DIAGNOSIS NAAND TREATEMENT PLANNING IN OTHOGNTHIC SURGERY

1. Rahul Tiwari
III yr OMFS PG
GOOD MORNING
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2.  Introduction
 Indications
 Psychological implications
 Collection of records
 Facial analysis
 Cephalometric analysis
 Model surgery
 Planning
 Conclusion
 References
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3. 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 deformity of the jaws and associated
structures .
 It is indicated in patients who have skeletal
problems, dento alveolar problems that are too
severe to be corrected by orthodontics alone, in
whom growth is completed and growth
modifications cannot be done.
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4.  When a jaw discrepancy accompanies a severe
malocclusion, there are three broad possibilities for
correction:
 (1) growth modification,
 (2) camouflage (orthodontic positioning of the teeth to
compensate for the jaw discrepancy),
or
 (3) orthognathic surgery in conjunction with
orthodontics to reposition the jaws and/or dentoalveolar
segments.
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5.  Growth modification, generally referred to as
dentofacial orthopedics, is the most desirable
approach to a severe skeletal problem when the potential
for further growth exists.
 Although the pattern of growth can be favorably
modified for some patients, the capacity for major
increments in growth is rather limited.
 The variation in response of individual patients,
however, suggests growth modification should be
attempted in preadolescent patients.
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6.  When a moderate skeletal discrepancy exists and there
is no potential for further growth (or if more change is
required than can be accomplished through growth
modification alone), orthodontic camouflage should be
considered.
 The teeth are repositioned to establish normal overjet
and overbite in an effort to compensate for the jaw
discrepancy .
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7.  The final treatment option for a severe skeletal discrepancy is orthognathic
surgery. Once growth has ceased, surgery becomes the only means of
correcting a severe jaw discrepancy. Although surgery may allow greater
changes, there are still limitations to the surgical options, depending on the
type of problem and direction of desired jaw movement, and certain
problems are more receptive to surgical correction than others.
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8.  The term reverse orthodontics is often used in reference
to the deliberate movement of teeth in a direction that
appears to make the worse initially when preparing the
dentition for orthognathic surgery.. When dental
compensations exist, they limit the distance the jaws can
be repositioned to achieve a desirable esthetic result.
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9.  First mandibular osteotomy : HULLIHEN (1849) done
to correct a protrusive malposition of a mandibular
alveolar segment.
 In 1927, WASSMUND introduced total maxillary
osteotomy and inverted “L” ramal osteotomy, by
external approach.
 In 1959, TRAUNER and OBWEGESER introduced
sagittal split osteotomy as the beginning of a new era of
orthognathic surgery.
 The beginning of the early orthognathic surgery was in
St.Louis where the orthodontist Edward Angle and the
surgeon Vilray Blair worked together
HISTORY
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10.  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 to such an extent
that, it is possible to reposition either or both the jaws
and to move the chin in all 3 planes of spaces & Rigid
internal fixation made it possible for comfort and better
immobilization after surgery.
AJODO. 2007 Feb;131(2):263-7
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11. ETIOLOGIC FACTORS
Dentofacial deformity Developmental problem.
ETIOLOGY
KNOWN SPECIFIC
CAUSE
HEREDITARY
FACTORS
ENVIRONMENTAL
INFLUENCES
Occasionally the deformity is due to a single specific cause,
much more frequently they result from a complex interaction among
multiple factors that influence growth and development.
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12. Respiratory influence
Mouth breathing has been blamed for altered dentofacial development
Harvold et al, showed that total blocking the nares
led to Various moderate to severe malocclusions,
Because the lower jaw was positioned forward , the
deformity always included a component of mandibular
prognathism along with various displacements of teeth
Total nasal obstruction
Downward backward rotation
Long face deformity
(AJODO, vol 79. 1981).
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13. 1.When orthodontic treatment alone cannot
correct a problem.
2.To improve jaw function.
3.To enhance the long term orthodontic result
(stability).
4.Reduction in overall treatment time.
5.Change in facial appearance.
6.Improved breathing.
7.Improved speech.
8.Improvement in jaw pain.
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14.  One answer to the question of "When is a problem too
severe for orthodontic treatment only?" is "When the
combination of tooth movement and growth modification does
not have the potential to bring the patient to normal occlusion."
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15. 9/19/2016 9:32:03 AMRT/10/DIAG. & PLANNING IN ORTHO. SRUG./88 15

16.  Facial deformity is defined as “ a physiognomic form that is
sufficiently negatively marked, so as to set the individual apart
from the general population”.
 A dentofacial anomaly may have an adverse effect on an
individuals self esteem and self confidence as well as evoke an
undesirable social response .
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

17. FACE IS THE INDEX OF MIND
 The area of the body which maximally determines
physical attractiveness is the face. It is a primary means of
identification , expression and non-verbal communication.
 There is a high value of cosmetic characteristics in the
current society and severe cranio-facial deformity may
cause significant psychosocial problems.
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18.  Concept of “Body image” ( Schilder and Schonfeld )
 2 components of body image are
1. Body sense
2. Body concept
Body sense
The actual appearance the person sees when viewing himself in a
mirror or photograph.
Body concept
The internal process of how the patient feels about his
appearance.
 Generally those patients with a good body image in
spite of having a deformity are better candidates for
surgery
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19. EXTERNAL & INTERNAL PRESSURE
 Edgerton & knorr pointed out the importance of external versus
internal motivation.
 Internal pressure’ would be that originating within the patient and
usually involves depression and a sense of inadequacy.
 ‘External pressure’ would include the need to please others and a
desire to overcome career or social problems through a change in
appearance.

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20.  Selection of patients for orthognathic treatment involves
various factors that may ultimately influence levels of
patient satisfaction.
 These include: physiological; medical; interpersonal
and psychological.
 The majority of studies investigating the psychological
aspects of patients undergoing orthognathic treatment,
have shown that patients seeking orthognathic treatment
are psychologically well adjusted prior to surgery, and
appear to have fewer deficits in their personality
dimensions than those patients seeking other ‘cosmetic-
type’ procedures.
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21. An orthodontist must determine at an early stage why
the patient is seeking treatment and what the patient
hopes to achieve .
The surgeon must then decide whether this demand can
be met surgically.
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22.  Lavell et al, emphasized that satisfaction begins
with selection of appropriate patients.
 The selection can be represented by the
acronym .....
‘SAFE’
S- Self-assessment of attractiveness
A-Anxiety
F- Fear
E- Expectations
Journal of Orthodontics, Vol. 33, 2006, 107–115
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23. High satisfaction with most of orthognathic patients
treated can be related to:-
Realistic expectations with regard to outcome.
Patients with a realistic expectation of post-operative
discomfort and recovery.
Effective pre-operative preparation of the patient.
Good psychological adjustment both pre- and post-
operatively.
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24. 9/19/2016 9:32:03 AMRT/10/DIAG. & PLANNING IN ORTHO. SRUG./88 24


25. Data base
(case history, patient examination,
Radiographic and model analysis)
Problem list in priority order –
Diagnosis
Possible solution to the problem – Tentative treatment plan.
Discussed with the patient & modified
Optimal treatment plan
Execution of treatment
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26. Patient History
Clinical
Examination
Analysis of
Diagnostic Records
Classification Problem List
= Diagnosis
Treat pathology
(caries, gingivitis etc.)
Problems
in
priority
order
A
B
C
D
Possible
solution to
individual
problems
Optimal
Treatment
Plan
Data
Base
A
B
C
D
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27.  1. ESSENTIAL PATIENT EVALUATIONS
 2.ADJUNCTIVE EVALUATIONS.
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28. A. General patient evaluation.
1.Medical history
2.Dental evaluation.
a.Dental history.
b.Dental health.
B. Social-psychological evalution
C. Esthetic facial evaluation.
1.Front face analysis
2. Profile analysis
D.Cephalometric evaluation.
1.soft tissue.
2.Skeletal relation
3.dental relation.
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29. E. Panoramic or full-mouth peri apical evaluation.
F. Occlusal evaluation.
1.Functional
2.Static.
G. Masticatory muscle & TMJ evaluation
1.Masticatory muscle.
2.Mandibular movements.
3.TMJ symptoms.
4.TMJ signs
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30. A. Comprehensive psychologic evaluation.
B. Additional photographs.
1.symmetric view
2.submental view
3.superior view.
4.three quarter face view.
C. Computed assited analysis
1.video manipulation
2.Three dimentional CT scan reconstruction.
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31. D. Additional Radiographs
1. Lateral cephalometric radiograph in Rest position.
2. P-A view.
E. Diagnostic Occlusal splints.
F. velvopharyngeal evalutions
1.speech evaluation.
2,Nasoendoscopy.
G.Tongue Evalution
1 speech evaluation
2.Radographic evaluation of tongue posture.
3.clinical evaluation of tongue posture
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32.  Demographic data Consists of basic chart information of
name, address (home, work or school), age, sex, marital
status and type of employment or school attended.
 Chief complaint
The first goal of the interview is to establish the patient’s
major reason for seeking treatment, which is the chief
complaint.
Collection of Data base:
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33.  Psychological makeup of the patient is important
because, despite on objectively favorable treatment
result, certain patients will express dissatisfaction with
their results due to unrealistic patient expectations
regarding the result of the treatment .
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34.  Unrealistic expectations are most likely to occur in
two types of patients,
patients with acquired deformities and
Those with external motivations.
Treatment of such patients must be entered into only after
careful consideration and psychologic consultation.
Frequently it is best not to treat the patients since they are
generally unhappy with the results achieved. These kind
of patients can be distinguished by a deliberate social
psychologic evaluation.
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35.  Classification of patients
 Highly positive reactive / group I
Patients who respond positively to all questions and are good
candidates for surgery
 Neutral reactors / group II
Patients who had given positive responses with 2 or 3 negative
or slightly negative responses belong to this group. In
general these patients require more than the usual amounts
of attention and counseling during the preoperative phase to
prevent difficulty later.
 Negative reactors / group III
Patients who gives negative responses to most of the questions
are unlikely to be satisfied by the results of surgery.
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36.  Patient’s medical information must aim to obtain
information regarding medical conditions like history of
medication, allergies to drug, bleeding disorder or other
congenital abnormalities .
 Respiratory problem, cardiac problem, asthma,
diabetics, anemia, rheumatic fever etc that may
complicate correction of a skeletal deformities.
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37. Family history
Includes information regarding the marriage of the
parents consanguineous/ non consanguineous
marriage, about the siblings, sibling’s general and
dental conditions, history of familial disease if any
and Parent’s concern for treatment.
Dental history.
Knowledge about previous orthodontic therapy, or existing
active orthodontic treatment carries important. Any
previous records if available or narrative description
about treatment from the previous dentist regarding the
nature of treatment and evaluation of results should be
reviewed
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38. - Study models.
- Panoramic and lateral cephalometric radiographs
- PA cephalogram in patients with significant
asymmetry
- Photographs: extra oral & intra oral
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39. Facial proportions and esthetics.
A precise and detailed soft tissue evaluation is always essential to
derive proper diagnosis and accurate treatment plan which
maximizes the patient’s benefit.
The most important point in proper analysis of facial esthetics is
the use of a clinical format.
Examination should not be based on static laboratory x-ray film
and photographic representation of the patient alone.
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40. 1.Outline form & symmetry
2. Facial level
3. Midline alignment.
4. Facial one thirds
5. Lower one-third evaluation
6. Upper & lower lip lengths
7. Upper tooth to lip relationship
8. Inter labial gap
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41. 1. Soft tissue profile angle
2. Naso labial angle
3. Orbital rim
4. Cheekbone contour
5. Nasal base-lip contour
6. Nasal projection
7. Throat contour
8. Subnasale-pogonion line
( sn-pg’)
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42.  Outline form & symmetry.
General outline form & symmetry of face are noted.
The widest dimension of the face is the zygomatic
width.
According to the normal values established by Farkas
with Anthropometric studies the bigonial width is
approximately 30% less than the bizygomatic
dimension.
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43. 9/19/2016 9:32:03 AMRT/10/DIAG. & PLANNING IN ORTHO. SRUG./88 43
 Brachycephalic – 75.9%
 Mesocephalic – 76-80.9%
 Dolicocephalic – 81%
 Euryproscopic - 97%
 Mesoproscopic – 97-104%
 Leptoproscopic – 104%

44. Facial level
To examine facial levels a reliable horizontal
landmark is necessary. With the patient in natural head posture,
the pupils are assessed for level with the horizon. If pupils are
level, they are used as the horizontal reference line and adjacent
structures are measured relative to this line. Structures
compared with the pupil line are:-
Upper canine level
Lower canine level
Chin & jaw level
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45. The relative positions of soft
tissue landmarks (nasal bridge,
nasal tip, philtrum, and chin
point) and dental midline
landmarks (upper incisor
midline, lower incisor midline)
are assessed for midline
alignment..
Philtrum is usually a reliable midline structure and can be used as the
basis for midline assessment most often.
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46. Transverse Facial Proportions:
Facial Thirds
SYMMETRY
BALANCE
MORPHOLOGY
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Mesurements of intercanthal and interpupilary distances.

47.  The Central Fifth:
 Delineated by the inner
canthus of the eyes.
 Inner canthal distance= alar
base of nose
 The Medial Fifth:
 Width of mouth=
interpupillary distance
 Line from the outer canthus
should coincide with the
gonial angles
 Outer fifth
 From the pinna
RULE OF FIFTHS
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48. The lips are measured
independently in a
relaxed position. The
normal length from
subnasale to upper lip
inferior is 19 to 22mm.
The lower lip is measured
from lower lip superior to
soft tissue menton and
normally measure in a
range of 38 to 44mm.
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49. Increased or decreased anatomic upper lip length
Increased or decreased maxillary skeletal length
Thick upper lip expose less incisor than thin upper lips,all
other factors being equal. The angle of view changes
the amount of incisor visible to the viewer.
The distance from upper lip inferior to maxillary incisal edge is measured.
The normal range is 1 to 5 mm. Women show more within this range.
Surgical and orthodontic vertical changes are based primarily on this
measurement .
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50. Increase in inter labial gap
are seen with anatomic
short upper lip, vertical
maxillary excess, and
mandibular protrusion
with open bite secondary
to cuspal interferences.
Decreased interlabial gap is
found with vertical
maxillary deficiency,
anatomically long upper
lip (natural change with
ageing, esp. in males)
and mandibular retrusion
with deep bite.

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51.  Ideal exposure with smile
is three-quarters of the
crown height to 2mm of
gingiva. Females show
more gingival exposure
than males.
Reveals 75% to 100% of the maxillary
anterior teeth and the interproximal
gingiva
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52. This angle is formed by
connecting soft tissue
glabella, subnasale, and
soft tissue pogonion.
General harmony of
forehead , midface ,and
lower face is appraised
with this angle
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53. This angle is formed by the
intersection of the
upper lip anterior and
columella at subnasale.
This angle can change
noticeably with
orthodontic and surgical
procedures that alter the
antero-posterior position
or inclination of the
maxillary anterior teeth.
Desirable range of 90 to
110 degrees
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54. Evaluation of nose
Bell described three type of nose
Leptorrhine-long, high and narrow nostrils.
Mesorrhine-lack of dorsal height and
columellar support.
Platirrhine-flat broad nose and wide nostrils
Alar base width is equal to the intercanthal width of eye
of which is influenced by inherited ethnic characters.
Lefort 1 osteotomies affect the alar base width, superior
repositioning is associated with widening of alar base.
simultaneous rhinoplasty is indicated if siginificant
change in alar base width is expected during surgery.
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55. The nasal projection measured
horizontally from subnasale to nasal tip is
normally 16 to20mm ,
. Nasal projection is an indicator of
maxillary antero posterior position.
This length becomes particularly
important when planning for anterior
movement of maxilla.
Nasal projection
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56. The orbital rim is an antero-
posterior indicator of
maxillary position.
Deficient orbital rims may
correlate positionally with a
retruded maxillary position
because the osseous structures
are often deficient as groups
,rather than in isolation.
The Eye globe normally is
positioned 2-4mm anterior to
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57. The surgical maxillary versus mandibular decision is
influenced by the orbital rim position.
Deficient orbital rims dictates the need for maxillary
advancement with all other parameters being normal..
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58.  Normally this sulcus is
gently curved and gives
information regarding
upper lip tension
Maxilla should not be retracted significantly when a deeply curved
thick lip is present since this produces poor lip support.
If possible maxilla should be moved forward towards the curved lip
to improve lip support.
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59. Lip projection.
Labio-mental sulcus.
Lip-chin –throat angle.
Lip-chin throat length.
Chin neck angle.
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60. Angle between lower lip ,chin ,C-
point,
Should be approximately 900.
Increased in-
Chin deficiency
Lower lip procumbency.
Excessive sub mental fat.
Low hyoid bone position.
Lip-chin throat
angle
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61. Also termed cervicomental
angle
Varies between 105-120º.
Absolute 110 o.
Distance Between pogonian
to neck chin angle is
50mm.
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62. The relationship of lips to the
sn-pg’ line is an important aid in soft
tissue analysis and treatment.
Tooth movement changes the
relationship of the lips to the sn-pg’
line and therefore the esthetic result.
SUBNASALE - POGONION LINE ( SN-PG’)
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63. CEPHALOMETRICS FOR
ORTHOGNATHIC SURGERY
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64. Developed by Charles Burstone et al
Presented first in Journal of Oral Surgery. 1978 April.
Followed by Soft tissue Cephalometric Analysis for Orthognathic
surgery in Journal of Oral Surgery. 1980 .
Data derived from samples obtained from Child Research Centre,
Univ. of Colorado school of medicine.
Sample type: Northern european descent
Sample Size = 27
16 females
11 males
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65.  A constructed plane called Horizontal Plane which
is surrogate Frankfort Horizontal plane
constructed by drawing a line 70 from SN plane
 Most measurements will be made from projections
either parallel or perpendicular to the Horizontal
Plane
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66. Chosen landmarks and measurements can be altered by
various surgical procedures.
The appraisal includes all facial bones and a cranial base
reference.
Rectilinear measurements can be readily transferred to a
study cast for mock surgery.
Critical facial components can be examined.
Consists of a series of measurements that can be
computerised.
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67. 9/19/2016 9:32:03 AMRT/10/DIAG. & PLANNING IN ORTHO. SRUG./88 67

68. GLABELLA NASION
ANS PNS
POINT A POINT B
SELLA PORION
BASION POGONION
GNATHION
MENTON
GONION
ORBITALE
CEPHALOMETRIC
LANDMARKS
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69. 69
Maxillary and Mandibular measurements
ANS-PNS
Ar-Go
Go-Pg
Gonial Angle and Chin
Prominence
Ar-Go-Gn
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70. Dental Angular Measurements
Upper Incisor – Nasal Floor angle
Lower Incisor – Mandibular Plane Angle
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71. Burstone’s Soft
Tissue Analysis
Legan &
Burstone
(1980)
J oral Surg. 1980
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72. 9/19/2016 9:32:03 AMRT/10/DIAG. & PLANNING IN ORTHO. SRUG./88 72

73. Dr.Aravind.M
G-Sn-Pg angle=12 °
G-Sn=6mm
G-Pg=0mm
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74. Dr.Aravind.M
Vertical Height
Ratio=1:1
G - Sn
Sn - Me
Nasolabial
Angle=110 °
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75. Interlabial Gap=2mm
Mentolabial
Sulcus=4mm
Upper lip protrusion=3mm
Lower lip
protrusion=2mm
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76. Maxillary Incisor
Exposure=2mm
Stms-Upper incisor
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77.  By William Arnett and Robert Bergman
AJODO 1999
 Sequale to Facial keys to orthodontic diagnosis and
treatment planning. Part I and II
AJODO 1993
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78. “We only treat what we are educated to
see. The more we see, the better the treatment
we render our patients”
-Arnett.
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79.  Model surgery is the dental cast version of cephalometric
prediction of surgical results.
 Typically model surgery is done just prior to the actual
surgery, after orthodontic preparation has been completed,
so there is no need to reposition teeth on casts, but a
simulation of the final occlusion can be seen prior to any
treatment if a diagnostic setup has been done.
 Mandibular advancement can be simulated, for instance,
by sliding the lower cast forward relative to the upper cast.
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80.  It is easier to study the possible tooth relationships if
the casts are mounted temporarily on an arbitrary
articulator so that they are held in the desired
position. The better the occlusion without any tooth
movement, the easier it is to articulate the casts by
hand and vice versa.
 If the maxilla will be repositioned vertically, it is
important to use a face-bow transfer to mount the
casts on a semi-adjustable articulator so that the
condyle-tooth relationships are recorded and
mandibular rotation is correctly accounted for doing
the cephalometric prediction.
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81. Purpose of model surgery.
 1) To verify that the planned movements are
possible
 2) To relate the mandibular and maxillary dentitions
in the position where the surgical splint will be
made.
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82. Impressions
Face-bow record
Wax bite to record
Pre surgical occlusion
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83. Casts mounted on semi-adjustable
articulator
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84. Fit the teeth accurately.
Minimum thickness – not
more than 2 mm.
Excess acrylic should be
trimmed off the buccal
aspect, to allow for
proper visual
verification during
surgery and oral
hygiene maintenance.
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85. 9/19/2016 9:32:03 AMRT/10/DIAG. & PLANNING IN ORTHO. SRUG./88 85


86.  The goal of the treatment plan is develop the plan that
will maximise the patient benefit. It is completely
based upon diagnostic truth.
 Surgical treatment possibilities
 Logical sequence in planning surgical orthodontic
treatment
 Treatment plan techniques of cephalometric
prediction and cast prediction
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87.  BELL & PROFITT
 PETERSON PRINCIPLES OF ORAL SURGERY
 PETER WARD BOOTH
 REYENEKE
 FONSECA
 DIMITROULIS
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88. THANK YOU
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