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Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
Diagnosis and treatment planning in Orthognathic Surgery
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Diagnosis and treatment planning in Orthognathic Surgery

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  • 1. DIAGNOSIS AND TREATMENT PLANNING IN ORTHOGNATHIC SURGERY Dr.N.R.K.Anil Kumar, II MDS, Department of oral and maxillofacial surgery.
  • 2. Contents  Introduction  History  Diagnosis and Treatment Planning  Clinical evaluation  Cephalometric evaluation
  • 3. Introduction  Malocclusion can be due to many possible reasons but they can be treated by:- 1. Modification of growth 2. Orthodontic camouflage which produces a dental compensation for the skeletal compensation. 3. Surgical repositioning of the jaws and/or dentoalveolar segments The term orthognathic originates from the words orthos and gnathos (Gr. orthos = straight; gnathos = jaw). Orthognathic surgery refers to surgical procedures designed to correct jaw deformities.
  • 4. HISTORY  Hullihen is regarded as the first surgeon to describe a mandibular orthognathic surgical procedure. In 1849, he reported an anterior subapical osteotomy.  Jaboulay and Berard (1898), Kostecka (1931) performed operations on condylar neck and upper part of ramus by closed blind approach.  Surgical treatment for mandibular prognathism started in early 19th century.  In 1959, Trauner and obwegeser introduced sagittal split osteotomy as the beginning of a new era of orthognathic surgery.
  • 5.  American surgeons modify the technique for maxillary surgery that has been developed in europe  Epker, bell and wolford developed lefort-1 maxillary downward fracture ,so that we can keep the maxilla stable in all 3 planes of spaces.  By 1980 progress has reached such an extent to reposition either or both the jaws to move chin in all 3 planes of spaces.  Rigid internal fixation made it possible for comfort and better immobilization was achieved.
  • 6. Envelope of discrepancy  Envelope of discrepancy shows how much of change can be produced by various treatment modalities. 3 5 25 2 5 15 5101 2 4 6 10 7 12 15 2 5 15 2510 4 6 10
  • 7. INDICATIONS  Severe skeletal class II &class III cases  Skeletal open bite and deep bite cases  Deep over bite in non growing individuals  Extreme vertical excess or deficiency in maxilla or mandible  Severe dentoalveolar problem  Extemely compromised periodontal situation  Skeletal asymmetry
  • 8. DIAGNOSIS AND TREATMENT PLANNING
  • 9.  There is no use of using a single diagnostic tool to implicate appropriate treatment as edward angle once hoped  Untill recently, hard tissues of the facial skeleton were the focus of diagnosis and treatment planning  It is now clear that the soft tissues are the limiting factor in the changes that can be produced in treatment and obtaining appropriate soft tissue proportions is the primary goal of treatment
  • 10. Patient evaluation  Patient concerns or chief complaints,  Clinical examination,  Radiographic imaging and analysis,  Dental model analysis.
  • 11. PATIENT’S CONCERNS  What are your concerns or problems?/what do you think is wrong  Have you had previous treatment for this condition, and what was the outcome?  Why do you want treatment?  What do you expect from treatment?
  • 12. History taking  Personal information  Chief complaint - Motivation questionnaires  Medical history  Dental and orthodontic history  Pre-surgical growth assessment
  • 13. Evaluation  Esthetic facial evaluation - frontal facial analysis - profile analysis - intra oral evaluation  Cephalometric evaluation  Panaromic / full mouth peripaical evaluation  Masticatory muscle and TM joint evaluation
  • 14. Photographs
  • 15. Frontal view Assessment of facial proportions and symmetry.
  • 16.  The ideal face in both males and females is vertically divided into equal thirds by horizontal lines at the hairline, the nasal base, and the menton
  • 17.  0.30  0.35  0.35  1 : 1.16 : 1.16
  • 18.  Fronto temporal point ( 0.65 )  Zygion ( 0.75 )  Gonion ( 0.66 )
  • 19.  6 – 8 yrs of age  Symmetry of canthi  Eyelids – ptosis, entropion, ectropion  Sclera, ocular imbalance  Scleral show – mid facial defieciency  Eyelid laxity – snap test
  • 20. NOSE  Both males & females show more growth in vertical ht than anteroposterior projection of nose but downward growth is greater in males  Form and symmetry  Location of deformity  Alar base width (34 + / - 4 mm)  A dorsal hump in the nose develops when class I & II malocclusion is present & is more pronounced in boys
  • 21. • Alar width / nasion to pronasale = 3/5 • Cheek prominence • 8 – 12 mm laterally • 10 – 20 mm inferior to lateral canthus •Ears • Upper 1/3rds just above the canthal level.
  • 22. Cheeks  Malar prominences
  • 23. Lips  Width of lips equal to interpupillary distance  If asymmetry exists - Cleft lip - Facial nerve dysfunction - Dental skeletal deformity  Gull wing upper lip has to be differentiated from vertical maxillary Normal patient 3 3 3 3 3 3 Vertical maxillary excess 6 6 6 6 6 6 Gull wing deformity 2 4 6 6 4 2
  • 24. LIPS  The height of center part of upper lip trails behind the vertical height of the lower face in childhood & then catches up during & after adolescence.  Lip incompetence is common in children  What looks like incompetent lips in childhood or early adolescence is merely a reflection of incomplete soft tissue growth  Lip height  Females : Upper lip - till 14 Lower lip - continues to grow up to the age of 16  Males : growth of both upper & lower lip continues into late teens
  • 25.  Lip thickness is maximum during the conclusion of adolescent growth spurt & then decreases during late teens.
  • 26. Smile evaluation  A balanced smile is achieved by appropriately positioning the teeth and gingiva in the area that is displayed by lip animation during smiling (dynamic display zone).  The amount of incisor and gingival display  The transverse dimension / broadness of the smile  The smile arc  Buccal corridor  Negetive space
  • 27. Incisor and gingival display The difference between social and enjoyment smile is not the activity of orbicularis oris musculature but of orbicularis
  • 28. Chin  Tapered / squarish  Pinch test – semiquantitative assessment of subcutaneous fat  Sub platysmal and supra platysmal fat - differentiated
  • 29. PROFILE VIEW  Fore head  Slopes anteriorly  Accentuated at supra orbital rim  Frontal bossing  Supra orbital hypoplasia  Glabellar angle  Gl- N to N – prs  132 + / - 15 degrees
  • 30. Soft tissue proportions: profile view.  The prominent part of the forehead (glabella) should be approximately the same as the base of the nose, and the forehead should slope gently posteriorly.  The radix (the depth of the concavity at the base of the forehead) should be prominent to obscure the eyelash on the opposite side.  Lateral orbital rims – 8 to12 mm behind the anterior projection of globe.  Infra orbital rim – 2mm anterior to the globe.
  • 31. Cheek bone contour
  • 32.  The contour of the alae from the base of the nose to its tip should be well defined to form a "scroll".  The bridge of the nose (nasal dorsum) should then be a straight line from the base of the radix to the nasal tip cartilage, and there should be a slight prominence of the tip relative to the bridge.
  • 33. Naso labial angle – 90 to 110 degrees 2 • Alar base has to be supported by skeletal nasal bone. • Nasal bridge – 5 – 8 mm ant to globes • Nasal tip ( prn ) – subnasale : subnasale – alar base crease = 2:1 • If values of 1: 1 – maxillary defeciency
  • 34. Clinical facial examination - Profile view  Mandibular area  Lower lip prominence  Soft tissue pogonion prominence  Neck – chin angle – 110  Throat length contour – 50 mm  Overjet
  • 35. Labiomental fold  The labiomental sulcus should form a shallow S curve, with the upper and lower portions similarly shaped. The prominence of the chin should be slightly less than the prominence of the lower lip.  The angle between the lower lip, chin, and deepest point along the chin-neck contour should be approximately 90 degrees
  • 36. Cervico mental area  Mandibular angle- Inferior border defenition - well defined in profile - skin laxity, cervical facial lipomatosis, high mandibular plane angle are conditions – obscure the defenition.  Neck – chin angle and length - normally 110 degrees - PoG – neck chin angle : distance is 50 mm.
  • 37. TMJ Examination • The range of movements • Deviation from normal movements • Any pain during movement • The joint sounds.
  • 38. Intra-oral examination Soft tissues  General periodontal condition  Tongue size, position and activity  Mentalis muscle activity  Finger or thumb sucking Hard tissue  Dental assessment
  • 39. Periodontal evaluation  Adequate attached gingiva  Maintain bone around the necks of each of the teeth at the interdental osteotomy sites
  • 40. Intra oral examination
  • 41. Dentition  Vertical  Overbite  Plane of occlusion  Curve of spee  Horizontal  Anatomical variation  Crowding / spacing  Overjet  Transverse  Crossbites
  • 42.  Maxillary retrusion  Mandibular retrusion  Clockwise mandibular rotation  Upper and lower denture base retrusion  Overjet increase
  • 43. Canting of bilateral structures, specially the lips and the dentition.
  • 44. CEPHALOMETRIC EVALUATION
  • 45. Burstone's Analysis (COGS) Burstone, Randal, Legan, Murphy & Norton (1978)
  • 46. ANATOMIC LANDMARKS  Sella (S)  Nasion (N)  Rhinion (Rh)  Glabella (G)  Orbitale ( O )  Articulare (Ar)  Pterygomaxillary fissure (PTM)  Posterior nasal spine (PNS)
  • 47. ANATOMIC LANDMARKS  Prosthion (P)  Anterior nasal spine (ANS)  Subspinale (A)  Menton (Me)  Gnathion (Gn)  Pogonion (Pg)  Mandibular plane (MP)
  • 48. ANATOMIC LANDMARKS  Infradentale ( I )  Supramentale (B)  Condylion (C )  Pronasale (P )
  • 49.  The COGS appraisal describes  Dental,  Skeletal  Soft tissue variations.
  • 50. CRANIAL BASE HORIZONTAL PLANE (HP), which is a surrogate Frankfort plane,constructed by drawing a line 7 o from the line S to N.
  • 51.  Ar- PTM :  The greater the distance between Ar-PTM, the more the mandible will lie posterior to the maxilla, assuming that all other facial dimensions are normal.  Therefore, one factor for prognathism or retrognathism can be evaluated by this measurement of cranial base.
  • 52. HORIZONTAL SKELETAL PROFILE  N-A –Pg (Angle): gives an indication of the overall facial convexity. A positive (+) angle of convexity denotes a convex face; a negative (-) angle denotes a concave face.
  • 53.  N-A :  N-B:  N-Pog
  • 54. VERTICAL SKELETAL AND DENTAL  Middle third facial height : Distance from N to ANS  Posterior maxillary height : PNS-N  Lower third facial height : ANS – GN  Divergence of mandible posteriorly : M.P-H.P angle(clockwise or counter - clockwise rotations of the maxilla and mandible)
  • 55.  U1 to NF: Anterior maxillary dental height  L1 to MP: Anterior mandibular dental height These two measurements define how far the incisors have erupted in relation to NF and MP respectively.
  • 56.  Max. molar to NF : Posterior maxillary dental height  Mand. Molar to MP: Post mandibular dental height
  • 57. MAX-MAND. RELATION  ANS-PNS: This measurement along with the N-ANS and PNS– N gives a quantitative description of the maxilla in the skull complex.
  • 58.  Ar - Go : Length of Mandibular ramus  Go - Pg : Length of Mandibular body  Ar - Go - Gn Angle : Gonial angle that represents the relationship between ramal plane and MP. Vertical /Horizontal growth  B - Pg : Distance from B point to line perpendicular to MP through Pg describes chin prominence.
  • 59. DENTAL  OP- upper HP:  AB – OP:  U1 to NF angle & L1 to MP angle: These angulations determine the procumbency or recumbency of the incisors.
  • 60. BURSTONE’S ANALYSIS CHARLS .J.BURSTON ET AL: JOS,VOL 36 , PG 269-277
  • 61. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 62. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 63. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 64. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 65. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 66. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 67. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 68. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 69. STEINER’S ANALYSIS S.N o Measurement Mean 1. SNA 820 2. SNB 800 3. ANB 20 4. SND 760 5. M.P to SN 320 6. U1 to N-A 4mm 7. U1 to N-A (angle) 220 8. L1 to N-B 4mm 9. L1 to N-B (angle) 250 10. Interincisal angle 1300 11. Occ. Plane to S-N (angle) 140 S-line: Upper lip: 0mm Lower lip: 0mm
  • 70. WITS APPRAISAL  AO is 2mm ahead of BO - skeletal class I
  • 71. SCHWARZ ANALYSIS Length of Mean Anterior cranial base Mandibular base ACB + 3mm Maxillary base mm Ramus length mm Ramus width mm
  • 72. SCHWARZ ANALYSIS Length of Mean Anterior cranial base Mandibular base ACB + 3mm Maxillary base mm Ramus length mm Ramus width mm
  • 73. SCHWARZ ANALYSIS Length of Mean Anterior cranial base Mandibular base ACB + 3mm Maxillary base mm Ramus length mm Ramus width mm
  • 74. SCHWARZ ANALYSIS Length of Mean Anterior cranial base Mandibular base ACB + 3mm Maxillary base mm Ramus length mm Ramus width mm
  • 75. SCHWARZ ANALYSIS Length of Mean Anterior cranial base Mandibular base ACB + 3mm Maxillary base mm Ramus length mm Ramus width mm
  • 76. HOLDAWAY’S SOFT TISSUE ANALYSIS Measurement Mean Facial angle 90-920 Upper lip curvature 1.5-4mm (2.5) Skeletal convexity at point A -2 to +2 H-line angle 7-150 Nose tip to H-line Upto 12mm Upper sulcus depth 3-7mm Upper lip thickness 15mm Upper lip strain Same as ULS Lower lip to H-line 0mm -1to +2mm Lower sulcus depth 5mm Soft tissue to chin thickness 10-12mm
  • 77. HOLDAWAY’S SOFT TISSUE ANALYSIS Measurement Mean Facial angle 90-920 Upper lip curvature 1.5-4mm (2.5) Skeletal convexity at point A -2 to +2 H-line angle 7-150 Nose tip to H-line Upto 12mm Upper sulcus depth 3-7mm Upper lip thickness 15mm Upper lip strain Same as ULS Lower lip to H-line 0mm -1to +2mm Lower sulcus depth 5mm Soft tissue to chin thickness 10-12mm
  • 78. HOLDAWAY’S SOFT TISSUE ANALYSIS Measurement Mean Facial angle 90-920 Upper lip curvature 1.5-4mm (2.5) Skeletal convexity at point A -2 to +2 H-line angle 7-150 Nose tip to H-line Upto 12mm Upper sulcus depth 3-7mm Upper lip thickness 15mm Upper lip strain Same as ULS Lower lip to H-line 0mm -1to +2mm Lower sulcus depth 5mm Soft tissue to chin thickness 10-12mm
  • 79. HOLDAWAY’S SOFT TISSUE ANALYSIS Measurement Mean Facial angle 90-920 Upper lip curvature 1.5-4mm (2.5) Skeletal convexity at point A -2 to +2 H-line angle 7-150 Nose tip to H-line Upto 12mm Upper sulcus depth 3-7mm Upper lip thickness 15mm Upper lip strain Same as ULS Lower lip to H-line 0mm -1to +2mm Lower sulcus depth 5mm Soft tissue to chin thickness 10-12mm
  • 80. GRUMMONS ANALYSIS
  • 81.  The first horizontal plane connects the medial aspects of the zygomaticofrontal sutures.  The second horizontal plane connects the center of the zygomatic arches.  The third horizontal plane connects the jugal processes.  A fourth horizontal plane runs through the menton and is parallel to the first plane. Grummons article JCO 1987
  • 82. Zygomaticofrontal sutural plane Zygomatic arch plane Jugal plane Z plane through menton Mandibular morphology Volumetric comparison
  • 83. Maxillo mandibular comparison of assymetry
  • 84. MSR-J maxillary width MSR-Ag mandibular width MSR-NC width of NC Nasal septum deviation MSR-Co Asymmetry in condyle MSR-Me Mandibular symmetry LINEAR ASYMMETRY MAXILLARY MANDIBULAR COMPONENTS
  • 85. VALIDITY OF CEPHALOMETRICS
  • 86.  Errors in cephalometric measurements  Radiographic cephalometry is a two dimensional representation of three dimensional object. a)Radiographic projection error Magnification Distortion b)Errors within measuring system c)Errors in landmark identification Quality of radiographic image Precision of landmark definition Reproducibility of landmark location The operator and registration procedure
  • 87. Limitations of cephalometric radiographic analysis  1)Growth pattern not taken into consideration  2)Mean values are based on different population  3)Two dimensional representation of three dimensional object  4)Form and functions not taken into consideration
  • 88. A combination of various cephalometric norms and variables should be compiled to arrive at a proper diagnosis.Although innumerable controversies exist in the field of cephalometrics, it is still a very significant & effective diagnostic tool. Conclusion:
  • 89. Methods of model surgery: Simple method. Anatomically oriented model surgery.
  • 90. Anatomically oriented model surgery. In complex cases, especially where multiple bimaxillary movements are required, it is essential to use a more refined technique such as the following variant of a popular “North American method”
  • 91. In this technique, in addition to the impressions and sqash bite, a face-bow recording is taken. 1. The working models are anatomically trimmed and articulated on the semi adjustable articulator using the face-bow recording and then the standard squash bite. Technique:
  • 92. 2. Horizontal and vertical reference lines are drawn on the mounting plaster to register the post-operative position of each maxillary and mandibular segments before surgery. Two sets of parallel horizontal lines A/A and B/B are drawn on the upper and lower models. These are easily done by rotating the detached model with the felt pen.The B lines should be just clear of the apices of the teeth, and not less than 15mm from the A lines. These lines will be used to plan the vertical
  • 93. 3. Three vertical lines VC, VB, VM are drawn from upper base line (A) to the lower baseline (A) on each buccal segment. These will help to indicate the anteroposterior movements achieved by the model surgery. Upper and lower midlines are also drawn. Marked models with the recorded distances.
  • 94. 4. The vertical distances from the buccal cusp tips of the three reference teeth to their A base lines are recorded to help calculate any vertical movements. Transverse changes are recorded by the inter-canine and inter-molar distances measured across the palate and recorded by taking reference points on the canine tips and the Cuspal reference points are used for transverse
  • 95. When all the reference lines have been drawn and the measurements completed, the osteotomy lines are drawn between A and B lines to correspond with the bone cuts. The plaster mounting assembly is then sectioned at the osteotomy sites with a saw or large abrasive disc and the whole arch or segments are Interrupted line is the proposed osteotomy site.
  • 96. Maxilla is reassembled with the wax after the osteotomy cuts. Mandible closes in to the intermediate occusal relationship. Intermediate wafer is made at this stage.
  • 97. Lower segmental set-down of 3mm is carried out with the forward slide of 5mm to correct the interarch occlusal relationship.
  • 98. Anterior view: models showing the upper midline split to widen the intercanine width and the lower anterior set-down.
  • 99. THANK YOU

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