INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.com
INTRODUCTION
AJO-DO 1991
The advent of orthognathic surgery has given the practicing
orthodontist, in conjunction with the...
However, the long-term stability of changes resulting from
these surgical procedures has been an area of major concern
sin...
REVIEW LITERATURE
PROFFIT AND WHITE (1970),AO,were among the first to
mention relapse after surgical-orthodontic therapy. ...
POULTON AND WARE (1971),AJO, stated that, “Probably the
suprahyoid muscles, which have been lengthened, are the main
force...
In 1973, MCNEILL, Trans. Eur. Orthod. Soc.,
Suggested three possible mechanisms for regression:
1.Distraction of the condy...
POULTON AND WARE (1973),AJO, showed skeletal changes
during maxillomandibular fixation. They measured relapses of
50% to 8...
WOLFORD ET AL. (1978),OS, noted that the mandibular
advancement is more stable in low-angle cases and less stable in
higha...
WORMS ET AL. (1980),AO, University of Minnesota, seven
factors that could contribute to regression:
1)Condyle displacement...
BLOOMQUIST (1983),AAO-AAOMS Clinical Congress.
Suggests a need to improve fixation at the osteotomy site,
advocating a sin...
MOORE AT AL,(1991),JOMFS, They found that the surgical
group with the heighest risk of condylar resorption is women 20-
30...
HARADA, SUMIDA, ENOMOTO, OMURA(2002), EJO, They
suggest that a combination of a Lefort-I and horse shoe
osteotomy is a use...
Theories for relapse:
AJO-DO 1991
(1) stretching of the muscles of mastication and the suprahyoid
musculature,(2) condylar...
Numerous fixation techniques to reduce
postsurgical relapse:
(1) upper- and lower-border wiring, (2) Steinmann pins to
sta...
Factors necessary to achieve stability
(vanarsdaal)
Orthodontic considerations:
1) Proper diagnosis of patients who would ...
2) Growth factors and the timing of the referral:
•For moderate and severe C-III mandibular exess pateints
•For mandibular...
4) Dental stability:
5) Pre surgical orthodontic
preparation:
3) TMJ stability:
www.indiandentalacademy.com
Surgical considerations:
1) Treatment plan:
surgery in which jaw,
single or double jaw procedures,especially for open bite...
4) Muscles of mastication and blood supply:
5) Supra hyoid muscle pull:
6) Type of mandibular rotation:
downward, backward...
Three principles that influence post-surgical
stability:
I) Stability is greatest when soft tissues are relaxed during
the...
II) Neuromuscular adaptation is essential requirement for
stability:
Fortunately, most orthognathic procedures lead to goo...
III) Neuromuscular adaptation affects muscular length, not
muscular orientation:
If the orientation of a muscle group such...
Post surgical stability – clinical success.
PROFFIT (1996) IJAODS
Stability after surgical repositioning of the jaws varie...
SURGICAL ORTHODONTIC TREATMENT:
A HIERACHY OF STABILITY IJAOOS,1996
MORE Maxilla up VERY STABLE
Mandible forward 90%
Chin ...
The most stable orthognathic procedure is superior
repositioning of the maxilla, closely followed by mandibular
advancemen...
Prevention of Relapse in Surgical-Orthodontic
Treatment JCO 1986
Factors that affect the stability of combined orthodontic...
2) Immediate pre-surgical treatment planning:-
it determines the exact magnitude of surgical correction and of
any adjunct...
Mandibular Advancement
Presurgical Orthodontic Treatment
• Eliminate dental compensations (make the occlusion more
Class I...
• Properly manage tooth size discrepancies.
• Adequately level both arches.
• Properly manage transverse discrepancies.
ww...
• Avoid bimaxillary protrusion.
Immediate Presurgical Treatment Planning
• Take accurate presurgical records.
www.indiande...
• Make an accurate cephalometric prediction tracing
• Determine the magnitude of suprahyoid muscle lengthening.
www.indian...
• Construct an occlusal surgical splint when necessary.
Surgery and Intermaxillary Fixation
• Mobilize soft tissues.
• Con...
• Prevent relapse during intermaxillary fixation.
• Avoid condylar resorption.
•Postsurgical Orthodontic Treatment
www.ind...
Maxillary Superior Repositioning
Presurgical Orthodontic Treatment
• Properly use vertical mechanics.
• Properly manage tr...
• Accurately characterize maxillary anatomy.
Surgery and Intermaxillary Fixation
• Avoid condylar distraction.
• Avoid poo...
• Avoid transverse maxillary relapse.
• Avoid interdental relapse.
Postsurgical Orthodontic Treatment
• Take immediate ort...
Maxillary Advancement and Inferior Repositioning
Maxillary Advancement
Presurgical Orthodontic Treatment
• Eliminate denta...
Immediate Presurgical Treatment Planning
Surgery and Intermaxillary Fixation
• Mobilize soft tissues.
• Prevent relapse du...
Maxillary Inferior Repositioning
Presurgical Orthodontic Treatment
• Properly manage lower arch position.
• Properly manag...
Immediate Presurgical Treatment Planning
• Construct an intraoral skeletal stabilization appliance.
• Evaluate interocclus...
Surgery and Intermaxillary Fixation
• Use appropriate bone-grafting techniques.
• Prevent relapse during intermaxillary fi...
CONCLUSION
“ALTHOUGH THE PROCEDURES PERFORMED
TODAY ARE BASED SCIENTIFICALLY ON A
VARIETY OF WORKING HYPOTHESES, THE RELAP...
www.indiandentalacademy.com
For more details please visit
www.indiandentalacademy.com
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Surgical relapse /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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  • Surgical relapse /certified fixed orthodontic courses by Indian dental academy

    1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. INTRODUCTION AJO-DO 1991 The advent of orthognathic surgery has given the practicing orthodontist, in conjunction with the oral surgeon, the ability to correct skeletal deformities that previously had to be treated by orthodontic means alone. Often these orthodontic attempts to camouflage the skeletal deformity were unsatisfactory, since they required the introduction of severe dental compensations in an attempt to accommodate to the poor skeletal relationships. As orthognathic surgery has grown more sophisticated, it has allowed the surgeon to address many deformities that were previously untreatable. www.indiandentalacademy.com
    3. 3. However, the long-term stability of changes resulting from these surgical procedures has been an area of major concern since the early days of orthognathic surgery, because the final, long-term result, both esthetic and functional, is directly related to the degree of postsurgical stability. Stability is a key goal of both orthodontic treatment and orthognathic treatment; lack of stability is considered a complication, particularly as relates to the surgical aspect of the correction. www.indiandentalacademy.com
    4. 4. REVIEW LITERATURE PROFFIT AND WHITE (1970),AO,were among the first to mention relapse after surgical-orthodontic therapy. They felt that relapse could be avoided by concentrating on eliminating the original causes contributing to the original malocclusion as much as possible, and by not operating while patients are still growing. KENT AND INDOUINA (1970) J. Louisiana Dent. Assoc state that correction of the openbite deformity is one of the most challenging problems. Openbite treated with the combined efforts of surgeon and orthodontist should produce stable results in certain cases; however, regression is seen because of the influence of the tongue, enveloping muscles of the jaw, unusual skeletal features, or bone pathology.. www.indiandentalacademy.com
    5. 5. POULTON AND WARE (1971),AJO, stated that, “Probably the suprahyoid muscles, which have been lengthened, are the main force contributing to the relapse.” WICKWIRE ET. AL. (1972),JOS, noted the affect of the mandibular osteotomy on tongue position. They felt that the anterior and superior position of he hyoid bone after Class II surgery of the mandible was viewed as another indication of muscle tension, stating that “It appeared, then, that stability of the surgical result would be associated in some way with the stability of the hyoid position.” www.indiandentalacademy.com
    6. 6. In 1973, MCNEILL, Trans. Eur. Orthod. Soc., Suggested three possible mechanisms for regression: 1.Distraction of the condyle from the glenoid fossa at the time of Surgery. 2.Condylar distraction due to healing scar tissue around the osteotomy site. 3.Posterior migration of the anterior mandibular segment in response to tension of the attached muscles and soft tissues during the fixation period. STEINHAUSER,JOS, stated that “We think there is less relapse tendency in the mandibular advancement when combined with suprahyoid myotomy, but we cannot yet prove this.” www.indiandentalacademy.com
    7. 7. POULTON AND WARE (1973),AJO, showed skeletal changes during maxillomandibular fixation. They measured relapses of 50% to 80%, but improved their results by the use of a neck brace and posterior interocclusal bite opening for several months after surgery. GUERNSEY(1974),OS, reported a retrospective study of six cases. He also found relapse in the immediate postoperative period and while the patients were still in intermaxillary fixation, and suggested suprahyoid myotomy. GOLDSPINK(1976),Bristol J. Wright Ltd. Reported that skeletal muscles will adapt to a physiologic stretching of 40% of their resting length after four weeks of stable skeletal immobilization. www.indiandentalacademy.com
    8. 8. WOLFORD ET AL. (1978),OS, noted that the mandibular advancement is more stable in low-angle cases and less stable in highangle cases. EPKER ET AL. (1978),OS, stated in 1978 that – “As a reliable surgical principle, the greater the magnitude of advancement, the greater will be the potential for relapse”. BELL AND JACOBS (1979),AJO, pointed out the need for possible maxillary surgery in conjunction with mandibular advancement to allow for autorotation and decrease the tendency for relapse. www.indiandentalacademy.com
    9. 9. WORMS ET AL. (1980),AO, University of Minnesota, seven factors that could contribute to regression: 1)Condyle displacement 2)Condyle resorption 3)Gnathological errors 4)Fibrous union 5)Misdiagnosis 6)Differential treatment planning 7)Proportionality. EPKER AND WESSBERG (1982),BJO, They conclude that dental stabilization alone without control of the proximal segment of the mandible results in the greatest likelihood of skeletal relapse following surgical advancement. Prolonged skeletal stabilization with control of the proximal segment of the mandible is suggested as the only practical method currently available for assuring maximum stability. www.indiandentalacademy.com
    10. 10. BLOOMQUIST (1983),AAO-AAOMS Clinical Congress. Suggests a need to improve fixation at the osteotomy site, advocating a single lag-screw at each osteotomy site to control changes between the proximal and anterior segments. PROFFIT, TURVEY, PHILIPS,1989,JOMFS. When maxilla is moved upward, the postural position of the mandible alters in concert with the new maxillary movement, and occlusal forces tend to increase rather than decrease.(This controls any tendency for maxilla to immediately relapse downward, and contributes to the excellent stability of this surgical movement) www.indiandentalacademy.com
    11. 11. MOORE AT AL,(1991),JOMFS, They found that the surgical group with the heighest risk of condylar resorption is women 20- 30 yrs of age with high mandibular plane angles and preoperrative TMD signs and symptoms. SNOW AT AL(1991),IJAOOS, Studied post surgical mandibular growth appeared to occur mainly in the vertical plane. BAILEY, DUONG, PROFFIT(1998),IJAOOS, Surgical correction of C-III problem is less stable than C-II correction in the short-term post-surgically, it appears to be more stable long term. www.indiandentalacademy.com
    12. 12. HARADA, SUMIDA, ENOMOTO, OMURA(2002), EJO, They suggest that a combination of a Lefort-I and horse shoe osteotomy is a useful technique reliable superior repositioning of the maxilla. The post operative change in the maxilla using this combination osteotomy is comparatively stable. www.indiandentalacademy.com
    13. 13. Theories for relapse: AJO-DO 1991 (1) stretching of the muscles of mastication and the suprahyoid musculature,(2) condylar distraction during surgery,(3) upward and forward rotation of the mandible, and (4) changes in rotational position between the proximal and distal segments. Simultaneously, various surgical techniques and postsurgical therapies have been advocated to minimize relapse: These are suprahyoid myotomy and cervical collars, which were used in attempts to reduce muscle tension after surgery. www.indiandentalacademy.com
    14. 14. Numerous fixation techniques to reduce postsurgical relapse: (1) upper- and lower-border wiring, (2) Steinmann pins to stabilize the maxilla, (3) skeletal-wire fixation, and (4) rigid fixation. Studies that examined independent mandibular advancements and maxillary LeFort I procedures have indicated a strong tendency toward reduced amounts of relapse when either skeletal-wire fixation or rigid fixation is used. www.indiandentalacademy.com
    15. 15. Factors necessary to achieve stability (vanarsdaal) Orthodontic considerations: 1) Proper diagnosis of patients who would most benefit from combined therapy: *In borderline situations *In other cases surgery is clearly needed www.indiandentalacademy.com
    16. 16. 2) Growth factors and the timing of the referral: •For moderate and severe C-III mandibular exess pateints •For mandibular deficiency patients •Patients with excessive vertical growth ( C-I & C-II ) •For maxillary transverse deficiency patients •Psycho social needs •The timing of referral. www.indiandentalacademy.com
    17. 17. 4) Dental stability: 5) Pre surgical orthodontic preparation: 3) TMJ stability: www.indiandentalacademy.com
    18. 18. Surgical considerations: 1) Treatment plan: surgery in which jaw, single or double jaw procedures,especially for open bite. 2) Design of osteotomy: maintenance of blood supply and accomplishment of objectives. 3) Type of fixation: *dental skeletal, rigid, semirigid, or combination *even with rigid osseous fixation, 13 of 50 mandibular advancement patients had greater than 25% relapse. www.indiandentalacademy.com
    19. 19. 4) Muscles of mastication and blood supply: 5) Supra hyoid muscle pull: 6) Type of mandibular rotation: downward, backward moment is more stable than upward, forward movement. 7) The stability decrease as the magnitude of surgical correction increases, especially in the following: * maxillary vertical deficiencies. * mandibular horizontal deficiencies. 8) Stability of the condylar position: 9) Neuromuscular adaptation: www.indiandentalacademy.com
    20. 20. Three principles that influence post-surgical stability: I) Stability is greatest when soft tissues are relaxed during the surgery and least when they are stretched: Moving maxilla up relaxes tissues, moving the mandible forward stretches tissues, but rotating it upward posteriorly and downward anteriorly decreases the amount of stretch. least stable mandibular advancement:- are those that lengthen the ramus and rotate the chin up. most stable mandibular advancement:- rotate mandible in opposite direction. The least stable orthognathic surgical procedure is widening of the maxilla that stretches the heavy, inelastic palatal mucosa. www.indiandentalacademy.com
    21. 21. II) Neuromuscular adaptation is essential requirement for stability: Fortunately, most orthognathic procedures lead to good neuromuscular adaptation. Repositioning of the tongue to maintain airway dimensions,(I.e., a change in tongue posture) occurs as an adaptation to changes produced by mandibular osteotomy. Neuromuscular adaptation does not occur when the pterygomandibular sling is stretched during mandibular osteotomy, as when the mandible is rotated to close an openbite. www.indiandentalacademy.com
    22. 22. III) Neuromuscular adaptation affects muscular length, not muscular orientation: If the orientation of a muscle group such as the mandibular elevators is changed, adaptation cannot be expected. Successful mandibular advancement requires keeping the ramus in an upright position rather than letting it incline forward as the mandibular body is brought forward. The same is true, in reverse, when the mandible is setback: a major cause of instability appears to be the tendency at surgery to push the ramus posteriorly when the chin is moved back. www.indiandentalacademy.com
    23. 23. Post surgical stability – clinical success. PROFFIT (1996) IJAODS Stability after surgical repositioning of the jaws varies depending on the direction of movement, the type of fixation used, and the surgical technique employed, largely in that order of importance. The various jaw movements possible at surgery were ranked in order of stability and predictability. www.indiandentalacademy.com
    24. 24. SURGICAL ORTHODONTIC TREATMENT: A HIERACHY OF STABILITY IJAOOS,1996 MORE Maxilla up VERY STABLE Mandible forward 90% Chin any direction STABLE 80% Maxilla asymmetry STABLE Mx up + Mn forward STABLE PREDICTABLE Mx forward + Mn back Rigid fix only Mandible asymmetry LESS Mn back Mx down PROBLEMATIC Mx wider www.indiandentalacademy.com
    25. 25. The most stable orthognathic procedure is superior repositioning of the maxilla, closely followed by mandibular advancement in patients whom anterior facial height is mantained or increased. Stability of mandibuar advancement is influnced by the pattern of rotation of the mandible as it is advanced. Rotating the mandible so that anterior face height is decreased, the mandibular angle decreases, the gonial angle tends tobe pulled forward. This stretches soft tissues in that area, and stability is compromised. (Then combined surgery is more stable) Mandibular setback is often unstable, so is downward movement of the maxilla, that creates downward-backward rotation of the mandible. (controlling the inclination of the ramus at surgery is key to stability) www.indiandentalacademy.com
    26. 26. Prevention of Relapse in Surgical-Orthodontic Treatment JCO 1986 Factors that affect the stability of combined orthodontic and surgical treatment vary according to the specific dentofacial deformity being corrected. However, there are usually four basic stages of treatment. There are four basic stages of treatment: 1) Pre-surgical orthodontic phase:- In this teeth are positioned so that surgery can produce an occlusion to be finished after surgery.www.indiandentalacademy.com
    27. 27. 2) Immediate pre-surgical treatment planning:- it determines the exact magnitude of surgical correction and of any adjunctive procedures such as genioplasty, chelioplasty, or alar cinch. 3) Surgical procedure & intermaxillary fixation:- 4) Post-surgical orthodontic treatment:- www.indiandentalacademy.com
    28. 28. Mandibular Advancement Presurgical Orthodontic Treatment • Eliminate dental compensations (make the occlusion more Class II). www.indiandentalacademy.com
    29. 29. • Properly manage tooth size discrepancies. • Adequately level both arches. • Properly manage transverse discrepancies. www.indiandentalacademy.com
    30. 30. • Avoid bimaxillary protrusion. Immediate Presurgical Treatment Planning • Take accurate presurgical records. www.indiandentalacademy.com
    31. 31. • Make an accurate cephalometric prediction tracing • Determine the magnitude of suprahyoid muscle lengthening. www.indiandentalacademy.com
    32. 32. • Construct an occlusal surgical splint when necessary. Surgery and Intermaxillary Fixation • Mobilize soft tissues. • Control condyle-proximal segment positions. www.indiandentalacademy.com
    33. 33. • Prevent relapse during intermaxillary fixation. • Avoid condylar resorption. •Postsurgical Orthodontic Treatment www.indiandentalacademy.com
    34. 34. Maxillary Superior Repositioning Presurgical Orthodontic Treatment • Properly use vertical mechanics. • Properly manage transverse discrepancies. • Maintain lower arch width. • Allow adequate space for the indicated surgery. • Properly relate teeth within the segments. • Maintain proper arch shape. Immediate Presurgical Treatment Planning • Take accurate presurgical records. • Make an accurate cephalometric prediction tracing. • Use accurate definitive model surgery. www.indiandentalacademy.com
    35. 35. • Accurately characterize maxillary anatomy. Surgery and Intermaxillary Fixation • Avoid condylar distraction. • Avoid poor bone contact. www.indiandentalacademy.com
    36. 36. • Avoid transverse maxillary relapse. • Avoid interdental relapse. Postsurgical Orthodontic Treatment • Take immediate orthodontic control after release of fixation. • Re-approximate teeth adjacent to osteotomies or ostectomies. • Use intermaxillary elastics sparingly. www.indiandentalacademy.com
    37. 37. Maxillary Advancement and Inferior Repositioning Maxillary Advancement Presurgical Orthodontic Treatment • Eliminate dental compensations (make the occlusion more Class III). • Properly manage transverse discrepancies. • Properly manage tooth size discrepancies; adequately level both arches. www.indiandentalacademy.com
    38. 38. Immediate Presurgical Treatment Planning Surgery and Intermaxillary Fixation • Mobilize soft tissues. • Prevent relapse during intermaxillary fixation. • Do not use pterygomaxillary junction bone grafts for stabilization. Postsurgical Orthodontic Treatment www.indiandentalacademy.com
    39. 39. Maxillary Inferior Repositioning Presurgical Orthodontic Treatment • Properly manage lower arch position. • Properly manage the shape of the upper arch or segments. www.indiandentalacademy.com
    40. 40. Immediate Presurgical Treatment Planning • Construct an intraoral skeletal stabilization appliance. • Evaluate interocclusal space. www.indiandentalacademy.com
    41. 41. Surgery and Intermaxillary Fixation • Use appropriate bone-grafting techniques. • Prevent relapse during intermaxillary fixation. • Control infection. Postsurgical Orthodontic Treatment www.indiandentalacademy.com
    42. 42. CONCLUSION “ALTHOUGH THE PROCEDURES PERFORMED TODAY ARE BASED SCIENTIFICALLY ON A VARIETY OF WORKING HYPOTHESES, THE RELAPS PROBLEMS THAT STILL OCCUR ARE REMINDERS THAT SOME OF THE TREATMENT PROVIDED MAY HAVE COMPONENTS OF EMPIRICISM”. www.indiandentalacademy.com
    43. 43. www.indiandentalacademy.com For more details please visit www.indiandentalacademy.com

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