reading frame of 1485 base pairs. Its sequence, called TPS1 (for trehalose-6-phosphate synthase), was represented by a single gene in the yeast genome and was found to be almost identical with the recently sequenced CIF1, a gene important for carbon catabolite inactivation, believed to be allelic with FDP1. A mutant obtained by disruption of TPS1 had a very low activity of trehalose-6-phosphate synthase, indicating that TPS1 is an important component of the enzyme. The mutant also showed a growth defect when transferred from glycerol to glucose, a phenotype similar to that of the cif1 and fdp1 mutants deficient in carbon catabolite inactivation. Thus, the smallest subunit of the biosynthetic enzyme trehalose-6-phosphate synthase appears to have, in addition, a central regulatory role in the carbohydrate metabolism of yeast.

Disruption of TPS2, the gene encoding the 100-kDa subunit of the trehalose-6-phosphate synthase/phosphatase complex in Saccharomyces cerevisiae, causes accumulation of trehalose-6-phosphate and loss of trehalose-6-phosphate phosphatase activity

Preparations of the trehalose-6-phosphate synthase/phosphatase complex from Saccharomyces cerevisiae contain three polypeptides with molecular masses 56, 100 and 130 kDa, respectively. Recently, we have cloned the gene for the 56-kDa subunit of this complex (TPS1) and found it to be identical with CIF1, a gene essential for growth on glucose and for the activity of trehalose-6-phosphate synthase. Peptide sequencing of the 100-kDa subunit of the trehalose-6-phosphate synthase/phosphatase complex (TPS2) revealed one sequence to be 100% identical with the deduced amino acid sequence of the upstream region of PPH3 on the right arm of chromosome IV. This sequence was used to clone an upstream region of PPH3 containing an open reading frame of 2685 nucleotides, predicted to encode a polypeptide of 102.8 kDa. The N-terminal sequence, as well as three internal amino acid sequences, obtained from peptide sequencing of the 100-kDa subunit, were identical with specific regions of the deduced amino acid sequence. Thus, the sequence cloned represents TPS2, the gene encoding the 100-kDa subunit of the trehalose-6-phosphate synthase/phosphatase complex. Interestingly, a stretch of about 500 amino acids from the first part of TPS2 was 33% identical with the entire TPS1 sequence. Disruption of TPS2 had no effect on trehalose-6-phosphate synthase activity but caused complete loss of trehalose-6-phosphate phosphatase activity, measured in vitro, and accumulation of excessive amounts of trehalose-6-phosphate instead of trehalose upon heat shock or entrance into stationary phase in vivo. These results suggest that TPS2 codes for the structural gene of the trehalose-6-phosphate phosphatase. Heat shock induced an increase in trehalose-6-phosphate phosphatase activity and this was preceded by an accumulation in TPS2 mRNA, suggesting that the trehalose-6-phosphate phosphatase is subjected to transcriptional control under heat-shock conditions.

Composition and functional analysis of the Saccharomyces cerevisiae trehalose synthase complex

In the yeast Saccharomyces cerevisiae, trehalose-6-phosphate synthase (TPS) and trehalose-6-phosphate phosphatase (TPP), which convert glucose 6-phosphate plus UDP-glucose to trehalose, are part of the trehalose synthase complex. In addition to the TPS1 (previously also called GGS1, CIF1, BYP1, FDP1, GLC6, and TSS1) and TPS2 (also described as HOG2 and PFK3) gene products, this complex also contains a regulatory subunit encoded by TSL1. We have constructed a set of isogenic strains carrying all possible combinations of deletions of these three genes and of TPS3, a homologue of TSL1 identified by systematic sequencing. Deletion of TPS1 totally abolished TPS activity and measurable trehalose, whereas deletion of any of the other genes in most cases reduced both. Similarly, deletion of TPS2 completely abolished TPP activity, and deletion of any of the other genes resulted in a reduction of this activity. Therefore, it appears that all subunits are required for optimal enzymatic activity. Since we observed measurable trehalose in strains lacking all but the TPS1 gene, some phosphatase activity in addition to Tps2 can hydrolyze trehalose 6-phosphate. Deletion of TPS3, in particular in a tsl1Delta background, reduced both TPS and TPP activities and trehalose content. Deletion of TPS2, TSL1, or TPS3 and, in particular, of TSL1 plus TPS3 destabilized the trehalose synthase complex. We conclude that Tps3 is a fourth subunit of the complex with functions partially redundant to those of Tsl1. Among the four genes studied, TPS1 is necessary and sufficient for growth on glucose and fructose. Even when overproduced, none of the other subunits could take over this function of Tps1 despite the homology shared by all four proteins. A portion of Tps1 appears to occur in a form not bound by the complex. Whereas TPS activity in the complex is inhibited by Pi, Pi stimulates the monomeric form of Tps1. We discuss the possible role of differentially regulated Tps1 in a complex-bound or monomeric form in light of the requirement of Tps1 for trehalose production and for growth on glucose and fructose.

Mandibular widening by intraoral distraction osteogenesis

Transverse mandibular deficiency with crowding of the mandibular anterior teeth is frequently present in patients with Class I and II malocclusions. The hallmarks of treatment by compensating orthodontics, functional appliances or orthopaedic devices are instability, compromised periodontium and compromised facial aesthetics. A new surgical technique has been developed to widen the mandible. The method is based upon gradual osteodistraction following vertical interdental symphyseal osteotomy. Ten patients with transverse mandibular deficiency and significant dental crowding were treated by symphyseal distraction and subsequent non-extraction decompensating orthodontic treatment. Either an intraoral tooth-borne Hyrax appliance or a new custom-made bone-borne osteodistractor was used to gradually widen the mandible. The surgical procedures were accomplished under local anaesthesia and intravenous sedation in an ambulatory surgical setting using an individualized distraction protocol. The appliances were activated 7 days after symphyseal osteotomies, once each day at a rate of 1 mm per day and stabilized for 30-40 days after distraction. After the segments were distracted, non-extraction orthodontic alignment of the mandibular anterior teeth was accomplished. The symphyseal distraction gaps were bridged by new bony regenerate. Distraction osteogenesis provided an efficient surgical alternative to orthognathic surgery for widening the mandible and treatment of transverse mandibular deficiency without extraction of teeth.

Biomechanics of differences in lower facial height

A two-dimensional model which allows calculation of mechanical advantage of the human temporalis and masseter muscles is presented. The model is manipulated to demonstrate how selected differences in facial morphology affect the mechanical advantage of the muscles. The model is then used to evaluate the differences in mechanical advantage between patients with the long face syndrome and those with the short face syndrome. Differences in facial morphology between these two groups result in significant differences in the mechanical advantages of their muscles. Mechanical advantage may, in part, explain observed differences in bite force between the two groups. The model suggests that some surgical procedures used to correct facial disharmonies may have a significant effect on the mechanical advantage of the jaw muscles.

Superior repositioning of the maxilla: stability and soft tissue osseous relations

The skeletal stability and soft-tissue changes associated with superior repositioning of the maxilla by Le Fort I osteotomy or simultaneous anterior and posterior maxillary osteotomies was studied in thirty patients by means of a computerized craniofacial model. Excellent skeletal stability was demonstrated 14 months postoperatively. Postsurgically, the reduction in lower face height and amount of maxillary incisor exposure resulted in improved facial balance. The use of a computerized osseous and soft-tissue craniofacial model has added a new dimension to evaluation of surgical changes associated with correction of dentofacial and craniofacial deformities.

Idiopathic intracranial hypertension in children: the Iowa experience

Idiopathic intracranial hypertension is an uncommon condition in children and is seen only about once a year in a large referral hospital. Sex incidence is equal, and obesity is a feature in about one third of patients. This article reviews the 30-year experience in an institution where idiopathic intracranial hypertension in adults has been extensively studied. Symptomatic causes of intracranial hypertension and both medical and surgical therapeutic options are reviewed.

Cephalometric analysis of dentofacial normals

A comprehensive cephalometric analysis of "normal" adults was accomplished by examining a carefully selected subject group. Fifty-six adult Caucasians with Class I skeletal and dental relationships and good vertical facial proportions were analyzed morphologically with a computerized craniofacial model. By the incorporation of a large number of soft-tissue measurements, facial profile and proportionality were analyzed and compared with methods that are presently used to evaluate facial esthetics. The data provide relevant measurements that are useful in the diagnosis and treatment of adults with dentofacial deformities. Horizontal soft-tissue chin prominence was nearly equal for males and females relative to subnasale, soft-tissue nasion, and glabella.

Daily energy expenditure and physical activity in survivors of childhood malignancy

Changes in body composition, in particular the onset of obesity, may result from reductions in total daily energy expenditure (TDEE) as a consequence of relative physical inactivity. Children previously treated for acute lymphoblastic leukemia (ALL) become obese, yet the mechanism remains undefined. TDEE and physical activity levels [PAL = TDEE/basal metabolic rate (BMR)] were measured in 34 long-term survivors of ALL and compared with results from 21 survivors of other malignancies and 32 healthy sibling control subjects using the flex-heart rate technique. Body composition was measured by dual energy x-ray absorptiometry. The median TDEE was reduced in the ALL group (150 kJ x kg d(-1)) compared with other malignancies and controls (207 and 185 kJ x kg d(-1), respectively, p < 0.01). This reduction was accounted for mainly by a relative decrease in the PAL of the ALL group (1.24) compared with both other malignancies and controls (1.58 and 1.47, respectively, p < 0.01). TDEE and PAL were correlated with percentage body fat (r = -0.39, p < 0.001 and r = -0.24, p < 0.05, respectively). Obesity in survivors of ALL may, in part, be explained by a reduction in TDEE as a consequence of reduced PAL. The cause of such reduction is uncertain.

The short face syndrome

Cephalograms of twenty-seven untreated adult Caucasians, selected on the basis of a clinical impression of reduced lower facial height, were studied. Various linear and angular measurements were studied and compared to the Bolton standards. The short face syndrome SFS is a clinically recognizable facial type with reduced lower facial height as the common denominator. On the basis of the FPI (facial proportion index), the RH (ramus height), the OP-PP distance (or posterior maxillary height), and the SN:MP angle, two subgroups were distinguished in the SFS group. SFS, was characterized by a long ramus, sharply reduced SN:MP angle, an FPI close to 10, and a slightly reduced posterior maxillary height. In contrast, SFS2 was characterized by a short ramus, a slightly reduced SN:MP angle, an FPI with values around or below zero, and a sharply reduced posterior maxillary height. The latter group was designated as vertical maxillary deficiency.

Distraction osteogenesis to widen the mandible

The purpose of this investigation was to elucidate the biology of distraction osteogenesis during mandibular widening. Midsymphyseal vertical interdental osteotomies were performed in nine Macaca mulatta monkeys. After a latency period a tooth-borne appliance was activated at a rate of 0.5 mm twice a day for 7-10 days. The appliance was then stabilized for a period of 4 or 8 weeks. The distraction gap at the inferior portion of the symphysis was bridged completely by new bony trabeculae. Bone formation in the interdental area was apparently related to the surgical technique. Newly formed bony trabeculae were oriented parallel to the direction of distraction. The location of the osteotomy site with an adequate margin of alveolar bone contiguous with the adjacent teeth was necessary for the induction of the distraction osteogenesis. Disproportional movement between superior and inferior portions of the distracted segments was noted.

Comparative study between the SFS and LFS rotation as a possible morphogenic mechanism

Cephalometric tracings of twenty-seven untreated adult Caucasians, selected on a clinical impression of reduced lower facial height were studied and compared with tracings of nine untreated adult Caucasians with increased lower facial height. Various linear and angular measurements for both groups were analyzed and compared. As has been previously described for the SFS, the LFS group can be subdivided into at least two subtypes. Subtype I is characterized by a long ramus, increased OP-PP, an increased SN:MP-angle, and excessive lower anterior facial height. These persons manifest the most typical clinical characteristics of the long face syndrome and have excessively long faces. In Subtype II, however, extreme backward and downward rotation of the mandible, combined with a short or extremely short ramus, is associated with an increase in lower anterior facial height. The increase in posterior maxillary height was not striking in this subtype. It was demonstrated that many of the characteristics of the LFS group and the SFS group can be explained by clockwise or counterclockwise rotation of the mandible "in concert" with the hyoid, tongue, pharynx, and cervical spine. The LFS group was characterized by a clockwise rotation of the mandible "in concert" with the hyoid, tongue, pharynx, and cervical spine. The mandible of the SFS group rotated similarly, but in the opposite counterclockwise direction. The vital need to maintain patency of the upper airway at the level of the base of the tongue may account for rotation in the LFS.

Relative osteopenia after treatment for acute lymphoblastic leukemia

Osteoporosis in adult life is associated with a significant morbidity and may be predisposed to by osteopenia and failure to reach peak bone mass in childhood. Children treated for acute lymphoblastic leukemia (ALL) may be at risk of osteopenia as a result of previous therapy or as a consequence of the disease process itself. Dual energy x-ray absorptiometry measurements of bone mineral content (BMC) for the whole body and at the lumbar spine and hip were taken in 35 (14 male) long-term survivors of ALL and compared with results in 20 (10 male) survivors of other malignancies and 31 (17 male) healthy sibling controls. The measured BMC was expressed as a percentage of a predicted value derived from the control group and based on the variables that had influence upon it. BMC (%) was reduced at the spine in the ALL group compared with controls [92.4 (8.0)% versus 100.4 (9.7)%, respectively; p < 0.005] and at the hip compared with both other malignancies and controls [89.0 (11.5)% versus 96.1 (11.7)% and 100.4 (9.2)%, respectively; p < 0.0005]. Increasing length of time off therapy was associated with a significant increase in %BMC at both the spine and the hip. For the spine, this association was significantly different between the ALL group and other malignancies, suggesting that any gain in %BMC after therapy was slower in children treated for ALL. Both exercise capacity and levels of physical activity were correlated with %BMC at the hip (r = 0.44, p < 0.001 and r = 0.29, p < 0.01, respectively). Previous exposure to methotrexate, ifosfamide, and bleomycin was associated with a reduction in %BMC at the spine. Exposure to 6-mercaptopurine and cisplatin was associated with a reduction at the hip. In conclusion, children treated for ALL are osteopenic. The mechanism is probably multifactorial but is partially related to previous chemotherapy, limited exercise capacity, and relative physical inactivity.

Comprehensive cardiac rehabilitation programme for implantable cardioverter-defibrillator patients: a randomised controlled trial

OBJECTIVE

To investigate the effects of a 12 week comprehensive cardiac rehabilitation (CCR) programme on patients who have undergone implantation of an implantable cardioverter-defibrillator (ICD).

DESIGN

Sixteen patients with ICDs (14 (88%) male, mean (SD) age 58 (10) years, range 34-74 years) were randomised to either attend an individually tailored CCR programme or receive usual care. They then changed to the alternative regimen for a further 12 weeks. Exercise capacity was assessed using a treadmill exercise test at baseline, after usual care, after CCR and 12 weeks after CCR to assess maintenance effects. Hospital anxiety and depression (HAD) scores were recorded at each stage.

RESULTS

Exercise times (min:s; mean (SD)) increased by 16% from a baseline mean of 9:55 (2:33) to 11:11 (2:17) following attendance at CCR (95% confidence interval (CI) 0:34 to 1:58; p = 0.001). This improvement was maintained 12 weeks after attendance at CCR, at 11:20 (2:17) (p = 1.00). HAD scores for anxiety and depression decreased during CCR from a baseline of 13.4 (3.6) to 8.1 (3.6), 95% CI 3.5 to 7.0 (p < 0.001) and 9.9 (3.4) to 6.7 (2.9), 95% CI 1.9 to 4.4 (p = 0.002), respectively. These improvements were maintained at 12 weeks after CCR. No ventricular arrhythmias or ICD discharges occurred during the exercise components of the CCR. The total number of ventricular arrhythmias and ICD discharges was similar 12 weeks before, during, and 12 weeks after CCR.

CONCLUSIONS

CCR appears to be safe for patients with ICDs. It can improve exercising ability and lower the levels of psychological distress. A larger multicentre study is recommended to confirm these findings.

Protease-activated receptor 2, a receptor involved in melanosome transfer, is upregulated in human skin by ultraviolet irradiation

Previous studies have shown that the protease-activated receptor 2 is involved in skin pigmentation through increased phagocytosis of melanosomes by keratinocytes. Ultraviolet irradiation is a potent stimulus for melanosome transfer. We show that protease-activated receptor 2 expression in human skin is upregulated by ultraviolet irradiation. Subjects with skin type I, II, or III were exposed to two or three minimal erythema doses of irradiation from a solar simulator. Biopsies were taken from nonexposed and irradiated skin 24 and 96 h after irradiation and protease-activated receptor 2 expression was detected using immunohistochemical staining. In nonirradiated skin, protease-activated receptor 2 expression was confined to keratinocytes in the lower one-third of the epidermis. After ultraviolet irradiation protease-activated receptor 2 expression was observed in keratinocytes in the upper two-thirds of the epidermis or the entire epidermis at both time points studied. Subjects with skin type I showed delayed upregulation of protease-activated receptor 2 expression, however, compared with subjects with skin types II and III. Irradiated cultured human keratinocytes showed upregulation in protease-activated receptor 2 expression as determined by immunofluorescence microscopy and Western blotting. Cell culture supernatants from irradiated keratinocytes also exhibited a dose-dependent increase in protease-activated receptor-2 cleavage activity. These results suggest an important role for protease-activated receptor-2 in pigmentation in vivo. Differences in protease-activated receptor 2 regulation in type I skin compared with skin types II and III suggest a potential mechanism for differences in tanning in subjects with different skin types.

Evidence for trehalose-6-phosphate-dependent and -independent mechanisms in the control of sugar influx into yeast glycolysis

In the yeast Saccharomyces cerevisiae, trehalose-6-phosphate (tre-6-P) synthase encoded by GGS1/TPS1, is not only involved in the production of trehalose but also in restriction of sugar influx into glycolysis in an unknown fashion; it is therefore essential for growth on glucose or fructose. In this work, we have deleted the TPS2 gene encoding tre-6-P phosphatase in a strain which displays very low levels of Ggs1/TPS1, as a result of the presence of the byp 1-3 allele of GGS1/TPS1. The byp 1-3 tps2 delta double mutant showed elevated tre-6-P levels along with improved growth and ethanol production, although the estimated concentrations of glycolytic metabolites indicated excessive sugar influx. In the wild-type strain, the addition of glucose caused a rapid transient increase of tre-6-P. In tps 2 delta mutant cells, which showed a high tre-6-P level before glucose addition, sugar influx into glycolysis appeared to be diminished. Furthermore, we have confirmed that tre-6-P inhibits the hexokinases in vitro. These data are consistent with restriction of sugar influx into glycolysis through inhibition of the hexokinases by tre-6-P during the switch to fermentative metabolism. During logarithmic growth on glucose the tre-6-P level in wild-type cells was lower than that of the byp 1-3 tps2 delta mutant. However, the latter strain arrested growth and ethanol production on glucose after about four generations. Hence, other mechanisms, which also depend on Ggs1/Tps1, appear to control sugar influx during growth on glucose. In addition, we provide evidence that the requirement for Ggs1/Tps1 for sporulation may be unrelated to its involvement in trehalose metabolism or in the system controlling glycolysis.

Surgical correction of the long face syndrome

The combined efforts of different specialists are needed for the successful treatment of patients with the long face syndrome. Both surgeons and orthodontists who recognize their own capabilities and limitations must combine their skills to achieve the best possible occlusion and facial esthetics. The surgical and orthodontic plan of therapy is designed to correct the patient's dentofacial deformity. Surgical reduction of facial height and proper alignment of the teeth by orthodontic means are common denominators of successful treatment. By properly planned and executed Le Fort I maxillary osteotomies, the vertical dimensions of the face can be shortened to improve the esthetic balance between the nose, upper lip, teeth, and chin and achieve lip competency. Variable open-bite and nonopen-bite maxillary deformities in forty adults with the long face syndrome were corrected by Le Fort I osteotomy and orthodontic treatment. The technical problems encountered in planning and executing treatment are discussed and illustrated by selected case reports.

Long-term skeletal and dental effects of mandibular symphyseal distraction osteogenesis

The purpose of this study was to evaluate the effects of mandibular symphyseal distraction osteogenesis using a tooth-borne expansion device. The sample included 20 Hispanic nonsyndromic patients (11 males and 9 females) between 13.5 years and 37.3 years of age. Predistraction (1.5 months before surgery), postdistraction (1 month after surgery), and long-term follow-up (1.3 year after surgery) records included posteroanterior, lateral, and panoramic radiographs and models. Postdistraction radiographic evaluation showed that symphyseal distraction osteogenesis produced insignificant increases in the bicondylar, bigonion, and biantegonion widths; intermolar and, especially, intercanine widths increased significantly and a distraction gap was observed in the symphyseal region. Follow-up model analysis showed the largest width increases between the first molars and second premolars and the smallest width increases between canines and first premolars. The difference between the postdistraction and long-term follow-up width changes was explained by the postdistraction orthodontic effect, which modified the shape of the dental arch. A disproportionate pattern of distraction, characterized by significantly greater dental than skeletal widening, was observed in the second molar and antegonion region. Distraction osteogenesis without presurgical orthodontic treatment produced significant proclination of the mandibular incisors; no proclination was observed in cases with predistraction orthodontic treatment. Dental crowding was resolved by the movement of teeth into the distraction regenerate and concomitant orthodontic treatment. Follow-up radiographs showed transverse skeletal stability of the distraction procedure. We conclude that mandibular symphyseal distraction osteogenesis increased mandibular arch width and partially corrected dental crowding, with a potential for disproportionate distraction patterns and proclination of the mandibular incisors.

Use of telemedicine for children with special health care needs

OBJECTIVE

In 1995, the Children's Medical Services (CMS) of the State of Georgia contracted with the Department of Pediatrics of the Medical College of Georgia (MCG) and the MCG Telemedicine Center to develop telemedicine programs to provide subspecialty care for children with special health care needs. This article presents project statistics and results of client evaluation of services, as well as physician faculty attitudes toward telemedicine.

DESIGN

A demonstration project using telemedicine between a tertiary center and a rural clinic serving children with special health care needs was established. Data were collected and analyzed for December 12, 1995 to May 31, 1997, during which 333 CMS telemedicine consultations were performed.

RESULTS

Most CMS telemedicine consultations (35%) involved pediatric allergy/immunology. Other subspecialties included pulmonology (29%), neurology (19%), and genetics (16%). Overall, patients were satisfied with the services received. Initially, physician faculty members were generally positive but conservative in their attitudes toward using telemedicine for delivering clinical consultation. After a year's exposure and/or experience with telemedicine, 28% were more positive, 66% were the same, and only 4% were more negative about telemedicine. The more physicians used telemedicine, the more positive they were about it (r =.30).

CONCLUSIONS

In terms of family attitudes and individual care, telemedicine is an acceptable means of delivering specific pediatric subspecialty consultation services to children with special health care needs, living in rural areas distant to tertiary centers. Telemedicine is more likely to be successful as part of an integrated health services delivery than when it is the sole mode used for delivery of care.

Hypomobility after maxillary and mandibular osteotomies

A retrospective recall study of forty patients was made to examine mandibular function after orthognathic surgery. Maximum maxillomandibular opening, protrusion, and lateral excursions were measured and compared with similar mandibular movements in a control group of patients of comparable age. Six months to 42 months after maxillary and mandibular osteotomies, the majority of patients demonstrated decreased maxillomandibular opening compared to the control group 54.8 mm (SD 4.7). The decrease was most dramatic in patients previously treated with sagittal split ramus osteotomies. The mean maxillomandibular opening after Le Fort I osteotomy to reposition the maxilla superiorly was 48.7 mm (SD 5.7); after bilateral intraoral vertical ramus osteotomies to retract the mandible it was 48.6 mm (SD 5.7); and after bilateral sagittal split ramus osteotomies to advance the mandible it was 35.1 mm (SD 6.7). The presence of mandibular hypomobility after orthognathic surgery and maxillomandibular immobilization may be due to pre-existing or surgically induced muscle or temporomandibular joint dysfunction. Our findings indicate the need for routine clinical assessment of mandibular function preoperatively and for a systematic regimen of muscular and occlusal rehabilitation postsurgically to normalize muscle function, condylar movement, and range of mandibular motion.