Orthognathic Surgery
INDIAN DENTAL ACADEMY
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Contents
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Definition, Team, Objectives
History of Orthognathic Surgery
Grading of patients
Envelope of d...
Contents
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Basis/Concept of Orthognathic Surgery
Patient preparation
Surgical Procedures
Rigid Internal Fix...
Definition
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Orthognathic surgery is the art and science of
diagnosis, treatment planning, and execution of
treatment by ...
Team
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Oral and maxillofacial
surgeon
Orthodontist
General dentist

Periodontist
Prosthodontist
Endodontists
Neurosu...
Objectives
Basic therapeutic goals:
Function
Aesthetics
Stability
Minimizing the treatment time

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Fonseca

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Objectives
Specific therapeutic goals:
Masticatory / Swallowing
Functional occlusion
Opening and closing of jaws
TMJ dysfu...
History of Orthognathic Surgery
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1849 - Simon Hullihen - Mandibular subapical
osteotomy

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1859 – von Langenbeck – Firs...
History of Orthognathic Surgery
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1934 - Auxhausen - Maxillary osteotomy

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1934 - Bell - Biologic basis of osteotomy

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History of Orthognathic Surgery
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1954 - Caldwell & Letterman - Vertical subcondylar
osteotomy

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1960’s - Stoker, Epker...
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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 - M...
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Group I
Group II
Group III

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Arnett . McLaughlin www.indiandentalacademy.com

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Sagittal Envelope of
Discrepancy

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Proffit

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Transverse Envelope of
Discrepancy

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IOTN Treatment Grades

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 Shaw and coworkers
Proffit . White . Sarver
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Proffit

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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 recomme...
Criteria for success
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Healthy musculature and temporomandibular
joints
Facial balance
Correct static and...
Criteria for success
1. Healthy musculature and
temporomandibular joints
 Normal range of
movement
 Structural stability...
Criteria for success
2. Facial balance
 Tweed, Down, Steiner,
McNamara – Averages
for general population
 Assumption tha...
Criteria for success
3. Correct static and functional occlusion
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Andrews six keys
Overjet, overbite and symmetrical ...
Criteria for success
5. Resolving the patient’s chief complaints
6. Stability
 Magnitude of tooth movement in three dimen...
Overview of Facial Planning Process
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Patient concerns
History
Clinical examination
Radiographic and imaging a...
Patient concerns
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What are your concerns or problems?
Have you had previous treatment for this
condition, and wha...
Patient History
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Personal information
Chief complaint - Motivation questionnaires
Medical
Dental and orthod...
Questionnaires

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Basic - general screening

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In-depth - complex problems

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Patient History
Personal information

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

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Medical history
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Patient History
Dental and orthodontic history
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Patient History
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History of the TMJ and musculature
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Patient History
Pre-surgical growth assessment

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Psychological ramifications of
orthognathic surgery
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Self-image
Motivations and patient expectations
Patient ...
Psychological ramifications
Self-image
 Class III – Masculine, leadership, aggression,
dominance, strength etc.
 Class I...
Psychological ramifications
Motivations and patient expectations
 What reasons do patients give for seeking
treatment?
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...
Psychological ramifications
Motivations and patient expectations
 Psychological well being
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Psychological health befo...
Psychological ramifications
Patient interview
 Social support system
 Assessment of personality
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Open ended question...
Psychological ramifications
Patient preparation
 Explain diagnosis
 Treatment options
 Risk / benefits
 Prepare the su...
Psychological ramifications
Response to treatment
 Post surgical perception
or problems with
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Swelling
B...
Clinical examination
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TMJ examination
Clinical facial examination
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Frontal view
Profile view
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High mid...
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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Clinical facial examination - Frontal view

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Horizontal reference lines
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Clinical facial examination - Frontal view

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Mandibular deviations and cants
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Clinical facial examination - Frontal view

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Vertical assessment - the facial thirds
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Clinical facial examination - Frontal view

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Vertical assessment of the lower third of the face
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Clinical facial examination - Frontal view

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Upper lip length

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Inter-labial gap
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Lower...
Clinical facial examination - Frontal view

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Upper incisor crown length and overbite
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Clinical facial examination - Frontal view

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Upper incisor exposure – lips at rest
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Clinical facial examination - Frontal view

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Exposure of the upper incisor and gingival tissue when smiling
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Clinical facial examination - Frontal view

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Closed lip position
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Clinical facial examination - Frontal view

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Upper and lower vermilion borders
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Frontal view - Summary

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Frontal view - Summary

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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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Clinical facial examination - Profile view
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Maxillary area
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Nasal base
Upper lip prominence
Upper lip support
Na...
Clinical facial examination - Profile view
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Mandibular area
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Lower lip prominence
Soft tissue pogonion
prominen...
Profile view - Summary

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Intra-oral examination
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Soft tissues
Finger or thumb sucking
Tongue size, position and activity
Mentalis muscl...
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Canine relationship
Midlines
Overjet and overbite
Crossbites
Crowding or spacing
Lower curve of spee
Period...
Records

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Imaging and radiographic analysis

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Facial photographs
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Routine facial photographs
In-depth facial photographs
Int...
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Routine facial photographs

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In-depth facial photographs

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Intra-oral photographs

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Radiographic and Imaging Analysis
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Radiographs
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Lateral cephalometry
Panoramic radiographs
Intra-oral radiogra...
Metallic midface markers
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Cheek bone
Soft tissue orbital rim
Nasal base
Subpupil
Neck-throat junction

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Dental Models
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Impression taking
Wax bite construction
Model analysis

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Importance of wax bite
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First tooth contact
Maximum intercuspation
Relates the mandible to
maxilla during
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Wax bite construction

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First wax bite
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Wax bite construction

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Second wax bite

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Third wax bite

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Model analysis
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Arch length
Tooth size analysis
Tooth position
Arch width analysis
Curve of spee
Cuspid-...
Diagnosis in three areas
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Musculature and TMJ
Face
Dentition

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1. Musculature and TMJ
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Head, neck and TMJ pain
and dysfunction
TMDs
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Masticatory muscle
disorders
Temporoman...
2. Face
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Clinical examination
STCA
Frontal - Grummons and
Ricketts
Profile - COGS - skeletal
and soft tissue – Bu...
Orthognathic Surgery -II
Dr Sangamesh B.

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Contents
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Definition, Team, Objectives
History of Orthognathic Surgery
Grading of patients
Envelope of d...
Contents
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Basis/Concept of Orthognathic Surgery
Patient preparation
Surgical Procedures
Rigid Internal Fix...
STCA
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Arnett etal 1999 AJO DO
Sample 46 adult caucasian– 20/M 26/F
Class I Occlusion
Balanced facial appe...
STCA
Following areas were evaluated;
 Dental and skeletal factors
 Soft tissue components
 Vertical facial heights or l...
STCA - Dental and skeletal factors

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STCA – Soft tissue thickness

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STCA - Vertical facial heights or lengths

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STCA - Vertical facial heights or lengths

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STCA - TVL projections

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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-...
STCA – Harmony values

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STCA – Harmony values for Females

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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

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STCA – Length of the lower third of the
face

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STCA – Short upper lip

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STCA – Normal upper to lower lip ratio

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

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STCA – Nasolabial angle and upper lip

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STCA – Upper incisor exposure – lips at
rest disharmony

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STCA – Exposure of upper incisor and
gingival tissue on smiling

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STCA – Prominence of soft tissue
pogonion
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Retrusive soft tissue pogonion Protrusive soft tissue pogonion
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Vertica...
STCA – Throat length and contour
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Long and short throat
length
Long straight throat
length is favorable for
mandib...
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 spe...
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Maxillary retrusion
Mandibular retrusion
Clockwise mandibular rotation
Upper and lower denture base retrusion
O...
Video imaging technology
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Acetate tracings
Photograph modification
Videocephalometrics

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Fonseca

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Proffit White...
Video imaging technology
Videocephalometrics
Advantages:
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Accuracy
Multiple analysis in short time
Individ...
Video imaging technology to orthognathic
surgery
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How does technology work?
Are the predictions generated by the co...
Surgical prediction
 Mandibular
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1989 - Hing
1993 - Schwartz - ‘Quick ceph’

Maxillary
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1994 - Konstaniantos et ...
Surgical prediction
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Skeletal and soft tissue response is different for
different surgical procedure and osteosynt...
Cephalometric Treatment Planning

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Arnett . McLaughlin

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CTP

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Step 1 – Correct the torque of the upper incisor
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CTP

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Step 2 - Correct the torque of the lower incisor
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CTP

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Step 3 – Position of maxillary incisors
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CTP

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

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

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Step 6 – Set the maxillary occlusal plane
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CTP

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Step 7 – Assess the chin height and AP projection to TVL
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CTP
Omitting steps
 If any of the steps are correct then they are
omitted
 Steps 1,2,4,7 provide a facially correct clas...
STO
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Initial surgical treatment objectives
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To establish orthodontic goals
To develop surgical objectives
To creat...
Pre-surgical Orthodontics
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Selection of appliance
Alignment
Vertical positioning of teeth
Anteroposterior positi...
Pre-surgical Orthodontic goals

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Fonseca

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Pre-surgical Orthodontic goals
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Sagittal dimension

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Pre-surgical Orthodontic goals
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Vertical dimension

Fonseca

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Pre-surgical Orthodontic goals
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Transverse dimension

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Fonseca

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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 p...
Model Surgery
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Traditional Method
Analytical model surgery

Maxillary surgeries
Mandibular surgeries
Double-...
Maxillary surgeries
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Impressions
Wax-bite
Face-bow transfer
Mounting of the casts on a semiadjustable
articu...
Model Surgery

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Model Surgery

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Model Surgery

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Isolated maxillary surgery
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Provide clearance in the mounting plaster for the
superior repositioning of the maxil...
Segmental maxillary surgery
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Additional measurements at dental landmarks in
each dentoalveolar segment are required

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Mandibular surgery
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Maxilla used as a template
As maxillary position is constant – use of
semiadjustable articulator o...
Double-jaw surgeries
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Determine the final position of maxilla
Intermediate splint
Mandibular repositioning
Final s...
Splints

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Analytical model surgery
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1992 – Bell
Three-dimensional surgical movements of jaws
Common reference plane - ...
Analytical model surgery
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Common reference plane - FH

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Analytical model surgery
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Model platform and the model block

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Analytical model surgery
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Measuring final models for dentofacial surgery

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Analytical model surgery

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Analytical model surgery

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Analytical model surgery
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Technique
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Record space available measurements on a model
surgery worksheet
Trim the c...
Analytical model surgery
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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...
Analytical model surgery

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Basis/Concept of Orthognathic Surgery
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Orthognathic surgeries – described in European
literature – 70 years
...
Basis/Concept of Orthognathic Surgery
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Revascularization studies of Bell and Fonseca:
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Vascular ischemia and tissue ne...
Revascularization studies of Bell and Fonseca
Findings
I Palatal soft tissue pedicle and the labial buccal gingiva
provide...
Revascularization studies
IV 1994 – Dodson et al. - Measured the blood flow to the
maxillary gingiva using laser doppler f...
Basis/Concept of Orthognathic Surgery
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Histological concept of blood flow in the gingival tissue
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1970 – Be...
Revascularization studies in mandible
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Immediately post operatively – generalized
intramedullary circulation ...
Revascularization studies in mandible
Vascular blood supply in mandible is centrifugal
– post operatively this arterial fl...
Orthognathic Surgery -III

Dr Sangamesh B.

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

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summary

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Mandibular exess

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Mandibular excess

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Maxillary excess

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Maxillary excess

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Maxillary excess

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Maxillary excess

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Maxillary excess

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Mandibular excess

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Mandibular excess

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Mandibular excess

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Maxillary excess ( vertical )

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Maxillary excess ( vertical )

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Maxillary excess ( vertical)

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Mandibular deficiency ( sagittal)

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Mandibular deficiency ( vertical)

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Genioplasty

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Genioplasty

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Maxillary excess

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Maxillary excess

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Maxillary excess (vertical)

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Maxillary excess (vertical)

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Open bite

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Open bite

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Open bite

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Open bite

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Maxilla
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1859 – von Langenbeck – first Orthognathic surgical
procedure for removal of Naso-pharyngeal polyp
18...
Maxilla
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1950 – Gillies and Harrison - 1950 – LeFort II osteotomy
involving the premaxilla and nasal complex
1...
Maxilla – Surgically Assisted Maxillary
Expansion
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BROWN (1938) first described SAME
Is essentially a combination o...
Maxilla- Surgically Assisted Maxillary
Expansion
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Diagnosis of transverse maxillary deficiency
Clinically
Radi...
Maxilla - Surgically Assisted Maxillary
Expansion
Treatment techniques
 Slow dentoalveolar expansion (SDE)
 Orthopaedic ...
Maxilla - Surgically Assisted Maxillary
Expansion
Indications
 Skeletal maxillomandibular transverse discrepancy
greater ...
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Maxilla - Surgically Assisted Maxillary
Expansion
ACTIVATION
 Two types
 During procedure the appliance activated 3-4 mm...
Segmental maxillary osteotomy
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Plating at a particular expansion
Higher chances of relapse
More expansion in th...
Complications
 Hemorrhage
 Osteotomy 5mm above apices
 Preserve bony coverage of the medial surface of
the central inci...
Surgical Techniques
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Le Fort III

Le Fort I
Le Fort II
Le Fort III

Le Fort II

Le Fort I

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

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Maxilla – Anterior segmental osteotomies
Indications
 Marked protrusion of maxillary teeth with normal
incisor axial incl...
Maxilla – Anterior segmental osteotomies
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Wunderer method
Wassmund method
Cupar method

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Maxilla – Posterior segmental osteotomies
Indications
 Posterior maxillary alveolar hyperplasia
 Total maxillary hyperpl...
Maxilla – Posterior segmental osteotomies

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Mid face osteotomy procedures
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Maxillary Qudarangular LeFort I and
Qudarangular LeFort II osteotomy
Highlevel midface...
Mid face osteotomy procedures
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Maxillary-mandibular horizontal deficiency
Class III skeletal malocclusion
Normal n...
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Highlevel midface osteotomy
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LeFort III Osteotomy
LeFort II Osteotomy

Indications
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Total midface hypoplas...
Mandible
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1849 – Hullihen – Anterior sub-apical osteotomy
1954 – Caldwell and Letterman – Intra-oral
vertical ramus...
Mandible
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1961 – Dalpont – Modification
of BSSO – Advance the
oblique cut to the molar region
and the vertical cut...
Mandible
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BSSO
TVRO
EVRO
Combination techniques
Inferior alveolar neurovascular bundle decompression
B...
BSSO

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Mandibular excess

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BSSO
Indications
 Horizontal mandibular excess
 Horizontal mandibular deficiency
 Horizontal mandibular asymmetry
 Set...
TVRO

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IVRO
Indications
 Setback of more than 12mm

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Midline osteotomy

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Combination
- Vertical ramus and sagittal osteotomy

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Ramus and Body osteotomy

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Anterior subapical osteotomy

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Total subapical osteotomy

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Distraction osteogenesis

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Orthognathic surgery before completion
of growth
Assumption - Early surgery retards further growth
expression
 Vertical m...
Orthognathic surgery before completion
of growth
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Accurate diagnosis of the growth status
Psychosocial concern...
Obstructive sleep apnea
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Non surgical
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Weight loss
Change in sleep position
Pharmacologic options
Oral devic...
Obstructive sleep apnea
Indications
 RDI > 20
 Failure to tolerate CPAP
 RDI < 20 in young patient
with congenital faci...
Adjunctive procedures
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Chin modification
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Rhinoplasty
Facial soft tissue contouring
Lip procedures
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Genioplasty
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1942 – Hofer – Horizontal
osteotomy of the
symphysis
1957 – Obwegeser –
Intra-oral procedure

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Chin modification - Genioplasty

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Chin modification - Genioplasty

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Chin silicone implant

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Rhinoplasty

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Alar cinch V-Y plasty

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Facial soft tissue contouring

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Lip procedures

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Submental procedures: Soft tissue
reduction

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Fixation methods
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Traditional fixation
Rigid internal fixation

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1992 Ellis et al. –
compared rigid fixation to
wire...
Fixation methods
Materials
 Non-resorbable

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SS
Vitallium
Titanium

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Bioresorbable
Polyglycolic acid
L-p...
Rigid Internal Fixation

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Rowe and Williams

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Killeys
Rigid Internal Fixation
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Maxilla
1.5mm and 2mm
L shape
T shape
X shape

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Mandible
Lag screws
Position sc...
Rigid Internal Fixation
Complications/Disadvantages:
 Instrumentation
 Improper placement – malocclusion, TMJ pain
 Inf...
Rehabilitation
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Biologic response to surgery
TMJ function and dentofacial deformities
Perioperative considerat...
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Special Considerations
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Functional outcomes following orthognathic
surgery
Soft tissue changes associated with ort...
Special Considerations
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Functional outcomes following orthognathic
surgery
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Simple functional tasks
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Maximal ...
Special Considerations
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Soft tissue changes associated with orthognathic surgery
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Facial proportions
Nasal struc...
Post Surgical Orthodontics
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Upper arch
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Lower arch
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17x25” TMA in 0.18” slot
19x25” TMA in 0.22” slot
21x2...
Post Surgical Complications

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Post Surgical Complications

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Post Surgical Complications

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TMD
Paraesthesia
Decreased bite force

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Relapse and Stability
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Rigid fixation has improved stability
Stability is mostly influenced by the pattern of
ro...
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Relapse and Stability

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

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  • Transcript of "orthognathic surgery"

    1. 1. Orthognathic Surgery INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. Contents          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 www.indiandentalacademy.com
    3. 3. Contents         Basis/Concept of Orthognathic Surgery Patient preparation Surgical Procedures Rigid Internal Fixation Special Considerations Rehabilitation Post Surgical Orthodontics Retention and Relapse www.indiandentalacademy.com
    4. 4. 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.  Fonseca www.indiandentalacademy.com
    5. 5. Team    Oral and maxillofacial surgeon Orthodontist General dentist Periodontist Prosthodontist Endodontists Neurosurgeons Opthamologists Otolaryngologists Plastic surgeon Speech pathologist www.indiandentalacademy.com
    6. 6. Objectives Basic therapeutic goals: Function Aesthetics Stability Minimizing the treatment time  Fonseca www.indiandentalacademy.com
    7. 7. 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  Fonseca www.indiandentalacademy.com
    8. 8. History of Orthognathic Surgery  1849 - Simon Hullihen - Mandibular subapical osteotomy  1859 – von Langenbeck – First orthognathic surgical procedure  1864 - Cheever - LeFort I  1907 - Dingman - Mandibular body osteoectomy  1921 – Cohn-Stock – Anterior maxillary osteotomy  1927 - Wassmund - Maxillary osteotomy www.indiandentalacademy.com
    9. 9. History of Orthognathic Surgery  1934 - Auxhausen - Maxillary osteotomy  1934 - Bell - Biologic basis of osteotomy  1942 - Gillies & Harrison - LeFort II &III  1942 - Schuchardt - similar to BSSO  1950 - Tessier - LeFort III &IV  1952 - Converse - Maxillary osteotomy www.indiandentalacademy.com
    10. 10. History of Orthognathic Surgery  1954 - Caldwell & Letterman - Vertical subcondylar osteotomy  1960’s - Stoker, Epker, Bell, Wilmar & Obwegeser LeFort I down fracture  1965 - Trauner & Obwegeser - BSSO www.indiandentalacademy.com
    11. 11.  1970 - Turvey, Epker, Fish & LaBanc - Bijaw surgeries  1973 - Henderson & Jackson - Pyramidal LeFort II  1992 - McCarthy - Distraction osteogenesis in congenitally hypoplastic mandible www.indiandentalacademy.com
    12. 12.  Group I Group II Group III  Arnett . McLaughlin www.indiandentalacademy.com  
    13. 13. Sagittal Envelope of Discrepancy  Proffit www.indiandentalacademy.com
    14. 14. Transverse Envelope of Discrepancy www.indiandentalacademy.com
    15. 15. IOTN Treatment Grades   Shaw and coworkers Proffit . White . Sarver www.indiandentalacademy.com
    16. 16.  Proffit www.indiandentalacademy.com
    17. 17. State of art care  Correctly diagnose existing deformities  Establish a proper treatment plan  Execute the recommended treatment  Arnett . McLaughlin www.indiandentalacademy.com
    18. 18. Criteria for success         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 www.indiandentalacademy.com
    19. 19. Criteria for success 1. Healthy musculature and temporomandibular joints  Normal range of movement  Structural stability  Free from pain  Remodeling   Local remodeling Total remodeling www.indiandentalacademy.com
    20. 20. Criteria for success 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   STCA – 45measurements CTP www.indiandentalacademy.com
    21. 21. Criteria for success 3. Correct static and functional occlusion    Andrews six keys Overjet, overbite and symmetrical midlines Condyles in glenoid fossa 4. Periodontal health   Alveolar bone Gingival tissue www.indiandentalacademy.com
    22. 22. Criteria for success 5. Resolving the patient’s chief complaints 6. Stability  Magnitude of tooth movement in three dimensions    Excessive compensation Disproportionate growth Stability of TMJ  Surgical technique – condyles should be seated without compression 7. Maintaining or increasing airway www.indiandentalacademy.com
    23. 23. Overview of Facial Planning Process       Patient concerns History Clinical examination Radiographic and imaging analysis Dental model analysis Arnett . McLaughlin  Fonseca www.indiandentalacademy.com
    24. 24. Patient concerns     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? www.indiandentalacademy.com
    25. 25. Patient History        Personal information Chief complaint - Motivation questionnaires Medical Dental and orthodontic history History of the TMJ and musculature Pre-surgical growth assessment Arnett . McLaughlin www.indiandentalacademy.com
    26. 26. Questionnaires  Basic - general screening  In-depth - complex problems www.indiandentalacademy.com Patient History
    27. 27. Personal information www.indiandentalacademy.com Patient History
    28. 28. Chief complaint - Motivation questionnaires    Dental changes Facial changes Relief of symptoms www.indiandentalacademy.com Patient History
    29. 29. Medical history www.indiandentalacademy.com Patient History
    30. 30. Dental and orthodontic history www.indiandentalacademy.com Patient History
    31. 31.  History of the TMJ and musculature www.indiandentalacademy.com Patient History
    32. 32. Pre-surgical growth assessment www.indiandentalacademy.com
    33. 33. Psychological ramifications of orthognathic surgery       Self-image Motivations and patient expectations Patient interviews Patient preparation Response to treatment Fonseca www.indiandentalacademy.com
    34. 34. 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. www.indiandentalacademy.com
    35. 35. Psychological ramifications Motivations and patient expectations  What reasons do patients give for seeking treatment?        Enhancement of self-image Oral function Social well being Future dental health TMJ Nasal function Psychological well being www.indiandentalacademy.com
    36. 36. Psychological ramifications Motivations and patient expectations  Psychological well being   Psychological health before surgery Assessing patients emotional distress www.indiandentalacademy.com
    37. 37. Psychological ramifications Patient interview  Social support system  Assessment of personality   Open ended question Silence  www.indiandentalacademy.com Proffit
    38. 38. Psychological ramifications Patient preparation  Explain diagnosis  Treatment options  Risk / benefits  Prepare the supporting people www.indiandentalacademy.com
    39. 39. Psychological ramifications Response to treatment  Post surgical perception or problems with         Swelling Bruising Nasal congestion Dry lips Facial abrasion Dribbling Sleeping – sitting for 2-3 weeks Murphy T. 2005 Jr of Orthod         Sleep discomfort Numbness Tingling Pain in jaw joints Possibility of altered speech Low feeling Soft diet Possible acne www.indiandentalacademy.com
    40. 40. Clinical examination   TMJ examination Clinical facial examination   Frontal view Profile view      High midface profile Maxillary area profile Mandibular area profile Intra-oral examination Arnett . McLaughlin www.indiandentalacademy.com
    41. 41. TMJ examination     The range of movements Deviation from normal movements Any pain during movement The joint sounds www.indiandentalacademy.com
    42. 42. Clinical facial examination - Frontal view   General outline Midline assessment www.indiandentalacademy.com
    43. 43. Clinical facial examination - Frontal view  Horizontal reference lines www.indiandentalacademy.com
    44. 44. Clinical facial examination - Frontal view  Mandibular deviations and cants www.indiandentalacademy.com
    45. 45. Clinical facial examination - Frontal view  Vertical assessment - the facial thirds www.indiandentalacademy.com
    46. 46. Clinical facial examination - Frontal view  Vertical assessment of the lower third of the face www.indiandentalacademy.com
    47. 47. Clinical facial examination - Frontal view  Upper lip length  Inter-labial gap www.indiandentalacademy.com  Lower lip length
    48. 48. Clinical facial examination - Frontal view  Upper incisor crown length and overbite www.indiandentalacademy.com
    49. 49. Clinical facial examination - Frontal view  Upper incisor exposure – lips at rest www.indiandentalacademy.com
    50. 50. Clinical facial examination - Frontal view  Exposure of the upper incisor and gingival tissue when smiling www.indiandentalacademy.com
    51. 51. Clinical facial examination - Frontal view  Closed lip position www.indiandentalacademy.com
    52. 52. Clinical facial examination - Frontal view  Upper and lower vermilion borders www.indiandentalacademy.com
    53. 53. Frontal view - Summary www.indiandentalacademy.com
    54. 54. Frontal view - Summary www.indiandentalacademy.com
    55. 55. Clinical facial examination - Profile view  High midface     Glabella Orbital rim Cheek bone Subpupil area www.indiandentalacademy.com
    56. 56. Clinical facial examination - Profile view  Maxillary area     Nasal base Upper lip prominence Upper lip support Nasal projection www.indiandentalacademy.com
    57. 57. Clinical facial examination - Profile view  Mandibular area     Lower lip prominence Soft tissue pogonion prominence Throat length contour Overjet www.indiandentalacademy.com
    58. 58. Profile view - Summary www.indiandentalacademy.com
    59. 59. Intra-oral examination       Soft tissues Finger or thumb sucking Tongue size, position and activity Mentalis muscle activity Dental assessment Molar relationship www.indiandentalacademy.com
    60. 60.        Canine relationship Midlines Overjet and overbite Crossbites Crowding or spacing Lower curve of spee Periodontal health www.indiandentalacademy.com
    61. 61. Records www.indiandentalacademy.com
    62. 62. Imaging and radiographic analysis  Facial photographs    Routine facial photographs In-depth facial photographs Intra-oral photographs www.indiandentalacademy.com
    63. 63. www.indiandentalacademy.com
    64. 64. Routine facial photographs www.indiandentalacademy.com
    65. 65. In-depth facial photographs www.indiandentalacademy.com
    66. 66. Intra-oral photographs www.indiandentalacademy.com
    67. 67. Radiographic and Imaging Analysis  Radiographs      Lateral cephalometry Panoramic radiographs Intra-oral radiographs Tomograms MRI www.indiandentalacademy.com
    68. 68. Metallic midface markers      Cheek bone Soft tissue orbital rim Nasal base Subpupil Neck-throat junction www.indiandentalacademy.com
    69. 69. Dental Models    Impression taking Wax bite construction Model analysis www.indiandentalacademy.com
    70. 70. Importance of wax bite    First tooth contact Maximum intercuspation Relates the mandible to maxilla during      facial examination, facial photography, cephalometry, tomography and model articulation www.indiandentalacademy.com
    71. 71. Wax bite construction  First wax bite www.indiandentalacademy.com
    72. 72. Wax bite construction  Second wax bite  Third wax bite www.indiandentalacademy.com
    73. 73. Model analysis          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 www.indiandentalacademy.com
    74. 74. Diagnosis in three areas    Musculature and TMJ Face Dentition www.indiandentalacademy.com
    75. 75. 1. Musculature and TMJ   Head, neck and TMJ pain and dysfunction TMDs    Masticatory muscle disorders Temporomandibular joint articular disorders Condylar remodelling   Local Total www.indiandentalacademy.com
    76. 76. 2. Face     Clinical examination STCA Frontal - Grummons and Ricketts Profile - COGS - skeletal and soft tissue – Burstone et al. www.indiandentalacademy.com
    77. 77. Orthognathic Surgery -II Dr Sangamesh B. www.indiandentalacademy.com
    78. 78. Contents          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 www.indiandentalacademy.com
    79. 79. Contents         Basis/Concept of Orthognathic Surgery Patient preparation Surgical Procedures Rigid Internal Fixation Special Considerations Rehabilitation Post Surgical Orthodontics Retention and Relapse www.indiandentalacademy.com
    80. 80. STCA         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 www.indiandentalacademy.com
    81. 81. STCA Following areas were evaluated;  Dental and skeletal factors  Soft tissue components  Vertical facial heights or lengths  TVL projections  Facial harmony www.indiandentalacademy.com
    82. 82. STCA - Dental and skeletal factors www.indiandentalacademy.com
    83. 83. STCA – Soft tissue thickness www.indiandentalacademy.com
    84. 84. STCA - Vertical facial heights or lengths www.indiandentalacademy.com
    85. 85. STCA - Vertical facial heights or lengths www.indiandentalacademy.com
    86. 86. STCA - TVL projections www.indiandentalacademy.com
    87. 87. STCA - TVL projections   The A/P position of the TVL will be frequently through subnasale TVL must be moved forward 1-3mm in case of maxillary retrusion    Long nose Depressed or flat orbital rims, cheek bones, subpupils, alar bases etc. Patient clinical visualization for verification www.indiandentalacademy.com
    88. 88. STCA – Harmony values www.indiandentalacademy.com
    89. 89. STCA – Harmony values for Females www.indiandentalacademy.com
    90. 90. STCA – Harmony values for Males www.indiandentalacademy.com
    91. 91.    Middle third Lower third Clinical commentary on    Facial growth Facial imbalances Bimaxillary surgery www.indiandentalacademy.com
    92. 92. STCA – Length of the lower third of the face www.indiandentalacademy.com
    93. 93. STCA – Short upper lip www.indiandentalacademy.com
    94. 94. STCA – Normal upper to lower lip ratio www.indiandentalacademy.com
    95. 95. STCA – Upper lip prominence  Related to A/P position of the maxilla, upper incisor torque and upper lip thickness www.indiandentalacademy.com
    96. 96. STCA – Nasolabial angle and upper lip www.indiandentalacademy.com
    97. 97. STCA – Upper incisor exposure – lips at rest disharmony www.indiandentalacademy.com
    98. 98. STCA – Exposure of upper incisor and gingival tissue on smiling www.indiandentalacademy.com
    99. 99. STCA – Prominence of soft tissue pogonion  Retrusive soft tissue pogonion Protrusive soft tissue pogonion    Vertical maxillary excess Mandibular retrusion Steep occlusal plane Vertical maxillary deficiency Mandibular protrusion Flat occlusal plane www.indiandentalacademy.com
    100. 100. STCA – Throat length and contour    Long and short throat length Long straight throat length is favorable for mandibular setback Short sagging throat length is unfavorable www.indiandentalacademy.com
    101. 101. 3. Dentition and intra-oral structures  Vertical     Horizontal     Overbite Plane of occlusion Curve of spee Anatomical variation Crowding / spacing Overjet Transverse  Crossbites www.indiandentalacademy.com
    102. 102.      Maxillary retrusion Mandibular retrusion Clockwise mandibular rotation Upper and lower denture base retrusion Overjet increase www.indiandentalacademy.com
    103. 103. Video imaging technology    Acetate tracings Photograph modification Videocephalometrics  Fonseca  Proffit White Sarver www.indiandentalacademy.com
    104. 104. Video imaging technology Videocephalometrics Advantages:        Accuracy Multiple analysis in short time Individualization - gender, age, race and ethnicity Prediction by algorithmic data Incorporation of changes during treatment Fonseca www.indiandentalacademy.com
    105. 105. Video imaging technology to orthognathic surgery    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? www.indiandentalacademy.com
    106. 106. Surgical prediction  Mandibular    1989 - Hing 1993 - Schwartz - ‘Quick ceph’ Maxillary  1994 - Konstaniantos et al. – ‘Dentofacial Planner’ www.indiandentalacademy.com
    107. 107. Surgical prediction    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 www.indiandentalacademy.com
    108. 108. Cephalometric Treatment Planning  Arnett . McLaughlin www.indiandentalacademy.com
    109. 109. CTP  Step 1 – Correct the torque of the upper incisor www.indiandentalacademy.com
    110. 110. CTP  Step 2 - Correct the torque of the lower incisor www.indiandentalacademy.com
    111. 111. CTP  Step 3 – Position of maxillary incisors www.indiandentalacademy.com
    112. 112. CTP  Step 4 – Auto-rotate the mandible to 3mm of overbite www.indiandentalacademy.com
    113. 113. CTP  Step 5 – Move the mandible to 3mm of overjet A/P movement www.indiandentalacademy.com
    114. 114. CTP  Step 6 – Set the maxillary occlusal plane www.indiandentalacademy.com
    115. 115. CTP  Step 7 – Assess the chin height and AP projection to TVL www.indiandentalacademy.com
    116. 116. 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 www.indiandentalacademy.com
    117. 117. STO  Initial surgical treatment objectives    To establish orthodontic goals To develop surgical objectives To create the predicted facial profile www.indiandentalacademy.com
    118. 118. Pre-surgical Orthodontics      Selection of appliance Alignment Vertical positioning of teeth Anteroposterior position of teeth Arch compatibility www.indiandentalacademy.com
    119. 119. Pre-surgical Orthodontic goals  Fonseca www.indiandentalacademy.com
    120. 120. Pre-surgical Orthodontic goals  Sagittal dimension www.indiandentalacademy.com
    121. 121. Pre-surgical Orthodontic goals   Vertical dimension Fonseca www.indiandentalacademy.com
    122. 122. Pre-surgical Orthodontic goals  Transverse dimension  Fonseca www.indiandentalacademy.com
    123. 123. Definitive Surgical Treatment Plan  Final surgical treatment objectives  Definitive treatment plan    Dental and periodontal treatment Extractions Surgery www.indiandentalacademy.com
    124. 124. Model Surgery       Traditional Method Analytical model surgery Maxillary surgeries Mandibular surgeries Double-jaw surgeries Fonseca www.indiandentalacademy.com
    125. 125. Maxillary surgeries       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 www.indiandentalacademy.com
    126. 126. Model Surgery www.indiandentalacademy.com
    127. 127. Model Surgery www.indiandentalacademy.com
    128. 128. Model Surgery www.indiandentalacademy.com
    129. 129. Isolated maxillary surgery     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 www.indiandentalacademy.com
    130. 130. Segmental maxillary surgery  Additional measurements at dental landmarks in each dentoalveolar segment are required www.indiandentalacademy.com
    131. 131. Mandibular surgery   Maxilla used as a template As maxillary position is constant – use of semiadjustable articulator or face-bow not always required www.indiandentalacademy.com
    132. 132. Double-jaw surgeries     Determine the final position of maxilla Intermediate splint Mandibular repositioning Final splint www.indiandentalacademy.com
    133. 133. Splints www.indiandentalacademy.com
    134. 134. Analytical model surgery        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 www.indiandentalacademy.com
    135. 135. Analytical model surgery  Common reference plane - FH www.indiandentalacademy.com
    136. 136. Analytical model surgery  Model platform and the model block www.indiandentalacademy.com
    137. 137. Analytical model surgery  Measuring final models for dentofacial surgery www.indiandentalacademy.com
    138. 138. Analytical model surgery www.indiandentalacademy.com
    139. 139. Analytical model surgery www.indiandentalacademy.com
    140. 140. Analytical model surgery  Technique    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 www.indiandentalacademy.com
    141. 141. Analytical model surgery  Technique   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 www.indiandentalacademy.com
    142. 142. Analytical model surgery www.indiandentalacademy.com
    143. 143. Basis/Concept of Orthognathic Surgery      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 www.indiandentalacademy.com
    144. 144. Basis/Concept of Orthognathic Surgery  Revascularization studies of Bell and Fonseca:  Vascular ischemia and tissue necrosis –      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 www.indiandentalacademy.com
    145. 145. 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 www.indiandentalacademy.com
    146. 146. 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) www.indiandentalacademy.com
    147. 147. Basis/Concept of Orthognathic Surgery  Histological concept of blood flow in the gingival tissue      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 www.indiandentalacademy.com
    148. 148. Revascularization studies in mandible      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 www.indiandentalacademy.com
    149. 149. 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)  www.indiandentalacademy.com
    150. 150. Orthognathic Surgery -III Dr Sangamesh B. www.indiandentalacademy.com
    151. 151. Surgical Procedure        Maxilla Mandible Bi-jaw DO Surgery before growth OSA Adjunctive surgical procedures www.indiandentalacademy.com
    152. 152. summary www.indiandentalacademy.com
    153. 153. Mandibular excess www.indiandentalacademy.com
    154. 154. Mandibular excess www.indiandentalacademy.com
    155. 155. Mandibular excess www.indiandentalacademy.com
    156. 156. Mandibular excess www.indiandentalacademy.com
    157. 157. Mandibular excess www.indiandentalacademy.com
    158. 158. Mandibular excess www.indiandentalacademy.com
    159. 159. Mandibular excess www.indiandentalacademy.com
    160. 160. Mandibular excess www.indiandentalacademy.com
    161. 161. Mandibular excess www.indiandentalacademy.com
    162. 162. Mandibular exess www.indiandentalacademy.com
    163. 163. Mandibular excess www.indiandentalacademy.com
    164. 164. Maxillary excess www.indiandentalacademy.com
    165. 165. Maxillary excess www.indiandentalacademy.com
    166. 166. Maxillary excess www.indiandentalacademy.com
    167. 167. Maxillary excess www.indiandentalacademy.com
    168. 168. Maxillary excess www.indiandentalacademy.com
    169. 169. Mandibular excess www.indiandentalacademy.com
    170. 170. Mandibular excess www.indiandentalacademy.com
    171. 171. Mandibular excess www.indiandentalacademy.com
    172. 172. Maxillary excess ( vertical ) www.indiandentalacademy.com
    173. 173. Maxillary excess ( vertical ) www.indiandentalacademy.com
    174. 174. www.indiandentalacademy.com
    175. 175. Maxillary excess ( vertical) www.indiandentalacademy.com
    176. 176. Mandibular deficiency ( sagittal) www.indiandentalacademy.com
    177. 177. Mandibular deficiency ( vertical) www.indiandentalacademy.com
    178. 178. Genioplasty www.indiandentalacademy.com
    179. 179. Genioplasty www.indiandentalacademy.com
    180. 180. Maxillary excess www.indiandentalacademy.com
    181. 181. www.indiandentalacademy.com
    182. 182. www.indiandentalacademy.com
    183. 183. Maxillary excess www.indiandentalacademy.com
    184. 184. Maxillary excess (vertical) www.indiandentalacademy.com
    185. 185. Maxillary excess (vertical) www.indiandentalacademy.com
    186. 186. Open bite www.indiandentalacademy.com
    187. 187. Open bite www.indiandentalacademy.com
    188. 188. Open bite www.indiandentalacademy.com
    189. 189. Open bite www.indiandentalacademy.com
    190. 190. Maxilla      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 www.indiandentalacademy.com
    191. 191. Maxilla      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 www.indiandentalacademy.com
    192. 192. Maxilla – Surgically Assisted Maxillary Expansion    BROWN (1938) first described SAME Is essentially a combination of distraction osteogenesis and controlled soft tissue expansion Etiology of transverse maxillary deficiency;     Congenital Developmental Traumatic Iatrogenic www.indiandentalacademy.com
    193. 193. Maxilla- Surgically Assisted Maxillary Expansion      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 www.indiandentalacademy.com
    194. 194. Maxilla - Surgically Assisted Maxillary Expansion Treatment techniques  Slow dentoalveolar expansion (SDE)  Orthopaedic rapid maxillary expansion (ORME)  Surgically assisted maxillary expansion (SAME)  Segmental maxillary osteotomy www.indiandentalacademy.com
    195. 195. Maxilla - Surgically Assisted Maxillary 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 www.indiandentalacademy.com
    196. 196. www.indiandentalacademy.com
    197. 197. Maxilla - Surgically Assisted Maxillary 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) www.indiandentalacademy.com
    198. 198. 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 www.indiandentalacademy.com
    199. 199. Complications  Hemorrhage  Osteotomy 5mm above apices  Preserve bony coverage of the medial surface of the central incisor roots  Inadequate release of maxillae www.indiandentalacademy.com
    200. 200. Surgical Techniques    Le Fort III Le Fort I Le Fort II Le Fort III Le Fort II Le Fort I www.indiandentalacademy.com
    201. 201. LeFort I Osteotomy A. Low-level osteotomy B. Approaches the orbital rim C. Cheek prominence D. Low-level osteotomy www.indiandentalacademy.com
    202. 202. 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 www.indiandentalacademy.com
    203. 203. Maxilla – Anterior segmental osteotomies    Wunderer method Wassmund method Cupar method www.indiandentalacademy.com
    204. 204. 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 www.indiandentalacademy.com
    205. 205. Maxilla – Posterior segmental osteotomies www.indiandentalacademy.com
    206. 206. 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. www.indiandentalacademy.com
    207. 207. Mid face osteotomy procedures     Maxillary-mandibular horizontal deficiency Class III skeletal malocclusion Normal nasal projection Zygoma and infraorbital deficiency www.indiandentalacademy.com
    208. 208.  Highlevel midface osteotomy    LeFort III Osteotomy LeFort II Osteotomy Indications    Total midface hypoplasia Apert’s syndrome Binder’s syndrome www.indiandentalacademy.com
    209. 209. 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 www.indiandentalacademy.com
    210. 210. 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 www.indiandentalacademy.com
    211. 211. Mandible           BSSO TVRO EVRO Combination techniques Inferior alveolar neurovascular bundle decompression Body osteotomy Midline osteotomy Inferior border osteotomy Anterior subapical osteotomy Total subapical osteotomy www.indiandentalacademy.com
    212. 212. BSSO www.indiandentalacademy.com
    213. 213. Mandibular excess www.indiandentalacademy.com
    214. 214. BSSO Indications  Horizontal mandibular excess  Horizontal mandibular deficiency  Horizontal mandibular asymmetry  Setback of 7-8mm www.indiandentalacademy.com
    215. 215. TVRO www.indiandentalacademy.com
    216. 216. IVRO Indications  Setback of more than 12mm www.indiandentalacademy.com
    217. 217. Midline osteotomy www.indiandentalacademy.com
    218. 218. Combination - Vertical ramus and sagittal osteotomy www.indiandentalacademy.com
    219. 219. Ramus and Body osteotomy www.indiandentalacademy.com
    220. 220. Anterior subapical osteotomy www.indiandentalacademy.com
    221. 221. Total subapical osteotomy www.indiandentalacademy.com
    222. 222. Distraction osteogenesis www.indiandentalacademy.com
    223. 223. 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 www.indiandentalacademy.com
    224. 224. 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 www.indiandentalacademy.com
    225. 225. Obstructive sleep apnea  Non surgical       Weight loss Change in sleep position Pharmacologic options Oral devices Avoidance of sedatives CPAP OR BiPAP www.indiandentalacademy.com
    226. 226. 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 www.indiandentalacademy.com
    227. 227. 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 www.indiandentalacademy.com
    228. 228. Genioplasty   1942 – Hofer – Horizontal osteotomy of the symphysis 1957 – Obwegeser – Intra-oral procedure www.indiandentalacademy.com
    229. 229. Chin modification - Genioplasty www.indiandentalacademy.com
    230. 230. Chin modification - Genioplasty www.indiandentalacademy.com
    231. 231. Chin silicone implant www.indiandentalacademy.com
    232. 232. Rhinoplasty www.indiandentalacademy.com
    233. 233. Alar cinch V-Y plasty www.indiandentalacademy.com
    234. 234. Facial soft tissue contouring www.indiandentalacademy.com
    235. 235. Lip procedures www.indiandentalacademy.com
    236. 236. Submental procedures: Soft tissue reduction www.indiandentalacademy.com
    237. 237. 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 www.indiandentalacademy.com
    238. 238. Fixation methods Materials  Non-resorbable  SS Vitallium Titanium       Bioresorbable Polyglycolic acid L-polylactide Degraded by carbohydrate metabolism via kerbs cycle into CO2 and H2O www.indiandentalacademy.com
    239. 239. Rigid Internal Fixation  Rowe and Williams  www.indiandentalacademy.com Killeys
    240. 240. Rigid Internal Fixation      Maxilla 1.5mm and 2mm L shape T shape X shape     Mandible Lag screws Position screws Plates www.indiandentalacademy.com
    241. 241. Rigid Internal Fixation Complications/Disadvantages:  Instrumentation  Improper placement – malocclusion, TMJ pain  Infection  Plate exposure  Loose screws - necrosis  Palpable screws  Lingual plate fracture of the distal segment www.indiandentalacademy.com
    242. 242. Rehabilitation       Biologic response to surgery TMJ function and dentofacial deformities Perioperative considerations Neuromuscular rehabilitation Range-of-motion excerises Mandibular hypomobility www.indiandentalacademy.com
    243. 243. www.indiandentalacademy.com
    244. 244. Special Considerations    Functional outcomes following orthognathic surgery Soft tissue changes associated with orthognathic surgery Psychological ramifications of orthognathic surgery www.indiandentalacademy.com
    245. 245. Special Considerations  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 www.indiandentalacademy.com
    246. 246. Special Considerations  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 www.indiandentalacademy.com
    247. 247. 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 www.indiandentalacademy.com
    248. 248. Post Surgical Complications www.indiandentalacademy.com
    249. 249. Post Surgical Complications www.indiandentalacademy.com
    250. 250. Post Surgical Complications    TMD Paraesthesia Decreased bite force www.indiandentalacademy.com
    251. 251. 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 www.indiandentalacademy.com
    252. 252. www.indiandentalacademy.com
    253. 253. www.indiandentalacademy.com
    254. 254. www.indiandentalacademy.com
    255. 255. Relapse and Stability www.indiandentalacademy.com
    256. 256.      Proffit. White. Sarver Proffit 3rd edition Arnett. McLaughlin Fonscea vol II Bell. Epker www.indiandentalacademy.com
    257. 257. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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