2. INTRODUCTION
• Face forms the identity of an individual.
• Facial disfigurement or facial deformities
invariably make an individual highly self
conscious of their abnormal features.
• The appearance sometimes bears a
psychological impact on the individual.
3. PROBLEMS ASSOCIATED
• ESTHETIC
• FUNCTIONAL:
- Speech
- Mastication
- Psychological
- Orthognathic surgical procedures can alter their
facial form and function to make it both
functionally efficient as well as esthetically
pleasing.
4. DEFINITION
• The word “ORTHOGNATHIC” is derived from
the Greek word ‘orthos’ meaning to straighten
and ‘gnathos’ meaning jaw.
• Literally means to straighten a jaw
• Involves the surgical manipulation of the
elements of the facial skeleton to restore the
proper anatomic and functional relationship in
patients with dentofacial and skeletal
deformities.
5. • Every population group has facial features
different from other population groups.
• Defining what is normal for an individual first
requires to analyse the degree of deviation
from what is measured to be normal for that
particular population group.
• Ultimate goal of orthognathic surgery is to
restore an esthetically pleasing face to the
individual.
6.
7. Etiopathogenesis:
The etiology of dentofacial deformities can be divided into:
• Congenital
• Acquired
Congenital:
• i. Differential growth: Dentofacial skeletal deformities generally
occur as a result of a differential growth of the upper facial skeleton
to the lower facial skeleton
• ii. Genetic: Underlying genetic predisposition
• iii. Syndromes: Syndromic conditions such as Aperts and Crouzons
syndrome and facial clefts can affect normal growth and
development of the face.
8. Acquired:
• Traumatic: Condylar fractures and subsequent
ankylosis causing an underdevelopment of the
jaws leading to a bird face deformity
• Others: Other conditions such as neoplastic
growth in the jaws, surgical resections,
iatrogenic radiations etc
10. Dental dysplasia:
• These are limited strictly to malallignment of the
dental component and not involving the skeletal
component. This can be corrected by orthodontic
treatment alone.
Skeletal dysplasia:
• When a patient has skeletal deformity with a
normal dentition and occlusion
Patient with retrogenia and no retrognathia.
11. Dentoskeletal dysplasia:
• The dentition is malpositioned in each arch
and with each other,
• also the skeletal relationship of the upper and
lower jaw is abnormal.
• A cleft patient with a deficient maxilla.
Treatment involves the correction of the
dentition with orthodontic treatment as well
as correction of the skeletal deformity.
14. • Prognathism is defined as abnormal projection
forward of one or both jaws
• Micrognathia is defined as the smallness of
the jaws especially the mandible.
• Apertognathia or open bite is a condition in
which there is space between the upper and
lower teeth when some teeth are in contact at
one or more points.
15. MANDIBULAR PROGNATHISM
Clinical features
• Concave face profile
• Prominent lower jaw
• Relative deficiency of maxilla and para alar region
• Acute nasolabial angle
• Reduced labiomental fold
• Incompetence of lips in severe cases
• Occlusal features: Class III molar relation, reverse
overjet anteriorly, posterior cross bite, lingually
inclined lower incisors
16. MAXILLARY PROGNATHISM
Clinical features
• Convex face profile
• Bird face deformity
• Short upper lip and everted lower lip
• Deep mentolabial fold
• Incompetant lips
• Hyperactive mentalis visible on attempting to get
the lips together
• Occlusal features: class II molar relation, Deep
bite, increased overjet
17. Assessment of the patient:
• The first dental visit is critical :
• the patient's chief complaint
• what the patient expects from the treatment
• medical status and medicines being taken by
the patient
18. Patient examination:
Inspection:
• Status of the oral hard and soft tissues:
• oral hygiene condition
• mobile, carious, unrestorable teeth etc
• Overcrowding
• spacing between teeth
19. • interarch relationship
• Occlusion
• overjet, overbite, crossbite, openbite etc
• canting of occlusal plane
• soft tissue abnormalities
• soft tissue relationship of tongue, cheek and
teeth, muscle tone in the lips etc.
• past dental history
• scars of a previously performed surgery, scars
from previous trauma also may be seen
20. TMJ evaluation and oral functions:
• Mouth opening
• lateral excursions
• deviation of lower jaw on opening
Palpation:
• clicking sounds in TMJ
• painful jaw movements
• The jaws can be palpated for malunited fractures,
previously treated tumors etc.
21. Measurement of facial proportions:
• This is done basically to ascertain which part
of the jaw or face is disproportionate.
• The patient is made to sit upright with the
head in position and the face is evaluated
from frontal and lateral(profile) view.
22. Facial balance
• This is assessed by dividing the face into thirds
• The upper third is from the anterior hairline to the
glabella Middle third from glabella to subnasale Lower
third from subnasale to menton
• When each of the thirds are equal, the face is said to
be balanced.
ii. facial proportions:
• The full face can also be divided into vertical fifths and
proportions examined
• Each portion is measured and is supposed to be equal.
24. • Radiographs, photographs, or orthodontic models of the
patients put accurate numerical values to the approximate
measurements made in the facial analysis.
• Helps in determining the exact region of disproportion and
also to assess the amount of deviation from normal values.
• Useful in chalking out a carefully planned treatment protocol.
Radiography of the jaws: This maybe of 3 types:
• Conventional radiography
• Cephalometry
• Special radiological investigations.
25. • Conventional radiography: This is done to assess
the general shape, structure of the skull,
intracranial pathologies
Cephalometric evaluation:
• A lateral cephalogram is studied by marking
certain predetermined points on the hard and
soft tissue landmarks and making measurements
to analyse which part of the jaw or face is
abnormal and how it can be corrected.
• A posterior anterior view cephalogram is also
analysed for symmetry of the face
26. Photography:
Facial photographs are taken in frontal, lateral
and oblique lateral views.
• For maintaining records
• For comparison between pre operative and
postoperative appearance
• to assist in computer aided analysis
• helps in treatment planning
27. • Model surgery:
• Construction of accurate occlusal models on
which a mock surgey is performed.
• Helps in predicting any occlusal problems that
may take place and also to modify the
orthognathic surgery accordingly.
28.
29. • Upper and lower arch impressions are made
• The midline is marked
• Centric jaw relation is recorded using a wax
sheet.
• A face bow transfer is done and the models are
articulated on a semi adjustable articulator.
• Horizontal and vertical reference lines are drawn
on the models.The vertical reference lines help to
indicate the anteroposterior movement and the
horizontal reference lines show the amount of
vertical changes.
30. • The osteotomy lines are drawn and cut with a
saw.
• The segments are then moved and fixed to their
desired positions with wax.
• The segments must be moved in such a way so as
to obtain the best possible occlusion.
• An occlusal acrylic splint or wafer is constructed
to be used as a guide to obtain the same
occlusion as achieved during the mock surgery.
31. Treatment planning:
• All the data and records collected till now are put together and a
detailed analysis is done.
• Treatment planning is started by reviewing all the orthodontic and
surgical options that address the problem.
• Treatment options:
• Conservative management:
– Myofunctional appliances
– Orthodontic treatment without surgery
• Surgical treatment:Steps:
• - Pre orthodontic phase
• - Pre surgical orthodontics
• - Surgical phase
• - Post surgical orthodontics
• - prosthodontic phase
32. Conservative non surgical
management:
• 1. Myofunctional appliances
•
• 2. Orthodontic treatment alone:
• - This is done in cases where the skeletal deformity is
mild and can be masked by the correction of the dental
deformity alone.
• - In cases where the patient may not be willing for an
extensive surgical procedure, a compromised
treatment in the form of orthodontics to correct only
the dental component is done.
•
33. • Decided whether to intervene prior to completion of
skeletal growth or to await skeletal maturity to
eliminate the variability of subsequent growth and the
need for a second surgery at a later date.
• The ideal time for surgery as advocated by most
surgeons is however once the growth is complete.
• Once the decision ismade for a dental-surgical
correction, a careful plan of the overall treatment is
layed out.
34. • The management is divided into the following
phases:
• 1. Pre orthodontic preparatory phase
• 2. presurgical orthodontic treatment phase
• 3. Surgical phase
• 4. Post surgical orthodontic phase
• 5. Prosthodontic treatment phase.
35. PHASES
1. Pre orthodontic preparatory phase: The
patient is prepared for the orthodontic as well
as the surgical phase by undergoing a
complete scaling, filling of carious teeth,
treatment of periodontal problems etc.
36. 2. Pre surgical orthodontics:
• Dentition is aligned orthodontically within each dental
arch
• Curve of Spee is leveled,
• The anterior dentition is decompensated
• This is performed individually in each arch without
attempting to correct the occlusion- this is done
surgically.
• The malocclusion appears to have worsened in this
phase and the patient should be informed about this.
37. • If segmental surgery is planned, space can be
created between th existing teeth without having
to extract the teeth.
• Dental casts are obtained during each phase
• No active orthodontic movement is done during
the surgical phase.The orthodontic wire is kept
passive.
• This phase takes about 6-18 months depending
upon what needs to be accomplished to
maximize final surgical stability at the occlusal
level.
38. Surgical phase:
• The patient is re evaluated clinically
• Radiographs are taken again
• Cephalometric and prediction tracings are
repeated
• Model surgery performed and a splint is
fabricated.
• The surgery is performed as planned.
• Postoperatve period: Airway management
39. • OPG taken and the position of the condyle is
evaluated.
• If the condylar position is found not satisfactory,
the patient is taken back for surgery and the
osteosynthesis is redone.
• If the occlusion has minor variation from the
planned occlusion, elastics can be used to guide
the jaws back to the desired occlusion during the
bone healing phase.
• Patient is maintained on a soft diet.
40. The surgical phase
• The part of the face that is found to compromise
the esthetics is sectioned, mobilised and
repositioned in a more desirable position to bring
about facial harmony. Sectioning of the part of
the jaw is known as osteotomy.
Surgical anatomy:
Bony movements of the jaws are limited by 2 very
important factors:
• 1. The blood supply to the osteotomised segment
• 2. The soft tissue movement that takes place
along with the bony movement.
41. • When a segment is osteotomised, the blood supply either on the
buccal or palatal/lingual side must be maintained intact.
• This maintains the viability of the segment and prevents necrosis.
• When the blood supply on one side is retained, the segment gets
revascularised and heals in the new position in which it has been
fixed.
• The soft tissues which envelope the bony segment which is
mobilised also has a limited capability for movement.
• Positioning it at a point beyond its capcity, compromises its
vascularity and also increases the degree of relapse of the bony
segment.
42. BLOOD SUPPLY MAXILLA
The arterial blood supply is derived from 4
primary sources.
• descending palatine branch of the maxillary
artery
• ascending palatine branch of facial artery
• anterior branch of ascending pharyngeal
artery, branch of external carotid.
• alveolar branches of the maxillary artery.
43. Single tooth osteotomies:
• This procedure is limited to upper anterior teeth
Indications:
• dilacerated teeth
• teeth intruded as a result of trauma
• single malpositioned tooth
• Incision:
• 2 vertical incisions are made on either side of the tooth
bucally through mucoperiosteum 1-2mm on either side of
the proposed bony osteotomy cut. The mucoperiosteal flap
is elevated high up in the labial sulcus above the root apex
of the teeth to be osteotomised.
44. Osteotomy cuts:
• 2 vertical cuts in the bone on either side of the tooth in the
interradicular area . The bony cuts are kept parallel to each
other.
• High up in the labial sulcus, above the root apex and a
horizontal bony cut is made joining these 2 vertical cuts
taking care to avoid damaging the root apices.
• The tooth with its supporting bone is osteotomised. The
cuts are directed towards the palate with a finger kept on
the palate to feel for the instrument cutting the palatal
bone.
• The fragment is mobilized and then fixed in the desired
position using wires to the adjacent teeth
• Immobilisation is required for atleast 4-6 weeks.
45.
46. Anterior segmental osteotomies:
It is basically of 2 types:
• Wassumund procedure
• Wunderer’s procedure.
• The main difference between these two osteotomised segments is
the source of blood supply to the osteotomised segment after
mobilisation
Indications:
• Premaxillary protrusion
• deep bite
• anterior open bite.
Model surgery is first done on the casts of the patient to check for the
final result on the patient.
47. Wassumund procedure:
Incision:
• Blood supply to the osteotomised segment
will be from the palatal mucoperiosteum.
• vertical incisions are made in the premolar
region
• small midline vertical incision is made to
expose anterior nasal spine and nasal septum.
• The premolars are extracted on both sides.
48. Osteotomy cuts:
• Buccal bone cuts are made first through the
socket of the extracted tooth vertically.
• The cut is then turned medially towards the
piriform aperture. care is taken to protect the
nasal mucosa.
• The palatal cortical plate of the extracted
premolar socket is cut vertically. This is then
continued on the palatal bone by tunelling under
the palatal mucoperiosteum.
• Care is taken to protect the soft tissues of the
palate to prevent perforation
49. • Essentially a blind procedure
• Where it is difficult to complete the procedure this way
a small sagittal incision is made in the centre of the
palate and the osteotomy at the junction of the nasal
septum with the palatal bone is sectioned.
• The nasal septum is attached to the nasal aspect of the
hard palate and needs to be detached for mobilisation
of the palate. The nasal septum is freed from the
palate using a nasal septal chisel anteriorly through a
midline vertical buccal incision.
50. • If superior repositioning of anterior segment of
the maxilla is required, length of nasal septum is
reduced using a ronguer.
• Segment is mobilized completely and
repositioned as desired and fixed using
orthodontic wires or with an arch bar previously
placed.
• Mucoperiosteal flap is closed using simple
interrupted sutures.
•
51. Wunderer procedure
Incision:
• blood supply to anterior segment is from the buccal
mucoperiosteum.
• Horizontal mucoperiosteal incision made across the palate
such that it lies posterior to the planned osteotomy site.
• Small vertical incisions are made in the buccolabial sulcus
at the place where the tooth is extracted.
• Another small vertical incision is made in the midline to
expose anterior nasal spine and nasal septum
• Bilateral premolars are extracted.
•
52. Osteotomy cuts:
• Buccal bone cuts are made similar to the
Wassamund procedure.
• Nasal septum is detached using nasal septal
chisel
• Palatal bone cut is made to completely mobilize
the anterior segment of the maxilla
• The anterior segment is thn mobilesed and fixed
in the preplanned position.
• Mucoperiosteal sutures are placed.
53. • Most commonly used procedure is now what
is known as the down fracture technique
described by Epkar and Wolford.
• In this procedure, a complete labial incision is
made similar to a Lefort I incision. Palatally no
incision is made.
54.
55. Posterior segmental osteotomies:
• This procedure was first described by
Schuchardt in 1959 as a two stage procedure
but now it is done in a single stage.
• Indications:
• To correct posterior open bite
• posterior cross bite correction
• to superiorly reposition a supraerupted
posterior segment
56.
57. Incision:
• A horizontal incision is made high up in the
buccal sulcus from the canine to the first
molar region.
• Osteotomy cuts:
• Premolar extracted to provide space
• Vertical bone cut made through the socket
• Horizontal bone cut made through the
maxillary antral wall, posteriorly it is tunneled
upto the tuberosity region about 5mm above
the root apices.
58. • Required bone is removed from the buccal
side if superior repositioning is required.
• A curved osteotome is inserted from the
buccal gap that is created and the posterior
segment separated.
• Avoid damage to the greater palatine vessels.
• Buccally bone cuts are made atleast 5mm
above the root apices to prevent damage to
the teeth.
59. • Incision may be required on the palatal side to
complete the osteotomy.
• Placed medial to the greater palatine vessels
and parallel to it.
• The medial wall of the antrum or the lateral
wall of the nose is sectioned using osteotomes
or a bur with care taken to protect the nasal
mucosa.
60. • Segment is mobilized and bone is reduced
where necessary.
• Segment is positioned in preplanned desired
position and fixed using arch bar and splint
• Flaps are sutured
61. Complications of segmental
osteotomy:
• damage to soft tissue, blood supply and
devitalisation of the segment.
• Damage to adjacent teeth , periodontal
pockets etc
• Where bone contact is not satisfactory,
delayed union
62. Le Fort I osteotomy:
Indications:
• Low midface hypoplasia
• Maxillary hypo/hyperplasias.
• Vertically short or long midface.
• For correcting cant of occlusion
• Cleft patients with midface deficiency.
63. Incisions:
• A horizontal incision is made in the buccal
sulcus through the periosteum just above the
apices of the teeth.
• Incision extends from the zygomatic buttress
to the midline and to the opposite side
zygomatic buttress region.
64. Exposure
• Almost the entire maxilla is seen on the buccal
side upto the zygomatic buttress
• Tunnel posteriorly to junction of tuberosity to
pterygoid plates.
• Anteriorly, the mucoperiosteum stripped
along the nasal floor to posterior edge of the
hard palate.
• Medially along the lateral wall of nose as far
as the inferior turbinate.
65. OSTEOTOMY CUTS
• 5mm above apex of canine and molar teeth
• Cut started high in the aperture area and
extended posteriorly sloping downwards and
backwards to the tuberosity area.
• Bone cuts can be made with a bur or stryker
saw.
66.
67. • If reduction of the vertical height of the
maxilla is required, the wedge of bone to be
removed is marked with a caliper prior to
cutting it.The bone removed is collected and
preserved to be used as free bone graft.
• Osteotome is used along the lateral wall of the
piriform aperture to separate the
dentoalveolar part from the rest of the
maxilla.
68. • Nasal septum is separated from the maxilla by
using a notched nasal septal chisel directed
along the floor of the nose.
• The maxillary tuberosity separated from the
pterygoid plates using a curved Tessier’s
osteotome which is directed downwards and
medially.
• With firm pressure applied over the anterior
alveolus, the maxilla can be downfractured to
complete the separation.
69. • The maxilla is positioned using a splint in the
preplanned position and fixed using bone
plates.
•
70. Complications of LeFort
osteotomy:
• Infraorbital nerve traction injury
• Unanticipated fractures
• Injury to maxillary artery and its branches
• Lacrimal duct injury
• Avascular necrosis
• Nasal septal deviation and buckling
• Flaring of alar base
71. Le Fort II osteotomy:
• Allows the surgeon to alter the nasomaxillary
projection without altering the orbital volume
and zygomatic projection.
• Used for correction of midfacial deficiency
with naso maxillary deficiency.
• Syndrome patients such as Binder’s syndrome
• Le Fort II osteotomy is designed to bring the
central midface forward along with the
dentoalveolar complex.
72. Le Fort III osteotomy
• Complete craniofacial dysjunction is achieved
• Allows the surgeon to alter the orbital position
and volume, zygomatic projection, position of
the nasal root, position of the maxilla
• Usually used in conjunction with craniofacial
surgery.
• Used to correct total midface hypoplasia
which involves deficiency of the malar bones
and the nasoethmoid complex and the orbits.
74. Vertical subsigmoid osteotomy:
Indications:
• Used for correction of mandibular
prognathism and to correct mild cases of
mandibular retrognathism.
• First described by Caldwell and Letterman
75. Incision:
• Initially this procedure was done by extraoral
approach but now it is done intraorally.
• Extraoral approach is submandibular incision.
• Intraoral incision is an extended third molar
incision, extended anteriorly to first molar
region and posteriorly to anterior border of
ramus.
• Masseter muscle is stripped entirely and the
lateral surface of the ramus exposed.
76.
77. • Antilingula
• Protect inferior alveolar nerve
• Cut from deepest part of sigmoid notch to
lower border of mandible
• Cut placed posterior to mandibular foramen
• Decortication of anterior segment when
mandible is pushed back to correct
prognathism
78. Complications:
• Extraoral scar
• Chances of necrosis of the ramus due to
compromise in blood supply from masseter
muscle.
• Injury to inferior alveolar nerve
79. Inverted ‘L’ and ‘C’ osteotomies:
• First introduced by Trauner.
• Used in case of retrognathism.
• Approach can be intraoral or extraoral
• Extraoral approach is by incision in
submandibular region (similar to vertical
subsigmoid approach)
• The lateral aspect of the ramus of the
mandible exposed.
• .
80. • The osteotomy cut is made first horizontal
starting from the anterior border of the
ramus- the base of the coronoid process
extending above the mandibular foramen.The
cut then runs vertically down to the inferior
border of the mandible
• Mandible is advanced and gap may be filled
with bone grafts
81.
82.
83. Intraoral sagittal split osteotomy:
• First described by Obwegeser. Later modified
by Hunsuck and Dalpont
Indications:
• Versatile procedure which can be used
effectively for both prognathic and
retrognathic mandible correction.
• Procedure done intraorally.
84. Incision
• Third molar region just lateral to the crest of
the alveolus.
• Extended anteriorly along the external oblique
ridge upto the planned vertical osteotomy cut.
Distally incision extended along the anterior
border of the ramus.
• Expose lateral ramus
• Posteriorly the masseter is left intact.
85.
86. OSTEOTOMY CUTS
• i. The horizontal cut on the medial aspect of
the ramus placed above the mandibular
foramen,
• ii. The vertical cut in the region of the third
molar from the external oblique ridge to the
inferior border of the mandible and
• iii. An osteotomy cut connecting the previous
2 cuts which runs along the external oblique
ridge.
87. Complications of BSSRO
• Injury to inferior alveolar nerve
• troublesome bleeding (inferior alveolar,
massetric artery)
• Unfavourable split
• Avascular necrosis
• Condylar resorption
• Malposiioned proximal segment
• Shattering of the ramus in case of thin
mandible
89. Body osteotomy- mandible:
• Rarely done due to fewer indications.Can be
used for correcting prognathism as well as
retrognathism.
This procedure is basically of 2 types:
a) Osteotomy done anterior to the mental
foramen
b) Osteotomy done posterior to the mental
foramen.
90.
91.
92. Complications:
• Injury to inferior alveolar/ mental nerve
• Widening of the arch.
• Development of double chin in severe set
back of mandible. This can be corrected by
soft tissue procedures.
93. Segmental procedures
• These procedures are done in cases where
there is no marked discrepancy in the jaw size
and the patient requires only dentoalveolar
correction
94. Anterior subapical osteotomy:
Indications:
• proclined /retroclined lower anterior teeth
• superiorly or inferiorly placed lower anterior
teeth
Incision:
• A gingival/translabial incision is made and flap
is reflected
• The first premolars are extracted.
99. GENIOPLASTY TYPES
Augmentation or reduction genioplasties can be
done in 2 dimensions:
• Horizontal augmentation: to improve the
prominence of the chin anteroposteriorly
• Vertical augmentation: to increase the length
of the chin in a superoinferior direction
• Horizontal reduction: To reduce the projection
of a protruded chin
• Vertical reduction: To reduce the length of the
chin.
100. Complications:
• Mental nerve injury,
• Malunion
• Nonunion
• Bony irregularities
• Step type deformities
• Lip drop
• Chin ptosis
• Over correction and under correction
101. Kole’s procedure:
• This procedure is done for the correction of an
anterior open bite.
• A standard anterior subapical osteotomy is
performed after which a portion of the lower
border is removed as in a genioplasty and
wedged into the space produced between the
dentoalveolar fragment.
• The newly formed chin is then reshaped and
wound closed in layers.
102. • This procedure is done for the correction of an
anterior open bite.
• A standard anterior subapical osteotomy is
performed after which a portion of the lower
border is removed as in a genioplasty and
wedged into the space produced between the
dentoalveolar fragment.
• The newly formed chin is then reshaped and
wound closed in layers.
103.
104. ALLOPLASTIC AUGMENTATION
CHIN
• Various materials used include: bone,
cartilage, silicon, Gortex etc.
Complications:
• foreign body reaction to the implant material
• bone resorption
• Migration, extrusion of the implant
• Dehiscence , infection of the wound
• Overprojection or underprojection
• Unpleasant sensation - cold climates.
105. Post surgical orthodontic phase
• Begins 4-8 weeks after surgery.
• The patient is brought back to a normal diet
• Any spaces between the teeth are closed up
• The occlusion is brought into maximum
intercuspation
• Minor occlusal discrepensies are corrected
• This phase lasts for another 4-6 months
• Finally the orthodontic brackets are removed
and the patient is given a retainer.
106. Prosthodontic phase:
• To give the patient a perfect dentition and
complete satisfaction of treatment, dental
implants may be placed where necessary,
esthetic restorations and periodontal
management to improve final esthetics.
107. SOFT TISSUE CHANGES
Lefort I osteotomy and advancement
• 1. Nasal tip gets advanced and elevated
• 2. nasolabial angle is decreased
• 3. lower lip may be shortened and slightly
everted
• paraalar hollowness gets eliminated
• widening of alar base
• thinning and stretching of the upper lip along
with shortening
