Principles of Orthognathic Management
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This document outlines the principles and process of orthognathic management for dentofacial deformities. It involves an initial joint orthodontic-orthognathic assessment including patient history, clinical examination, documentation, dental casts, and radiographs to evaluate the skeletal and dental deformities. A treatment plan is developed which may involve presurgical orthodontics, surgical correction using procedures like LeFort osteotomies or bisagital split osteotomies, and postsurgical orthodontics and care. The goal is to carefully plan and coordinate orthodontic and surgical treatment to correct dentofacial deformities.
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Principles of Orthognathic Management
- 1. Principles of Orthognathic Management of Dentofacial Deformities DR.WAHEED MURAD FCPS ( R2) ORAL AND MAXILLOFACIAL SURGERY DEPARTMENT ZU ,KARACHI
- 2. Joint Orthodontic-Orthognathic Initial Assessment History Clinical examination
- 3. a. Patient’s Perception of the problems b. Goals of seeking any possible treatment. c. Patients current medical status d. Psychosocial status e. Patients surgical, orthodontic ,periodontic, endodontic,Complex restorative, and prosthetic considerations Joint Orthodontic-Orthognathic Initial Assessment
- 4. Evaluation of Face Frontal Face Analysis FRONT FACE ANALYSIS
- 5. Evaluation of Face Lateral Profile
- 6. Intraoral Examination a. Dental arch form b. Symmetry c. Tooth alignment d. Occlusal abnormalities in the transverse, anteroposterior, and vertical dimensions.
- 7. Extraoral Examination a. Muscles of Mastication b. TMJ Function
- 11. Cast
- 12. Radiograph Lateral Cephalometric film Panoramic radiograph
- 13. Supplemental Radiographs a. P A views b. TMJ images c. CT d. CBCT e. Sterilothic model constructed from CT
- 14. Problem list a. Skeletal deformities b. Dental deformities
- 15. Treatment plan a. Orthodontic Correction b. Surgical Correction c. Combinations
- 16. Presurgical Treatment Phase a. Periodontal Considerations b. Restorative Considerations c. Presurgical Orthodontic Considerations
- 17. Presurgical Orthodontic Considerations . a. Relief of crowding and alignment b. Decompensation
- 18. Decompensation
- 19. Final Surgical Planning a. Re-evaluate the initial assessment b. Re-examine patient’s facial structure and the malocclusion c. Presurgical digital photographs d. Conventional radiographs or e. CT scans
- 20. Final Surgical Planning Model surgery Image prediction.
- 21. Model Surgery
- 22. Surgical treatment phase a. Mandibular Excess b. Mandibular Deficiency c. Maxillary Excess d. Maxillary Deficiency e. Combination Deformities and Asymmetries
- 23. Mandibular Excess/Deficiency Bisagital Split Osteotomy
- 24. Mandibular Excess/Deficiency Vertical Ramus Osteotomy (VRO)
- 25. Sub apical Osteotomy Mandibular Excess/Deficiency
- 27. Mandibular Excess/Deficiency Inverted L Osteotomy
- 29. Maxillary Excess / Deficiency Lefort Osteotomy
- 30. Maxillary Excess / Deficiency Distraction Osteogenesis
- 31. Perioperative care a. Preoperative Care b. Postoperative care
- 32. Postsurgical Treatment Phase a. Post surgical Orthodontics b. Postsurgical Restorative and Periodontal treatment c. Follow up
- 33. TAKE HOME MESSAGE Plan Before You Attempt
Editor's Notes
- d. * The patients purpose of seeking treatment is’‘external motivation’, ie motives based on the perception of others through social or professional interactions on their image and identity, This group of patients will require more psychological support and exploration of their concerns prior to starting any intervention In contrast, patients that have internal motivations, ie those not influenced by their peers, are more suitable for intervention. * evaluate affordibilty of ptnt
- a. Form Transverse dimensions(rule of fifths) Symmetry , Vertical relationships ,Upper third Middle third Lower third Lips
- b, Soft tissue profile angle 2. Naso labial angle 3. Maxillary sulcus contour 4. Mandibular sulcus contour 5. Orbital rim 6. Cheekbone contour 7. Nasal base-lip contour 8. Nasal projection 9. Throat length and contour 10. Subnasale-pogonion line ( sn-pg‘)
- Any inflamatory sign ,hypertrophy Pain ,tenderness , anyclicking sound,range of motion in variaous axis
- Photographic documen tation of the pretreatment condition of the patient should be a standard part of the evaluation. Video and digital computerized images have been introduced over the past decade as an additional aid in evaluating facial morphology
- Sqash bite To record preurgical occlusion
- Duplicate the cast so one is kept for presurgical occlusion record and other is used for model surgery
- Lateral Cephalometric film and Panoramic radiograph are routinely used in the patient evaluation and are an important part of the initial assessment
- a.Other radiographic images may be helpful in evaluating patients for surgical correction. These may include : pa ,tmj,ct,cbct e.. In difficult, complex cases, it may be helpful to obtain a stereolithic three-dimensional model constructed from CT data
- After careful clinical assessment and evaluation of the diagnostic records, a problem list and treatment plan is developed, combining the opinions of all practitioners participating in the patient’s care, including the orthodontist, oral-maxillofacial surgeon, periodontist, and restorative dentist
- Adress the correction of problem list
- a,scalling ,root planning oral hygien measures b. carious teeth treatment,endo treatment.non restorable teeth shouldd be extracted c
- a. Relief of crowding and alignment done through arch expansion, interproximal enamel reduction, or dental extractions
- b. (Reverse Orthodontic or worsening of malocclusion Objective of presurggical orthodontic is to Increase the severity of vertical and/or horizontal and sagittal aspects of malocclusion by unmasking the nature’s camouflage for skeletal discrepancy.
- After the completion of the presurgical periodontics, restorative dentistry, and presurgical orthodontics Final Surgical Planning is done
- The change in facial appearance can be demonstrated with the use of computer technology by superimposing digital images of the patient’s profile over bone landmarks obtained from the cephalomet ricradiograph. The bone structures are then manipulated to duplicate the bone movements desired at the time of surgery.
- Before explaining surgical treatment phase let me calssify the dentofacial deformities In Anterioposterior ,vertical and transverse dimensions In all three dimensions In all dimensions
- verical ramus osteotomy(extraoral and intra oral approach) (specialy when asymetrical setback is required) dis: difficulty in handling the proximal segment adverse post surgical oclusal changes
- subapical osteotomy : when prognathism is limited to anterior dento alveolar area but chin position is normal ,then subapical osteotomy is done
- when discrepancy chin position but oclusion is normal *done in AP discrepency as well as vertcal discrepancy
- Inverted L Osteotomy with bone grafting(onlyin mand deficiency not in prognethism) f
- Distraction osteogenesis : for mand deficency
- a. In severe midface deformities with infraorbital rim and malar eminence deficiency, a Le Fort III or modified Le Fort III type of osteotomy is necessary
- C . Used fpr maxillary augmentation in all three planes. for transverse deficiency of maxilla lefort 1 osteotomy done , midplatal split done and distraction is placed This procedure is called SARPE
- a.*medical history *complete physical examination *preoperatve laboratory test *radiological examination(chest x ray ) if necessary *anesthesia review Make ptnt NPO usually 6 hour before surgery b *recovery room (until ptn is vitally stable,alert.comfortable and fully oriented) *postsurgical hospital stay 1 4 days *discharge ptnt when i.ptnt vitally stable and feelingcomfortable ii.urinating well without assisting iii.taking food and fluid orally iv.ambulating well *postoperative radiographs * At the time of surgery, a small acrylic occlusal wafer is usually used to help position and stabilize the occlusion and imf is done. IMF is released (usually in the operating room) in order to prevent risk of aspiration in case ptnt has vomiting after break of NPO . Light elastics used to guide the jaw into the new postsurgical occlusion
- a. Final alignment and positioning of teeth is accom plished,as is closure of any residual extraction space is done . c. initially 7 days after treatment and after when required