Surgery in orthodontics

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surgical procedures that are commonly carried out in orthodontics

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  • Craniosynostosis and severe hemifacialmicrosomia
  • Difference in extractions needed with the two approachesserious error to attempt camouflage on the theory that if it fails, the patient can then be referred for surgical correction
  • Example of camouflage v/s surgeryDecompensation
  • Cases of growth excess are corrected after the deceleration of growth has occurred because early treatment might require retreatmentHowever, cases of growth deficiency that are severe and progressive(ankylosis of the mandible after a condylar injury or severe infection) require surgery before puberty; stable cases might not
  • most stable orthognathic procedure >>Moving the maxilla up, so that the mandible can rotate up and forwardMoving maxilla up relaxes tissues; postural position of mandible due to neuromuscular adaptation exerts occlusal forces to maxilla and prevents relapse
  • Hemifacialmicrosomia
  • Pt with long face and Skeletal ant. open bite;Le Fort I osteotomy with maxillary impaction could have resulted in rotation of the nasal tip upwards resulting in deepening of the supratip depression, and widening of the alar baseRhinoplasty improved nasal contour
  • Genioplasty affecting the facial expression of man; forward and upward movement of chin
  • No breaks or loss of buccal or lingual bony plates
  • Impaction of teeth usually occurs as a result of arch length discrepancy or presence of mucosal and bony barriers that prevent their eruption.
  • Surgical techniques for removal of frenal attachmentssimple excision techniqueZ-plasty techniquelocalized vestibuloplasty with secondary epithelialization
  • Surgery in orthodontics

    1. 1. 1 Surgery in Orthodontics Ujwal Gautam Roll no. 431 BDS 4th year (2009 batch) BPKIHS
    2. 2. 2 Major procedures • Orthognathic surgeries • Cosmetic surgeries Minor procedures • Extractions – therapeutic extraction – serial extraction – carious teeth – malformed teeth – supernumerary teeth – impacted teeth • Surgical uncovering of teeth • Frenectomy • Pericision • Corticotomy
    3. 3.  Orthognathic surgeries corrects dento-facial disproportions involving the maxilla, the mandible or both in all three planes of space 3
    4. 4. Indication If neither growth modification procedures nor orthodontic camouflage provides solution NOT a substitute but adjunct to or in conjunction with orthodontic treatment. 4
    5. 5. 5 Camouflage v/s Surgery Decision for camouflage or surgery must be made before treatment begins Greater emphasis on soft tissue consideration essential when camouflage versus surgery is considered
    6. 6. 6 Envelope of Discrepancy
    7. 7. 7 Surgery preferred over Orthodontic Camouflage for; o Long Vertical Facial pattern o Moderate or severe antero-posterior jaw discrepancy o Crowding >4-6 mm o Exaggerated features o Transverse Skeletal problem
    8. 8. Contemporary Surgical Techniques: – Mandibular Surgery – Maxillary Surgery – Dentoalveolar Surgery – Distraction Osteogenesis – Adjunctive Facial procedures 8 LeFort I osteotomy Segmental osteotomies Sagital Split osteotomy Oblique sub condylar osteotomy Rhinoplasty Genioplasty Sub mental procedures Lip procedures Surgically assisted rapid Palatal Expansion (SARPE)
    9. 9. Class III mandibular excess 9
    10. 10. Class II mandibular deficiency 10
    11. 11. Horizontal deficiency and vertical chin excess 11
    12. 12. Class II maxillary protrusion 12
    13. 13. Excess vertical growth of maxilla and down and back rotation of mandible 13
    14. 14. Class III maxillary deficiency and mandibular excess 14
    15. 15. Distraction Osteogenesis • based on manipulation of a healing bone • osteotomized area is stretched before calcification has occurred in order to generate the formation of additional bone formation and investing soft tissue • Patients with craniofacial syndrome are the prime candidates • Advantages of distraction are that – Larger distances of movement are possible than with conventional orthognathic surgery, and – Deficient jaws can be increased in size at an earlier age • Disadvantage is that precise movements are not possible 15
    16. 16. 16
    17. 17.  Adjunctive Facial procedures • improve the esthetics of the patient • to improve the soft tissue contours beyond what is available from repositioning the jaws 17
    18. 18. Rhinoplasty  cosmetic surgery of the nose focused on the contour of the nasal dorsum, the shape of the nasal tip and the width of the alar base  particularly effective when nose is deviated to one side, has a prominent dorsal hump, or has a bulbous or distorted tip.  Usually follows LeFort I osteotomy which compromises the appearance of nose 18
    19. 19. 19
    20. 20. Chin Augmentation or Reduction  most frequently used adjunct to orthodontics  Improves the stability of the lower incisors as well as enhancing facial appearance tightens the suprahyoid musculature and produces desirable changes in chin-neck contour  Reduction of the chin with osteotomy can be a possibility to camouflage a skeletal Class III problem 20
    21. 21. 21
    22. 22.  Extractions Most commonly undertaken minor surgical procedures in conjunction with orthodontic therapy. 22
    23. 23. Therapeutic extraction – for gaining space – Choice of teeth extraction is based on number of factors including the amount of arch length-tooth material discrepancy, the direction and amount of jaw growth, the facial profile, the state and position of teeth in particular and the entire dentition and finally the age of the patient. – Integrity of alveolus should be maintained – Permanent 1st premolars are the most commonly extracted teeth 23
    24. 24. Serial extractions – interceptive orthodontic procedure – usually initiated in the early mixed dentition when severe arch length discrepancy exists – includes planned extraction of certain deciduous teeth and later specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into normal alignment 24
    25. 25. Procedures Dewels method Tweeds method Nance method 25
    26. 26. Extraction of supernumerary, impacted and ankylosed teeth • Involves removal of local cause of malocclusion 26
    27. 27. Surgical extraction of bilateral unerupted supernumerary teeth in maxillary central incisor region 27
    28. 28. • Impacted teeth can be guided into normal position by removal of overlying soft tissue and removal of bone covering • orthodontic guidance can be required using attachments to guide erupting tooth into arch 28  Surgical uncovering of impacted teeth
    29. 29.  Frenectomy • surgery to remove the interdental fibrous tissue and reposition the frenum • Generally performed for Midline Diastema • maxillary midline diastema is often accompanied by the insertion of a thick, fleshy fibrous labial frenum into a notch in the alveolar bone. 29
    30. 30. frenectomy performed prior to space closure Merit-  removal of etiology  Space closure can be easily attained orthodontically Demerit-  scar tissue that could prevent orthodontic space closure. 30
    31. 31. frenectomy should be performed after space closure Merit-  reduces the risk of scar tissue formation that can prevent closure of midline diastema.  post surgical scar tissue stabilizes the teeth together. Demerit-  during closure, soft tissue may be enlarged and sore preventing complete space closure.  if the space is large and frenal attachment is thick, it may not be possible to completely close the space before surgical intervention, requiring multiple stages of treatment. 31
    32. 32. Frenectomy and midline diastema 32
    33. 33.  Corticotomy • undertaken in patients having dental proclination with spacing • Involves sectioning of dento-alveolar region into multiple small units to hasten orthodontic tooth movement • Although the nerve supply to the teeth is interrupted, sensation usually returns and endodontic treatment almost never required 33
    34. 34.  Pericision • Also known as circumferential supracrestal fibrotomy • Adjunct to an retention procedure after corrrection of rotations • performed to counter the relapse tendency of the stretched gingival fibres – trans-septal and alveolar crest group in derotated tooth • Surgical sectioning of gingival fibres • performed a few weeks before removal of orthodontic appliance or if it is performed at the same time the appliance is removed, a retainer must be inserted almost immediately. 34
    35. 35. References Proffit W. R.; Contemporary Orthodontics; Mosby Inc; 4/e; 2007 Bhalajhi S. I.; Orthodontics The Art and Science; Arya(MEDI) Publishing House; 4/e; 2009 Proffit, White, Sarver; Contemporary Treatment of Dentofacial Deformity; St. Louis, Mosby,2003 Singh G.; Textbook of Orthodontics; Jaypee Brothers Medical Publishers Ltd; 2/e; 2007 35

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