orthognathic surgery/ fixed orthodontics courses

Orthognathic Surgery
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Contents
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Definition, Team, Objectives
History of Orthognathic Surgery
Grading of patients
Envelope of discrepancy
Overview of Facial Planning Process
STO/CTP
Pre-surgical Orthodontic goals
Definitive Surgical Treatment Plan
Model Surgery

Contents
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Basis/Concept of Orthognathic Surgery
Patient preparation
Surgical Procedures
Rigid Internal Fixation
Special Considerations
Rehabilitation
Post Surgical Orthodontics
Retention and Relapse

Definition


Orthognathic surgery is the art and science of
diagnosis, treatment planning, and execution of
treatment by combining orthodontics and oral
and maxillofacial surgery to correct
musculoskeletal, dento-osseous, and soft tissue
deformities of the jaws and associated structures.

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Fonseca


Team
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Oral and maxillofacial
surgeon
Orthodontist
General dentist

Periodontist
Prosthodontist
Endodontists
Neurosurgeons
Opthamologists
Otolaryngologists
Plastic surgeon
Speech pathologist


Objectives
Basic therapeutic goals:
Function
Aesthetics
Stability
Minimizing the treatment time



Fonseca


Objectives
Specific therapeutic goals:
Masticatory / Swallowing
Functional occlusion
Opening and closing of jaws
TMJ dysfunction
Structural abnormalities
Myofascial pain
Speech
Stability of orthodontic results
Improve dental and periodontal health
Improve psychosocial impairments
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Fonseca


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1849 - Simon Hullihen - Mandibular subapical
osteotomy

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1859 – von Langenbeck – First orthognathic surgical
procedure

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1864 - Cheever - LeFort I

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1907 - Dingman - Mandibular body osteoectomy

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1921 – Cohn-Stock – Anterior maxillary osteotomy

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1927 - Wassmund - Maxillary osteotomy

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1934 - Auxhausen - Maxillary osteotomy

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1934 - Bell - Biologic basis of osteotomy

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1942 - Gillies & Harrison - LeFort II &III

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1942 - Schuchardt - similar to BSSO

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1950 - Tessier - LeFort III &IV

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1952 - Converse - Maxillary osteotomy

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1954 - Caldwell & Letterman - Vertical subcondylar
osteotomy

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1960’s - Stoker, Epker, Bell, Wilmar & Obwegeser LeFort I down fracture

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1965 - Trauner & Obwegeser - BSSO


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1970 - Turvey, Epker, Fish & LaBanc - Bijaw surgeries

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1973 - Henderson & Jackson - Pyramidal LeFort II

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1992 - McCarthy - Distraction osteogenesis in
congenitally hypoplastic mandible


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Group I
Group II
Group III



Arnett . McLaughlin www.indiandentalacademy.com

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Sagittal Envelope of
Discrepancy

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Proffit


Transverse Envelope of
Discrepancy


IOTN Treatment Grades

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 Shaw and coworkers
Proffit . White . Sarver

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Proffit


State of art care
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Correctly diagnose existing deformities

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Establish a proper treatment plan

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Execute the recommended treatment

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Arnett . McLaughlin


Criteria for success
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Healthy musculature and temporomandibular
joints
Facial balance
Correct static and functional occlusion
Periodontal health
Resolving the patient’s chief complaints
Stability of dental, skeletal, and growth changes
Maintaining or increasing airway

Arnett . McLaughlin


1. Healthy musculature and
temporomandibular joints
 Normal range of
movement
 Structural stability
 Free from pain
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Remodeling
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Local remodeling
Total remodeling


2. Facial balance
 Tweed, Down, Steiner,
McNamara – Averages
for general population
 Assumption that if the
dental and skeletal values
are normal the face would
be normal
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STCA – 45measurements
CTP


3. Correct static and functional occlusion
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Andrews six keys
Overjet, overbite and symmetrical midlines
Condyles in glenoid fossa

4. Periodontal health
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Alveolar bone
Gingival tissue


5. Resolving the patient’s chief complaints
6. Stability
 Magnitude of tooth movement in three dimensions
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Excessive compensation
Disproportionate growth

Stability of TMJ
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Surgical technique – condyles should be seated without
compression

7. Maintaining or increasing airway

Overview of Facial Planning Process
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Patient concerns
History
Clinical examination
Radiographic and imaging analysis
Dental model analysis

Arnett . McLaughlin

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Fonseca


Patient concerns
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What are your concerns or problems?
Have you had previous treatment for this
condition, and what was the outcome?
Why do you want treatment?
What do you expect from treatment?


Patient History
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Personal information
Chief complaint - Motivation questionnaires
Medical
Dental and orthodontic history
History of the TMJ and musculature
Pre-surgical growth assessment

Arnett . McLaughlin


Questionnaires

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Basic - general screening

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In-depth - complex problems


Patient History

Personal information


Patient History

Chief complaint - Motivation questionnaires
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Dental changes
Facial changes
Relief of symptoms


Patient History

Medical history

Patient History

Dental and orthodontic history

Patient History

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History of the TMJ and musculature

Patient History

Pre-surgical growth assessment


Psychological ramifications of
orthognathic surgery
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Self-image
Motivations and patient expectations
Patient interviews
Patient preparation
Response to treatment

Fonseca


Psychological ramifications
Self-image
 Class III – Masculine, leadership, aggression,
dominance, strength etc.
 Class II profile – Feminine, submissive, naive etc.
 Round face – Child like, warm, honest,
trustworthy etc.


 What reasons do patients give for seeking
treatment?
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Enhancement of self-image
Oral function
Social well being
Future dental health
TMJ
Nasal function
Psychological well being

 Psychological well being
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Psychological health before surgery
Assessing patients emotional distress


Patient interview
 Social support system
 Assessment of personality
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Open ended question
Silence

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Proffit

Patient preparation
 Explain diagnosis
 Treatment options
 Risk / benefits
 Prepare the supporting people


Response to treatment
 Post surgical perception
or problems with
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Swelling
Bruising
Nasal congestion
Dry lips
Facial abrasion
Dribbling
Sleeping – sitting for 2-3
weeks

Murphy T. 2005 Jr of Orthod

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Sleep discomfort
Numbness
Tingling
Pain in jaw joints
Possibility of altered speech
Low feeling
Soft diet
Possible acne


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TMJ examination
Clinical facial examination
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Frontal view
Profile view
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High midface profile
Maxillary area profile
Mandibular area profile

Intra-oral examination
Arnett . McLaughlin


TMJ examination
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The range of movements
Deviation from normal movements
Any pain during movement
The joint sounds


Clinical facial examination - Frontal view

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General outline
Midline assessment



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Horizontal reference lines


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Mandibular deviations and cants


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Vertical assessment - the facial thirds


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Vertical assessment of the lower third of the face


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Upper lip length

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Inter-labial gap

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Lower lip length


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Upper incisor crown length and overbite


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Upper incisor exposure – lips at rest


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Exposure of the upper incisor and gingival tissue when smiling


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Closed lip position


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Upper and lower vermilion borders

Frontal view - Summary


Clinical facial examination - Profile view
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High midface
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Glabella
Orbital rim
Cheek bone
Subpupil area


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Maxillary area
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Nasal base
Upper lip prominence
Upper lip support
Nasal projection


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Mandibular area
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Lower lip prominence
Soft tissue pogonion
prominence
Throat length contour
Overjet


Profile view - Summary


Intra-oral examination
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Soft tissues
Finger or thumb sucking
Tongue size, position and activity
Mentalis muscle activity
Dental assessment
Molar relationship


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Canine relationship
Midlines
Overjet and overbite
Crossbites
Crowding or spacing
Lower curve of spee
Periodontal health


Records


Imaging and radiographic analysis

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Facial photographs
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Routine facial photographs
In-depth facial photographs
Intra-oral photographs


Routine facial photographs


In-depth facial photographs


Intra-oral photographs


Radiographic and Imaging Analysis
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Radiographs
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Lateral cephalometry
Panoramic radiographs
Intra-oral radiographs
Tomograms
MRI


Metallic midface markers
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Cheek bone
Soft tissue orbital rim
Nasal base
Subpupil
Neck-throat junction


Dental Models
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Impression taking
Wax bite construction
Model analysis


Importance of wax bite
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First tooth contact
Maximum intercuspation
Relates the mandible to
maxilla during
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facial examination,
facial photography,
cephalometry,
tomography and
model articulation



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First wax bite


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Second wax bite

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Third wax bite


Model analysis
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Arch length
Tooth size analysis
Tooth position
Arch width analysis
Curve of spee
Cuspid-molar relation
Tooth arch symmetry
Buccal tooth tipping (Curve of wilson)
Missing, broken down or crowned teeth

Diagnosis in three areas
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Musculature and TMJ
Face
Dentition


1. Musculature and TMJ
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Head, neck and TMJ pain
and dysfunction
TMDs
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Masticatory muscle
disorders
Temporomandibular joint
articular disorders

Condylar remodelling
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Local
Total


2. Face
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STCA
Frontal - Grummons and
Ricketts
Profile - COGS - skeletal
and soft tissue – Burstone
et al.


Orthognathic Surgery -II
Dr Sangamesh B.


STCA
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Arnett etal 1999 AJO DO
Sample 46 adult caucasian– 20/M 26/F
Class I Occlusion
Balanced facial appearance
All records – NHP
If not in NHP – TVL
TVL – Subnasale perpendicular to NHP
Arnett . McLaughlin


STCA
Following areas were evaluated;
 Dental and skeletal factors
 Soft tissue components
 Vertical facial heights or lengths
 TVL projections
 Facial harmony


STCA - Dental and skeletal factors


STCA – Soft tissue thickness


STCA - Vertical facial heights or lengths


STCA - TVL projections


STCA - TVL projections
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The A/P position of the
TVL will be frequently
through subnasale
TVL must be moved
forward 1-3mm in case of
maxillary retrusion
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Long nose
Depressed or flat orbital
rims, cheek bones,
subpupils, alar bases etc.
Patient clinical visualization
for verification

STCA – Harmony values


STCA – Harmony values for Females


STCA – Harmony values for Males


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Middle third
Lower third
Clinical commentary on
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Facial growth
Facial imbalances
Bimaxillary surgery


STCA – Length of the lower third of the
face


STCA – Short upper lip


STCA – Normal upper to lower lip ratio


STCA – Upper lip prominence
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Related to A/P position of
the maxilla, upper incisor
torque and upper lip
thickness


STCA – Nasolabial angle and upper lip


STCA – Upper incisor exposure – lips at
rest disharmony


STCA – Exposure of upper incisor and
gingival tissue on smiling


STCA – Prominence of soft tissue
pogonion
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Retrusive soft tissue pogonion Protrusive soft tissue pogonion
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Vertical maxillary excess
Mandibular retrusion
Steep occlusal plane

Vertical maxillary deficiency
Mandibular protrusion
Flat occlusal plane


STCA – Throat length and contour
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Long and short throat
length
Long straight throat
length is favorable for
mandibular setback
Short sagging throat
length is unfavorable


3. Dentition and intra-oral structures
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Vertical
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Horizontal
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Overbite
Plane of occlusion
Curve of spee
Anatomical variation
Crowding / spacing
Overjet

Transverse
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Crossbites


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Maxillary retrusion
Mandibular retrusion
Clockwise mandibular rotation
Upper and lower denture base retrusion
Overjet increase


Video imaging technology
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Acetate tracings
Photograph modification
Videocephalometrics

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Fonseca

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Proffit White Sarver

Video imaging technology
Videocephalometrics
Advantages:
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Accuracy
Multiple analysis in short time
Individualization - gender, age, race and ethnicity
Prediction by algorithmic data
Incorporation of changes during treatment

Fonseca


Video imaging technology to orthognathic
surgery
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How does technology work?
Are the predictions generated by the computer
accurate enough for the surgical team to follow
precisely?
Is it medicolegally safe to use;are the patients
likely to litigate if they feel the outcome is not
what they expected?


Surgical prediction
 Mandibular
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1989 - Hing
1993 - Schwartz - ‘Quick ceph’

Maxillary
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1994 - Konstaniantos et al. – ‘Dentofacial Planner’


Surgical prediction
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Skeletal and soft tissue response is different for
different surgical procedure and osteosynthesis
Algorithms in the prediction software should be
modifiable
Types of procedure should be agreed by the surgeon
then proceed for prediction tracing


Cephalometric Treatment Planning



Arnett . McLaughlin


CTP

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Step 1 – Correct the torque of the upper incisor

CTP

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Step 2 - Correct the torque of the lower incisor

CTP

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Step 3 – Position of maxillary incisors

CTP

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Step 4 – Auto-rotate the mandible to 3mm of overbite

CTP

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Step 5 – Move the mandible to 3mm of overjet A/P movement

CTP

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Step 6 – Set the maxillary occlusal plane

CTP

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Step 7 – Assess the chin height and AP projection to TVL

CTP
Omitting steps
 If any of the steps are correct then they are
omitted
 Steps 1,2,4,7 provide a facially correct class I
occlusion
 Step 3 is for LeFort I – Upper incisor AP and
vertical change
 Step 6 – Occlusal plane modification
 Step 7 – Chin osteotomy

STO
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Initial surgical treatment objectives
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To establish orthodontic goals
To develop surgical objectives
To create the predicted facial profile


Pre-surgical Orthodontics
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Selection of appliance
Alignment
Vertical positioning of teeth
Anteroposterior position of teeth
Arch compatibility



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Fonseca


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Sagittal dimension


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Vertical dimension

Fonseca


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Transverse dimension

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Fonseca


Definitive Surgical Treatment Plan
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Final surgical treatment objectives
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Definitive treatment plan
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Dental and periodontal treatment
Extractions
Surgery


Model Surgery
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Traditional Method
Analytical model surgery

Maxillary surgeries
Mandibular surgeries
Double-jaw surgeries
Fonseca


Maxillary surgeries
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Impressions
Wax-bite
Face-bow transfer
Mounting of the casts on a semiadjustable
articulator
Vertical reference lines are drawn – A/P
positioning or arch rotation
Horizontal reference lines

Model Surgery


Isolated maxillary surgery
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Provide clearance in the mounting plaster for the
superior repositioning of the maxilla
Adjust the incisal guidance pin
Acrylic splints are fabricated
Final vertical position of the maxilla is confirmed
using the external reference point


Segmental maxillary surgery
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Additional measurements at dental landmarks in
each dentoalveolar segment are required


Mandibular surgery
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Maxilla used as a template
As maxillary position is constant – use of
semiadjustable articulator or face-bow not always
required


Double-jaw surgeries
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Determine the final position of maxilla
Intermediate splint
Mandibular repositioning
Final splint


Splints


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1992 – Bell
Three-dimensional surgical movements of jaws
Common reference plane - FH
Semiadjustable articulator
Dental models : Patient‘s facial structures – 1:1
Cephalometric radiographs – 10% enlargement
CT scans – 1:1


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Common reference plane - FH


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Model platform and the model block


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Measuring final models for dentofacial surgery


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Technique
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Record space available measurements on a model
surgery worksheet
Trim the cast to simulate normal anatomic
characteristics at the oestotomy site
Scribe the long axis and the proximal root surface
anatomic features of each tooth on the stone


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Technique
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Scribe an X over each tooth at the alveolar crest and at
the level of the apex of the longest tooth; both labially
and lingually
Measure the distance between the marks on the buccal
and lingual surface of the model at the apical and
crestal aspects; these are presurgical interdental records


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Orthognathic surgeries – described in European
literature – 70 years
1960’s - Kole and Bell – Scientific basis of
Orthognathic surgery
1970’s – Modification of various surgical
procedures
1969-1975 – Bells’s research established the
biological basis of Orthognathic surgery
Fonseca


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Revascularization studies of Bell and Fonseca:
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Vascular ischemia and tissue necrosis –
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Improper design of the soft tissue incision
Excessive stretching of the palatal soft tissue pedicle
Segmentalization of the maxilla
Extensive hypotension
Severance of the descending palatine vessels


Revascularization studies of Bell and Fonseca
Findings
I Palatal soft tissue pedicle and the labial buccal gingiva
provide a adequate nutrient pedicle for single stage
osteotomy
II Bilateral transection of the descending palatine vessels
did not adversely affect the LeFort I osteotomy procedure
if the basic surgical principles were followed
III Investigated the limits of LeFort I osteotomy using
standard circumvestibular incision, segmentalizing the
maxilla, stretching the vascular pedicle and transecting
the descending palatine arteries – result was
uncomplicated post-operative healing with transient
vascular ischemia

Revascularization studies
IV 1994 – Dodson et al. - Measured the blood flow to the
maxillary gingiva using laser doppler flowmetry
following LeFort I osteotomy with sacrifice of bilateral
descending palatine arteries – Only transient vascular
ischemia and restored blood flow in the anterior maxilla
one week post operatively
V 1991 – You et al. - Showed no histological osteonecrosis
and restored vascularity
VI 1997 – Siebert et al. – Elucidated the “palatal
contributions” to the blood supply to the moblized LeFort
I segment. (Ascending palatine branch of facial artery and
anterior branch of the ascending pharyngeal artery)


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Histological concept of blood flow in the gingival tissue
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1970 – Bell - 5-6mm of osteotomy distance from the apices of the
maxillary teeth
1973 – Pepersack – Confirmed the above finding
Kahnberg and Engestrom – 100% teeth in the osteotomized
maxilla regained their vitality within 18months
Kahnberg and Engestrom – 50% had radiographically healthy
sinuses after 6months – 50% had minimal mucosal swellings
Di et al. – Minimal pulpal changes and normal growth of
developing teeth


Revascularization studies in mandible
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Immediately post operatively – generalized
intramedullary circulation in proximal and distal
segments
Only avascular area – margins of the osteotomy site
Boc and Peterson – decrease in pulpal and periodontal
ligament blood flow immediately following surgery
1 week – vascularization at both the segments,
hypervascularity at the surgical site and no evidence of
soft tissue reattachment
Bell and Schendel – Modified BSSO – less stripping of
the pterygomassetric sling – leads to decreased necrosis

Revascularization studies in mandible
Vascular blood supply in mandible is centrifugal
– post operatively this arterial flow is from
peripheral anastomosis
(Mental artery and mandibular branch of the
sublingual artery)
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Orthognathic Surgery -III

Dr Sangamesh B.


Surgical Procedure
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Maxilla
Mandible
Bi-jaw
DO
Surgery before growth
OSA
Adjunctive surgical procedures


summary


Mandibular excess


Mandibular exess


Maxillary excess


Maxillary excess ( vertical )


Maxillary excess ( vertical)


Mandibular deficiency ( sagittal)


Mandibular deficiency ( vertical)


Genioplasty


Maxillary excess (vertical)


Open bite


Maxilla
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1859 – von Langenbeck – first Orthognathic surgical
procedure for removal of Naso-pharyngeal polyp
1867 – David Cheever – for treatment of complete nasal
obstruction
1921 – Cohn-Stock – Anterior maxillary osteotomy
1927 - Wassmund – LeFort I/Total maxillary osteotomy
1934 – Axhausen – for correction of healed maxillary
fracture


Maxilla
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1950 – Gillies and Harrison - 1950 – LeFort II osteotomy
involving the premaxilla and nasal complex
1959 – Schuchardt – Posterior maxillary osteotomy
1965 – Obwegeser – Complete mobilization of maxilla –
Major advance in stability (Haller, Hogemann & Willmar
and Perko)
1973 – Henderson – Classic pyramidal LeFort II
1969-1975 – Bells’s research established the biological
basis of Orhtognathic surgery


Maxilla – Surgically Assisted Maxillary
Expansion
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BROWN (1938) first described SAME
Is essentially a combination of distraction
osteogenesis and controlled soft tissue expansion
Etiology of transverse maxillary deficiency;
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Congenital
Developmental
Traumatic
Iatrogenic


Maxilla- Surgically Assisted Maxillary
Expansion
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Diagnosis of transverse maxillary deficiency
Clinically
Radiographically
Clinically
 Unilateral or bilateral cross bite
 Crowded, rotated or buccally placed teeth
 Narrow or tapering maxillary arch
 High or narrow palatal arch
 Hour glass shaped maxillary arch
 One or more teeth in cross bite is probably skeletal deficiency
Radiographically
 P A cephalogram is the choice

Maxilla - Surgically Assisted Maxillary
Expansion
Treatment techniques
 Slow dentoalveolar expansion (SDE)
 Orthopaedic rapid maxillary expansion (ORME)
 Surgically assisted maxillary expansion (SAME)
 Segmental maxillary osteotomy


Expansion
Indications
 Skeletal maxillomandibular transverse discrepancy
greater than 5mm
 Significant transverse maxillary deficiency associated
with narrow maxilla and wide mandible
 Failed orthodontic expansion
 Necessity for a large amount of expansion more than 7
mm
 Extremely thin delicate gingival tissue
 Presence of significant buccal gingival recession in
canine bicuspid area
 Significant nasal stenosis

Expansion
ACTIVATION
 Two types
 During procedure the appliance activated 3-4 mm
and then turned back to final opening of 1-1.5
mm
 Following surgical procedures, after five days at a
rate of 0.5mm per day (Ilizarov)


Segmental maxillary osteotomy







Plating at a particular expansion
Higher chances of relapse
More expansion in the molar region than in the
canine region
Widening of more than 6mm is not feasible
Inelasticity of the palatal mucosa is the major
limiting factor


Complications
 Hemorrhage
 Osteotomy 5mm above apices
 Preserve bony coverage of the medial surface of
the central incisor roots
 Inadequate release of maxillae


Surgical Techniques




Le Fort III

Le Fort I
Le Fort II
Le Fort III

Le Fort II

Le Fort I


LeFort I Osteotomy
A. Low-level osteotomy
B. Approaches the orbital rim
C. Cheek prominence
D. Low-level osteotomy


Maxilla – Anterior segmental osteotomies
Indications
 Marked protrusion of maxillary teeth with normal
incisor axial inclination to the alveolar bone
 Anterior open bite when vertical maxillary excess
is not present
 Patient noncompliance in anterior retraction
 Root resorption, ankylosis – orthodontic tooth
movement is not advisable
 Improvement by reduction of prominent upper lip

Maxilla – Anterior segmental osteotomies




Wunderer method
Wassmund method
Cupar method


Maxilla – Posterior segmental osteotomies
Indications
 Posterior maxillary alveolar hyperplasia
 Total maxillary hyperplasia
 Distal positioning of the posterior maxillary
alveolar fragment to provide space for proper
eruption of impacted canine or bicuspid
 Spacing in dentition
 Transverse excess or deficiency
 Posterior open bite

Maxilla – Posterior segmental osteotomies


Mid face osteotomy procedures




Maxillary Qudarangular LeFort I and
Qudarangular LeFort II osteotomy
Highlevel midface osteotomy





LeFort III Osteotomy
LeFort II Osteotomy

Facial malformations – Hemifacial microsomia,
Crouzon’s syndrome, Apert’s syndrome etc.

Mid face osteotomy procedures





Maxillary-mandibular horizontal deficiency
Class III skeletal malocclusion
Normal nasal projection
Zygoma and infraorbital deficiency




Highlevel midface osteotomy





LeFort III Osteotomy
LeFort II Osteotomy

Indications




Total midface hypoplasia
Apert’s syndrome
Binder’s syndrome


Mandible





1849 – Hullihen – Anterior sub-apical osteotomy
1954 – Caldwell and Letterman – Intra-oral
vertical ramus osteotomy – Setback procedure –
could not allow advancement
1955 – Trauner and Obwegeser – BSSO


Mandible






1961 – Dalpont – Modification
of BSSO – Advance the
oblique cut to the molar region
and the vertical cut to the
lateral cortex
1968- Hunsuck – Shortened
the cut on the medial cortex of
the ramus – at the level of
mandibular foramen
1970 – Bell, Schendel and
Epker – Modified the
technique by making a
complete cut till the lower
border of the mandible

Mandible











BSSO
TVRO
EVRO
Combination techniques
Inferior alveolar neurovascular bundle decompression
Body osteotomy
Midline osteotomy
Inferior border osteotomy
Anterior subapical osteotomy
Total subapical osteotomy

BSSO


BSSO
Indications
 Horizontal mandibular excess
 Horizontal mandibular deficiency
 Horizontal mandibular asymmetry
 Setback of 7-8mm


TVRO


IVRO
Indications
 Setback of more than 12mm


Midline osteotomy


Combination
- Vertical ramus and sagittal osteotomy


Ramus and Body osteotomy


Anterior subapical osteotomy


Total subapical osteotomy


Distraction osteogenesis


Orthognathic surgery before completion
of growth
Assumption - Early surgery retards further growth
expression
 Vertical maxillary excess
 Maxillary deficiency





LeFort III – Crouzon’s disease or Apert’s syndrome

Mandibular prognathism
Mandibular deficiency


Orthognathic surgery before completion
of growth








Accurate diagnosis of the growth status
Psychosocial concerns – social pressure and peer
acceptance
Surgery for excess has greater risk of unfavorable
outcome than surgery for deficiency
Surgical treatment done on patient request
Inform the necessity to repeat the treatment at a
later age

Obstructive sleep apnea


Non surgical







Weight loss
Change in sleep position
Pharmacologic options
Oral devices
Avoidance of sedatives
CPAP OR BiPAP


Obstructive sleep apnea
Indications
 RDI > 20
 Failure to tolerate CPAP
 RDI < 20 in young patient
with congenital facial
deformity
 Oxygen desaturation <
85%
 Cardiac arrhythmias
associated with
obstruction

Treatment options
 Tracheostomy
 Nasal/septal surgery
 Uvulopalatopharyngoplasty
 Genial / hyoid advancement
 Maxillomandibular
advancement
 Tongue reduction


Adjunctive procedures


Chin modification







Rhinoplasty
Facial soft tissue contouring
Lip procedures







Chin augmentation
Chin reduction

Lengthening of the philtrum
Management of aging changes in the lips
Lip augmentation
Lip reduction: reduction cheiloplasty

Submental procedures


Soft tissue reduction

Genioplasty




1942 – Hofer – Horizontal
osteotomy of the
symphysis
1957 – Obwegeser –
Intra-oral procedure


Chin modification - Genioplasty


Chin silicone implant


Rhinoplasty


Alar cinch V-Y plasty


Facial soft tissue contouring


Lip procedures


Submental procedures: Soft tissue
reduction


Fixation methods



Traditional fixation
Rigid internal fixation



1992 Ellis et al. –
compared rigid fixation to
wire fixation methods




Predominance of indirect
bone healing in wire
fixation
Primary healing from
medullary bone in rigid
fixation


Fixation methods
Materials
 Non-resorbable



SS
Vitallium
Titanium











Bioresorbable
Polyglycolic acid
L-polylactide
Degraded by
carbohydrate metabolism
via kerbs cycle into CO2
and H2O





Rowe and Williams



Killeys







Maxilla
1.5mm and 2mm
L shape
T shape
X shape






Mandible
Lag screws
Position screws
Plates


Complications/Disadvantages:
 Instrumentation
 Improper placement – malocclusion, TMJ pain
 Infection
 Plate exposure
 Loose screws - necrosis
 Palpable screws


Lingual plate fracture of the distal segment

Rehabilitation







Biologic response to surgery
TMJ function and dentofacial deformities
Perioperative considerations
Neuromuscular rehabilitation
Range-of-motion excerises
Mandibular hypomobility








Functional outcomes following orthognathic
surgery
Soft tissue changes associated with orthognathic
surgery
Psychological ramifications of orthognathic
surgery




Functional outcomes following orthognathic
surgery


Simple functional tasks






Maximal excursions
Maximal bite forces
Jaw muscle strength

Analysis of mastication




Masticatory cycles
Masticatory forces
Masticatory performance



Soft tissue changes associated with orthognathic surgery





Facial proportions
Nasal structures
Labial structures
Techniques of soft tissue control











V-Y closure
Alar cinch
Combination of V-Y closure and alar cinch
Contouring the ANS
Septoplasty
Double V-Y closure

Chin

Secondary revision of poor surgical results

Post Surgical Orthodontics


Upper arch






Lower arch




17x25” TMA in 0.18” slot
19x25” TMA in 0.22” slot
21x25” Nitinol in 0.22” slot
0.16” SS

Elastics – 23hrs 55min – 5min for brushing

Post Surgical Complications


Post Surgical Complications





TMD
Paraesthesia
Decreased bite force


Relapse and Stability







Rigid fixation has improved stability
Stability is mostly influenced by the pattern of
rotation of the mandible as it is advanced
Advancement of maxilla and/or mandible will
stretch soft tissues promoting relapse
The more advancement needed, the greater the
probability for relapse


Relapse and Stability








Proffit. White. Sarver
Proffit 3rd edition
Arnett. McLaughlin
Fonscea vol II
Bell. Epker


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