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Pre & post surgical orthodontics /certified fixed orthodontic courses by Indian dental academy
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Pre & post surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Pre & post surgical orthodontics /certified fixed orthodontic courses by Indian dental academy Pre & post surgical orthodontics /certified fixed orthodontic courses by Indian dental academy Presentation Transcript

  • Pre and Post Surgical Orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • Introduction 1. Pre Orthodontic Preparation – Control of pathologic problems 2. Pre-surgical orthodontics 3. Final surgical preparations 4. Surgery and postoperative care 5. Post-surgical orthodontics 6. Retention Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics • Adult Patients a) b) c) d) Chronic systemic diseases Pregnancy Prolonged use of drugs Dental problems Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics a) Chronic systemic diseases – Hypertension and diabetes – Taxes patient compliance – Drugs and diet alteration b) Pregnancy – general anesthesia – surgery must be delayed for 4-6 months after delivery Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics c) Prolonged use of Drugs – – interactions with general anesthetics Prostaglandins Prostaglandin inhibitors Corticosteroids and NSAIDs Chronic Arthritis Pre and Post Surgical Orthodontics Dr. Punit Thawani Other drugs Tricyclic antidepressants, antiarrtiarrhythmic drugs, antimalarial drugs
  • Before Orthodontics • Phenytoin – gingival overgrowth – seizures may be exacerbated by orthodontic appliances • Dryness of the mouth – irritation due to the orthodontic appliance – smooth appliance – oral hygiene Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics d) Dental Disease • Caries control – • 0.05% NaF mouthrinse Missing teeth – – Bridges – need removal Riding pontic Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics • • • Metal crowns Porcelain crowns Acrylic crowns Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics Periodontal problems • oral hygiene maintainance • Hopelessly mobile teeth – Offer better stabilization during surgery than removable partial dentures. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics Mucogingival considerations Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics • Mucogingival considerations – Maintenance of attached gingiva • Orthodontic expansion of the dental arches • Surgical incisions in the vestibule. – Class III correction & Genioplasty • Ressective osseous surgery Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics Implications of reduced periodontal support • Lighter force • Greater counter-moments are needed for tooth movement Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics Impacted and unerupted teeth. • Growing children – unerupted teeth may be encountered during the osteotomy cuts. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics • Adults – maxillary canines and third molars can be removed at the time of LeFort I osteotomy Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Before Orthodontics Mandibular 3rd molars • Remove 6 months before a BSSO, so that the socket is properly healed at the time of surgery • Complications – – – – Bad split Chances of infection Difficult to use rigid internal fixation, due to the space occupied by the tooth. Increased chances of fracture Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Surgical and orthodontic treatment BASIC OUTLINE • Pre-surgical orthodontics - removes dental compensations, and positions the teeth properly in relationship to the individual skeletal bases. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Surgical and orthodontic treatment • Heavy archwires are placed and the appliance is used for stability and fixation during surgery. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Surgical and orthodontic treatment • Active orthodontics is reinitiated to refine the occlusion. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Goals – 1. Align and level teeth without concern for dental occlusion. 2. Establish proper anterior-post. and vertical position of the incisors. 3. Achieve arch compatibility. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics General guideline • Post surgical orthodontics (Between 4-6 months) If the patient is not properly prepared – • Surgery cannot be carried out effectively, • Quality of the result is diminished • Post surgical orthodontic treatment time increases Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics • 1. 2. 3. 4. Selection of the appliance Stability Esthetics Slot Size Bonding vs Banding Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Stability • Stabilize the teeth against stresses encountered at surgery and during IMF • PAE is recommened • Begg appliance for surgical patients – rectangular wire in the ribbon mode. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Esthetics Lingual appliances • Impossible to use the appliance for IMF • Post op – patients have difficulty in mouth opening • Hugo et al (J Adult Orthod &Orthognath Surg 2000) – use of labial appliances just before the surgery and thereafter until the end of the treatment. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics • • Width of the labial brackets have been reduced to increase esthetics Extremely narrow brackets have poor rotational and tip control. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Tooth colored brackets • Plastic brackets – Fracture – Poor torque control • Ceramic brackets – Good torque control – Brittle and can fracture – Should be prepared with alternative measures Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Slot Size Either slot size – 18 or 22 • 17x 25 ss for 18 slot • 21x25 ss or TMA for 22 slot • segmented arch mechanics - 22 slot Bonding vs banding – • bond anteriors, and band posteriors. • perio problems, bands are to be avoided Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Appliance modifications 1. Extreme prescriptions must be avoided. “Extraction series” – too much tip Opposite side bracket should not be used Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics 2. Include all teeth in strap up Mand. 2nd molars – before surgery Max. 2nd molars – after surgery 3. Auxillary molar tubes and headgear tubes • lingual attachments Cross elastics Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics 4. Brackets with adequate mesio-distal and rotational control – twin brackets ½ the m-d width of the tooth single brackets with rotational wings • Integral hooks in the brackets – – – Help in stabilization Long hooks should be avoided brackets may get dislodged if these hooks are used for stabilization, hooks on the archwire preferred. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Alignment of the arch • Principles of alignment remain the same. • Initial tipping – – undersizes, round and resilient wires. free sliding, freedom to tip and light continuous forces. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Leveling of the Arch Presurgical Postsurgical Intrusion Extrusion Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics • Final vertical height ➫ Position of the lower incisors – Increase the face height → the lower incisors should not be intruded – In patients with normal or excessive face height, the lower incisors must be intruded pre-surgically Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Final position of the incisors is determined pre surgically Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Segmental procedures ➫ Teeth should be leveled within the segments Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Ant – post positioning of the incisors • Affects the sagittal placement of the jaws during surgery • dental compensations must be removed • Movements opposite to camouflage Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics • Extraction pattern in surgical patients – – – Opposite to camouflage Worsening of the occlusion Extraction of teeth during the surgery itself Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Over – treatment • Orthodontic relapse + IMF • Wire fixation with IMF – Mandible tends to slip back – Low. Ant . Procline, U ant. Retrocline • Rigid fixation – Very short period of IMF – No need to overcorrect. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Segmental surgeries • Establish torque of incisors pre surgically • ½ extraction site left open Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Anchorage consideration • Opposite directions of movement • Intermaxillary elastics • Extra oral forces rarely needed • Small amount of space can be left open Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Arch compatibility • Shape and width • Co-ordinated arch wire Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics • • • Torquing of roots Not more than 5 mm of dental expansion ½ cusp cross-bite can be corrected post-surgically Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics Confirming compatibility of arches – • Class II patient – Protrude the mandible • Class III patient – Frequent models Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Pre-Surgical Orthodontics • At the end of the pre-surgical phase, the patient should be in a full sized rectangular steel wire which will help stabilize the teeth during surgery Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Stabilizing wires • Full dimension, filling the slot – 17 x 25 ss for 18 slot – 21 x 25 ss or TMA for 22 slot – 19 x 25 wire in a 22 slot is acceptable • Attachments for IMF – Attachments on the arch-wire are preferred – Kobayashi hooks not useful • The stabilizing wire must be passive Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Stabilizing wires Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Final surgical Planning 2 weeks before surgery • OPG • Lat. Ceph • Casts • Photos – intra and extra-oral • PA ceph – if there is facial asymmetry • IOPAs and occlusal view if needed. • Face bow transfer onto an articulator if needed Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Final surgical Planning • OPG – Root proximity at osteotomy site – Confirm with IOPAs • Lateral Ceph. – For pre surgical prediction • Models – Model surgery – Preparation of the splint Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Final surgical Planning Need for a facebow transfer 1. Mand. dentition – condylar relation maintained Mand. is required to auto-rotate Segmental subapical procedures of the mandible. 2. In case of 2 jaw surgeries Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Final surgical Planning • Condyle - mandibular dentition relation is to be chanced during surgery, a facebow transfer is not needed. • Mounting on a simple articulator will do. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery Purpose of model surgery • 1) To verify that the planned movements are possible • 2) To relate the mandibular and maxillary dentitions in the position where the surgical splint will be made. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery Model surgery – 4 weeks after stabilizing wire is placed Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Impressions Wax bite to record Pre surgical occlusion Face-bow record Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Casts mounted on semi-adjustable articulator Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Mounting of maxillary cast with spacer Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Blue plaster used for initial mounting Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Jig positioned in articulator Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Maxillary cast stabilized with putty Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Initial mounting plaster removed Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Maxillary impaction Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Measurement of amount of impaction Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Simulation of mandibular autorotation Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Intermediate splint Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Mandible advanced to desired position Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Final splint fabricated Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery Final Splint Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - 2 jaw surgery If the jig is not available, markings can be made on the cast Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Casts mounted on articulator Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Max. cast sectioned and positioned as required Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Duplication of maxillary cast Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Mandibular cast positioned – hinge articulator Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Wires made as required Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Final splint made Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Final splint placed back on original mounting Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Intermediate splint made with final splint in place Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Intermediate and final splints Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint ‘Piggy – back splints’ Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery – ‘Piggy-back’ splint Piggy – back splint on the casts Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Requirements of the splint • Fit the teeth accurately • Minimum thickness – not more than 2 mm Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Requirements of the splint • Excess acrylic should be trimmed off the buccal aspect, to allow for proper visual verification during surgery and oral hygiene maintenance. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - Problems • Dental interferences – Further presurgical orthodontics? Interference in second molar region • Usually caused due to not bonding lower 2nd molar and bonding upper 2nd molar. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - Problems • • Condylar distraction Trim cusp or prolong pre-surgical orthodontics Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Model Surgery - Problems • Incompatibility of canine widths – – – • Easy to check in Class II – not Class III Can result in ant. Open-bite Go back to lighter wire Lack of space between roots to place osteotomy cuts Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • During Surgery • Splint used to help attain final occlusion • Segmental osteotomies – wire placement • IMF with splint in place • Teeth might penetrate thro splint • Splint should be in place until start of post surgical orthodontics Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Operative Events • Hospitalization – 2-3 days for single jaw – 4-5 days for double jaw • • • • Facial edema – 2-3 weeks Resumes partial function in 2 weeks Mastication after 6-8 weeks Complete bone healing – 6 months Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Operative Care • 1 week soft diet – Milk, mashed potatoes, scrambled eggs • After 2 weeks – more chewing – Chapattis, vegetables, and meat in small pieces • • Progress to normal diet Normal diet in 6-8 weeks Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Operative Physiotherapy • As soon as the initial intracapsular joint edema has resolved – after about 1 week. – 1st week after surgery – open and close mouth gently within comfortable limits – Over next 2 weeks – 3 10-15 minute sessions of opening and closing and lateral movements. – 3rd – 8th weeks, range of motion is increased, and should be normal in 8 weeks. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Operative Care • Orthodontist should see the pt within the 1st week – review the occlusal status and check the status of the orthodontic appliance. • Post surgical orthodontics – adequate bone healing – adequate mouth opening Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Operative Care • • • Rigid internal fixation and jaw exercises ➫ 2-3 weeks Wire fixation and IMF ➫ 3-4 weeks after the IMF is released. Splint and light elastics to guide occlusion Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Surgical Orthodontics • • • • After adequate healing of bone (surgeon’s opinion) Splint and stabilizing wires should be removed together Splint and wires provide solid occlusion Prevent CO-CR discrepancy Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Surgical Orthodontics • Working archwires placed – 0.016” steel – 21 x 25 NiTi or Braided Steel – Stabilizing wire left in place in 1 arch Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Surgical Orthodontics • Maxillary segmental procedures – Teeth across the osteotomy site should be ligated tightly – Box elastics are placed on both sides of the osteotomy site – from one side to the other – ? Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Surgical Orthodontics • Light box elastics – Extrude teeth – Guide occlusion – Elastics crossing osteotomy site? • Protocol – 1st month – full time, including while eating – 2nd month – Full time, remove while eating – 3rd month – Night time only Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Surgical Orthodontics • Good amount of settling in first month • Step bends in archwires Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Surgical Orthodontics • • • Headgears and extra oral forces Heavy intermaxillary elastics Overlay wire for transverse stabilization Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Post Surgical Orthodontics • Finishing with positioners – Parasthesia after surgery – Variable biting force • At the end – Proper settling – Root parallelism – esp. osteotomy site Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Retention • • • Not very different from routine orthodontics. Transverse retention Fixed retainers Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Summary Before surgery Alignment Leveling – by intrusion Arch compatibility Preparation of osteotomy site Before and/or Post. crossbite correction – if after surgery orthodontic expansion is planned Leveling by extrusion After surgery Settling and leveling by extrusion Root paralleling at osteotomy sites Detailed tooth positioning Retention Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Clinical Management Of Some Commonly Encountered Orthognathic Surgical Patients 1. Mand. Deficiency with normal or reduced facial height 2. Excessive face height (long face) 3. Class III problems 4. Facial asymmetry 5. Crossbite and open bite Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height • • • • • Horizontal growth pattern Class II molar and Canine relationship – often with a div. 2 pattern. Excessive curve of spee in the lower arch. Incisor crowding Deep bite – usually causing some gingival irritation Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height • • • Chin button well developed Deficiency near the lower lip region – seen as a deep mentolabial sulcus, a curl of the lower lip and an aged appearance. TMJ disorders – (disputed) Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Surgical plan • In most of these patients, – – Mandibular deficiency needs to be corrected Height of the face must be increased. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Mandibular subapical procedure vs. BSSO Subapical procedure – When face ht. is not to be increased BSSO – To increase face height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height • Rotation of mandible – chin moved back and incisors forward • Genioplasty if needed – Reduce chin prominence – Further increase face height • No maxillary surgery to increase face height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre surgical Orthodontics Position of the incisors – vertically and sagittally Vertical – Determines final face height Sagittal – Determines amount of movement Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height • Expansion of arch may be necessary – Wider part of mandible comes forward – Can be done orthodontically or surgically – Extractions may not be required Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height • Considerations during model surgery – Face bow transfer rarely required – Maintain bilateral symmetry – even if crossbite develops – Keep skeletal midlines matching • Post surgical orthodontics – – Level COS by extrusion Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mand Deficiency with normal or reduced facial height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems • • • • Vertical excess of post maxilla ↑mand plane angle Incisor exposure Incompetent lips Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems • • • Gummy smile Narrow maxilla Cross-bite Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Surgical considerations • impacting to maxilla – mandibular autorotation • Rotating the mandible upwards and forwards after a BSSO • Chin procedures Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems • Maxillary procedure – Stable – Corrects most of the problem • BSSO with rotation – Soft tissue stretch – Unstable • Chin procedures – used as adjuncts Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Pre surgical Orthodontics • Orthodontist must know 2 things – – Maxilla in 1 piece or segmented? – how many pieces, and where – Chin position? - or is proper lip – chin balance going to be achieved by orthodontic treatment Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems • Segmented procedures – Align within the segment – Stabilize with a wire with step, or segments of 21 x 25 SS wire – Roots of adjescent teeth • Leveling – If mild, by intrusion – If severe - surgically Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems • Expansion – – – – Orthodontically Surgically But not both Causes more relapse Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems • Maxillary impaction – – – – – ↑ wrinkles on the cheek Drastic reduction in incisor exposure Widening of alar bases Aged appearance More tolerated in younger individuals than adults Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems • • If maxilla is moved back - ↓lip support Maxilla may have to be moved forward to get good lip support • Genioplasty – avoid major jaw surgery Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Before model surgery • How much is the maxilla going to be moved • How to reduce residual overjet (if any) • Surgical expansion? – Prepare overlay wire Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Post surgical Orthodontics • Segmental procedures – torque on anteriors – Flexible rectangular wires in upper – 0.016” SS in lower • Stabilizing transverse corrections Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Face Problems Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • • • • Flatness in the lower 1/3rd of the face – especially in the labio-mental fold. Soft tissues seem to be tight. Midface deficiency – “sunken in” appearance is seen. Thin vermillion border, and reduced maxillary incisor exposure at rest. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • Natural compensation – Flared upper incisors, retroclined lower incisors. – Spacing between lower teeth – should think of large tongue – Maxilla may have small or even missing teeth. – Check for attached gingiva in lower anterior – labial region. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • Surgical techniques 1. Mandibular – 1. (BSSO) 2. Mandibular sub apical procedures 2. Maxillary – 1. Lefort I osteotomy - high level 2. Expansion 3. Genioplasty Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • • Jaw at fault should be operated If mandible too prognathic – both jaws – Too much setback ➫ Double chin • Maxillary impaction in case of hyperdivergent jaws Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • • • Jacobs – ‘two patient’ concept Incisors should be positioned as ideally as possible to their respective jaw bases, without concern for inter-arch occlusion. Maxilla – require extractions and significant retraction • Mandible – Non extraction or extraction for molar correction – Molar inclination correction Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • If upper expansion is needed – Teeth should be aligned within the segments – Arches should NOT be co-ordinated presurgically – Gross coordination surgically – Final coordination post surgically Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • • Frequent progress models Before surgery, patients should be informed about – – Possibility of late mandibular growth – Large amount of setback – double chin, may require second soft tissue surgery – Possibility of nasal changes – alar base widening and upturning of the nose. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Post surgical orthodontics Basic principles to be followed Check for relapse tendency Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Tendency towards relapse • Moderate class III elastics (200-300 gms)– heavier rectangular wires needed • Upper incisors can be flared to an extent • Interproximal reduction, and retroclination of lower incisors • Leave larger overjet and overbite Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients • If relapse is still expected, the retention appliance can be made with hooks for attachment of light class III elastics while sleeping Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Class III patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry • More through diagnosis – PA view – Submento-vertex – CT scan Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry Surgery in children • Severe or progressive asymmetry – Hemifacial microsomia – mandibular ankylosis due to condylar fracture Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry • Principle of treatment – – Modify growth to its full potential so that the child grows out of the deformity • Initial functional appliance treatment – Eliminate need for surgery – Make surgery easier – Help in muscular adaptation Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry • Role of orthodontist – – Growth guidance after surgery – Maintenance of normal joint function – Alignment of permanent teeth Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry Asymmetry problems in adolescents • Continue growth guidance – prevents bimaxillary problems • Problems of excessive growth – Hemifacial hypertrophy • Orthognathic surgery at the end of growth Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry Problems of excessive growth • Diagnosis – 99mTc scan • After growth – surgical correction Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry • In severe cases – surgical correction before growth is completed – Only mandibular surgery – cant of occlusal plane corrected by functional appliances Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry Asymmetry in adults • Extent of surgery – – Correct asymmetry at its source – Camouflage • Pre and post surgical orthodontics – similar to any other case Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry Guidelines – • More concern about transverse than vertical asymmetry • More concern about chin position than mandibular angles • Maxillary midline more critical than mandibular midline Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry • If nose and jaw are deviated to the same side, both should be corrected • Asymmetry of higher structures - infraorbital rims, Zygomatic arch – onlay grafts should be considered Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry • Pre-surgical orthodontics – Matching skeletal and dental midlines • Asymmetric extractions • Asymmetric elastics and cross elastics • Loops and springs – Know the type of surgery • Genioplasty • Ramus osteotomy Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry • Post surgical orthodontics – Leveling by extrusion – May be longer in such patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Dento-facial Asymmetry Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Adults with cross-bite can be divided into 3 groups • Patients with a narrow maxilla – (RME would have been done) • Large mandible • Patients with mandibular arch locked within the maxilla (Scissors bite if unilateral or Brodie bite if bilateral.) Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Surgically assisted RME • Preferable in patients below 25 • Not very predictable between 25-35 • Never done above 35 yrs of age Osteotomy in the lateral buttress area is preferred. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Patients with a wide mandible • Try to treat the jaw at fault • When in doubt – widen the maxilla • Mandibular narrowing – Step ostectomy in anterior mandible – Remove bone in premolar region & setback Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Interlocking crossbite (scissors bite, Brodie bite, ‘X’ Occlusion) • Severe overlapping of teeth • Upper jaw has to be moved superiorly and laterally (unilateral) • Mandible can be widened if necessary – (distraction osteogenesis) - or advanced Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Pre surgical orthodontics • Short • Bonding to lower arch not possible • Only upper alignment • Lower arch stabilized by directly bonding 19 gauge wire to teeth during surgery Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Post – surgical orthodontics • Longer than usual • Aligning lower arch, and refining occlusion Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults Adults with open-bite • Segmental procedures to impact posterior maxilla • Segmental procedure to elevate mandibular anteriors • If teeth do not respond to orthodontics Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults • Segmental procedure to elevate mand. anteriors Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Cross bites and Open bites in Adults • Pre surgical orthodontics – Align within the segments – Prepare osteotomy site • Orthodontic movement should not be done to correct the defect – relapse • Post surgical orthodontics – stabilization of expansion – at least 6 months Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Surgery in Patients with TMJ Problems • General guideline for management Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Surgery in Patients with TMJ Problems • • Orthodontics and/or surgery to correct occlusion TMJ surgery – Not responding to reversible therapy – Progressive internal joint pathologies Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Stability of Surgical Corrections The stability of orthognathic surgical procedures depends on the following – 1. Direction of movement 2. Type of fixation used 3. Surgical technique employed Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability Maxillary impaction Mandibular advancemet (short and normal face) Genioplasty Maxillary advancement Max. up + Mand. forward Mandible back Maxilla down Maxillary widening Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability Maxillary impaction • Most stable procedure • Mandible auto-rotates to maintain the freeway space • Wire/IMF vs RIF equally good results • Wire/IMF – – 6 weeks after the surgery - 20% of patients showed 2-4 mm of change in the upward direction 6weeks to 1 year - that much downward movement of the max Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability RIF or wire/IMF seemed to make no significant differences in stability. More than 90% chance of max being within 2 mm of post surgical position after 1 year • Bishara et al 1988 • Denison et al 1989 • Proffit et al 1992 Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability Mandibular advancement (BSSO) • normal or short face height is considered Wire/IMF • first 6 weeks post surgery – • 6 weeks to one year – • the mand had a tendency to move slightly back. the changes seemed to be recovered function Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability RIF • smaller tendency to move back • greater chance of slight forward movement 90% chance of stability • • • • Pre and Post Surgical Orthodontics Dr. Punit Thawani Proffit et al 1990 Kouma et al 1991 Gomes et al 1993 Ingervall et al 1994
  • Hierarchy of Stability • BSSO with rotation to close an open bite – Soft tissue stretch – RIF more stable than wire/IMF – Interpositional bone grafts and heavy plates • Ritzik et al 1990 Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability Maxillary impaction & mand. Advancement Wire/IMF • Individual procedures – Maxilla ↑ – Mandible ← • Unlike the individual procedures – No recovery between 6 mo to 1 year and relapse continued in 1/3rd of the patients Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability • By the end of 1 year, only 60% of the patients were judged to have excellent clinical results Post surgical bite opening tendency is seen Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability RIF • RIF in mandible improved stability • Slight relapse of the mandible between 6 weeks to 1 year • Over 90% patients were judged to have good clinical outcomes • No bite opening tendency is seen. • • Pre and Post Surgical Orthodontics Dr. Punit Thawani Hennes et al – 1988 Sinclair et al – 1991 • Proffit et al – 1992 • Ayoub et al – 1993
  • Hierarchy of Stability Maxillary advancement • If moved only anteriorly – 80% stable • If simultaneous downward movement – unstable • • Pre and Post Surgical Orthodontics Dr. Punit Thawani Proffit et al – 1991 Bishara , Chi - 1992
  • Hierarchy of Stability Mandibular setback • BSSO and Trans-oral vertical ramus osteotomy (VRO). • VRO seemed to be more stable than BSSO Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability VRO • chance of further backward • but forward relapse also occurred With BSSO • no post surgical backward movement, but forward relapse occured • RIF with BSSO seemed to make relapse tendencies worse Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability VRO • improper positioning of condyles in fossa resulted in backward movement Both procedures • Change in ramus inclination resulted in forward relapse • Pre and Post Surgical Orthodontics Dr. Punit Thawani Proffit et al (1991)
  • Hierarchy of Stability Inferior repositioning of the maxilla • wire/IMF - almost all the inferior movement is lost. • RIF – strong relapse tendency. • occlusal forces • Ways of maintaining the correction are – – – – use of heavy fixation bars from zygomatic arch to the maxillary posterior teeth, use of interpostional bone grafts, or simultaneous ramus osteotomy • Proffit et al 1991 Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability Widening of the maxilla • 1 year later, almost 50% of the expansion was lost in the second molar region • Reduction in post surgical width of about 2 mm in 2/3rd of the patients. • • • Proffit et al 1992. Stretching of the palatal mucosa Modest overcorrection and stringent retention Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Hierarchy of Stability 3 Basic principles that influence post surgical stability – • Stability is greatest when soft tissues are relaxed during surgery and least when they are stretched. • Neuromuscular adaptation • Neuromuscular adaptation affects muscle length and not muscle orientation. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long term Prognosis of BSSO Mandibular Relapse and its Relation to Different Facial Types Yoshida et al Angle Orthodontist – March 2000 • • • • 15 patients – BSSO mandbibular setback Wire/IMF Followed for 10.3 years post surgery 2 types of facial patterns – – Mesoprosopic – Euryprosopic Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long term Prognosis of BSSO Mandibular Relapse and its Relation to Different Facial Types • Yoshida et al Angle Orthodontist – March 2000 Relapse tendency – Euryprosopic – forward rotation of mand – Mesoprosopic – backward rotation of mand. • Suggestions to reduce relapse – Euryprosopic – Sufficient setback – Mesoprosopic – adequate overbite – Good post-treatment occlusion Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Euryprosopic Pre and Post Surgical Orthodontics Dr. Punit Thawani Mesoprosopic
  • Long Term stability of Surgical Open bite Correction by Le Fort I osteotomy • • • • Proffit, Bailey, Phillips, Turvey AO Feb 2000 54 patients of open bite 26 - maxillary impaction only 26 - had max impaction and mandibular advancement Immidiate post surgical records, 1 year post surgical, and at least 3 years post surgical cephs were taken. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Term stability of Surgical Open bite Correction by Le Fort I osteotomy • Proffit, Bailey, Phillips, Turvey AO Feb 2000 In both the goups, there is – a tendency for the maxilla and mandible to move slightly downwards – maxillary and mandibular posterior teeth to erupt – mand anterior teeth to erupt. • Hence – increase in mand plane angle and face height Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Term stability of Surgical Open bite Correction by Le Fort I osteotomy Proffit, Bailey, Phillips, Turvey AO Feb 2000 Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long Term stability of Surgical Open bite Correction by Le Fort I osteotomy • • Proffit, Bailey, Phillips, Turvey AO Feb 2000 Despite skeletal changes, almost no changes in occlusion Authors attribute the change to – Continued growth into adult years – Inadequate physiologic adaptation in maintaining the freeway space Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Long term stability of mandibular setback surgery: A follow-up of 80 bilateral sagittal split osteotomy patients Mobarak, Espeland, Krogstad and Lyberg Int J of Ad. Orthod & Orthognath. Surg 2000 • During surgery – proximal segment tended to rotate clockwise, changing the orientation of the ramus to a more upright position • Follow up – Ramus returned to original inclination Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Stability of Le Fort I osteotomy in maxillary inferior positioning: Review of the literature Costa et al Int J of Ad. Orthod & Orthognath. Surg 2000 • Starling’s law states that a stretched muscle has increased contractile strength • Fixation techniques – – – – Wire fixation and IMF Rigid fixation only Rigid fixation and bone grafting Rigid fixation and alloplastic materials (porous block hydroxyapetite) Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Stability of Le Fort I osteotomy in maxillary inferior positioning: Review of the literature Costa et al Int J of Ad. Orthod & Orthognath. Surg 2000 • Wire/IMF – highest relapse – 50% overcorrection • RIF – more stable upto 2 mm • Rigid fixation with autogenous bone stable, and predictable Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Stability of Le Fort I osteotomy in maxillary inferior positioning: Review of the literature Costa et al Int J of Ad. Orthod & Orthognath. Surg 2000 • Rigid fixation with porous block hydroxyapetite showed excellent stability 2 studies • Greater relapse in the posterior part of the maxilla Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mandibular advancement surgery in high angle and low angle Class II patients: Different long term skeletal responses. Mobarak, Espeland, Krogstad and Lyberg AJO 2001 • 61 patients • BSSO only, no additional procedure performed, and Rigid internal fixation (RIF) followed for 3 years after surgery • 20 patients (20.8 + 4.8) - Low angle group • 20 patients (43 + 4) - High angle group • Remaining 21 patients in the normal group Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mandibular advancement surgery in high angle and low angle Class II patients: Different long term skeletal responses. • • Mobarak, Espeland, Krogstad and Lyberg AJO 2001 Stability of increasing MPA Dental changes – retroclination of the lower incisors, while the upper incisors remained more or less upright. Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mandibular advancement surgery in high angle and low angle Class II patients: Different long term skeletal responses. Mobarak, Espeland, Krogstad and Lyberg AJO 2001 Timing of relapse – • Low angle group about 98% of the relapse occurred within the first 2 months • High angle group, the relapse was more gradual – • • • 30 % in the first 2 months 25 % between 2 months to 1 year 38% in the between 1 year to 3 years Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mandibular advancement surgery in high angle and low angle Class II patients: Different long term skeletal responses. • Mobarak, Espeland, Krogstad and Lyberg AJO 2001 Relapse due to – – Intersegment mobility – Distraction of condyle • Implant studies (Rubenstein et al - 93, Rebellato et al -94) • Most of the relapse due to repositioning of condyle in fossa Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • Mandibular advancement surgery in high angle and low angle Class II patients: Different long term skeletal responses. • Mobarak, Espeland, Krogstad and Lyberg AJO 2001 Other possible causes for late changes – late mandibular growth in the original direction – residual effects of incompletely adapted suprahyoid musculature – Condylar resorption Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • References • Contemporary treatment of Dentofacial Deformity – Proffit, White & Sarver • Surgical Orthodontic Treatment – Proffit and White • Contemporary Orthodontics – Proffit • Orthognathic surgery: A hierarchy of Stability – Proffit et al - Int. J or Adult Orthod Orthognath Surg 1996 Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • References • Lingual Orthodontics and Orthognathic surgery – Int. J or Adult Orthod Orthognath Surg 2000 • Stability of Le Fort I osteotomy in maxillary inferior positioning: Review of the literature Costa et al - Int. J or Adult Orthod Orthognath Surg 2000 • Long term stability of mandibular setback surgery: A follow-up of 80 bilateral sagittal split osteotomy patients - Mobarak, et al - Int. J or Adult Orthod Orthognath Surg 2000 Pre and Post Surgical Orthodontics Dr. Punit Thawani
  • References • Long Term stability of Surgical Open bite Correction by Le Fort I osteotomy - Proffit, Bailey, Phillips, Turvey – AO Feb 2000 • Long term Prognosis of BSSO Mandibular Relapse and its Relation to Different Facial Types - Yoshida et al - AO March 2000 • Mandibular advancement surgery in high angle and low angle Class II patients: Different long term skeletal responses - Mobarak, Espeland, Krogstad and Lyberg – AJO 2001 Pre and Post Surgical Orthodontics Dr. Punit Thawani
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