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Pre and post surgery final /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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Pre and post surgery final /certified fixed orthodontic courses by Indian dental academy

  1. 1. Pre and Post Surgical Orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Contents 1.Pre Orthodontic Preparation – Control of pathologic problems 2.Pre-surgical orthodontics 3.Final surgical preparations 4.Surgery and postoperative care 5.Post-surgical orthodontics 6.Retention www.indiandentalacademy.com
  3. 3. Before Orthodontics • Adult Patients a)Chronic systemic diseases b)Pregnancy c)Prolonged use of drugs d)Dental problems www.indiandentalacademy.com
  4. 4. Before Orthodontics a) Chronic systemic diseases – Hypertension and diabetes – Drugs and diet alteration b) Pregnancy – general anesthesia – surgery must be delayed for 4-6 months after delivery www.indiandentalacademy.com
  5. 5. Before Orthodontics c) Prolonged use of Drugs – interactions with general anesthetics – Prostaglandins www.indiandentalacademy.com
  6. 6. Before Orthodontics • Phenytoin – gingival overgrowth – seizures may be exacerbated by orthodontic appliances • Dryness of the mouth – irritation due to the orthodontic appliance – oral hygiene www.indiandentalacademy.com
  7. 7. Before Orthodontics d) Dental Disease • Caries control – 0.05% NaF mouthrinse • Missing teeth – Bridges – need removal – Riding pontic www.indiandentalacademy.com
  8. 8. Before Orthodontics Periodontal problems  oral hygiene maintainance  Hopelessly mobile teeth  Offer better stabilization during surgery than removable partial dentures. www.indiandentalacademy.com
  9. 9. Before Orthodontics Implications of reduced periodontal support • Lighter force • Greater counter-moments are needed for tooth movement www.indiandentalacademy.com
  10. 10. Before Orthodontics Impacted and unerupted teeth. • Growing children – unerupted teeth may be encountered during the osteotomy cuts. www.indiandentalacademy.com
  11. 11. Before Orthodontics • Adults –third molars can be removed at the time of LeFort I osteotomy www.indiandentalacademy.com
  12. 12. Before Orthodontics Mandibular 3rd molars • Remove 6 months before a BSSO, so that the socket is properly healed at the time of surgery • Complications – Bad split – Chances of infection – Difficult to use rigid internal fixation, due to the space occupied by the tooth. www.indiandentalacademy.com – Increased chances of fracture
  13. 13. Surgical and orthodontic treatment BASIC OUTLINE • Pre-surgical orthodontics - removes dental compensations, and positions the teeth properly in relationship to the individual skeletal bases. www.indiandentalacademy.com
  14. 14. Surgical and orthodontic treatment • Heavy archwires are placed and the appliance is used for stability and fixation during surgery. www.indiandentalacademy.com
  15. 15. Surgical and orthodontic treatment • Active orthodontics is reinitiated to refine the occlusion. www.indiandentalacademy.com
  16. 16. Pre-Surgical Orthodontics Goals – 1.Align and level teeth without concern for dental occlusion. 2.Establish proper anterior-post. and vertical position of the incisors. www.indiandentalacademy.com
  17. 17. Pre-Surgical Orthodontics General guideline If the patient is not properly prepared – • Surgery cannot be carried out effectively, • Quality of the result is diminished • Post surgical orthodontic treatment time increases www.indiandentalacademy.com
  18. 18. Pre-Surgical Orthodontics • Selection of the appliance 1.Stability 2.Esthetics 3.Slot Size 4.Bonding vs Banding www.indiandentalacademy.com
  19. 19. Pre-Surgical Orthodontics Stability  PAE is recommened  Begg appliance for surgical patients rectangular wire in the ribbon mode. www.indiandentalacademy.com
  20. 20. Pre-Surgical Orthodontics Esthetics Lingual appliances • Post op – patients have difficulty in mouth opening • Hugo et al (J Adult Orthod &Orthognath Surg 2000) – use of labial appliances just before the surgery and thereafter until the end of the treatment. www.indiandentalacademy.com
  21. 21. Pre-Surgical Orthodontics • Width of the labial brackets have been reduced to increase esthetics • Extremely narrow brackets have poor rotational and tip control. www.indiandentalacademy.com
  22. 22. Pre-Surgical Orthodontics Tooth colored brackets • Plastic brackets – Fracture – Poor torque control • Ceramic brackets – Good torque control – Brittle and can fracture – Should be prepared with alternative measures www.indiandentalacademy.com
  23. 23. Pre-Surgical Orthodontics Slot Size Either slot size – 18 or 22 • 17x 25 ss for 18 slot • 21x25 ss or TMA for 22 slot Bonding vs banding – • bond anteriors, and band posteriors. • perio problems, bands are to be avoided www.indiandentalacademy.com
  24. 24. Pre-Surgical Orthodontics Alignment of the arch  Principles of alignment remain the same.  Initial tipping  undersizes, round and resilient wires.  free sliding, freedom to tip and light continuous forces. www.indiandentalacademy.com
  25. 25. Pre-Surgical Orthodontics Leveling of the Arch Presurgical Postsurgical Intrusion Extrusion www.indiandentalacademy.com
  26. 26. Pre-Surgical Orthodontics • Final vertical height ➫ Position of the lower incisors – Increase the face height → the lower incisors should not be intruded – In patients with normal or excessive face height, the lower incisors must be intruded pre-surgically www.indiandentalacademy.com
  27. 27. Pre-Surgical Orthodontics Final position of the incisors is determined pre surgically www.indiandentalacademy.com
  28. 28. Pre-Surgical Orthodontics Segmental procedures ➫ Teeth should be leveled within the segments www.indiandentalacademy.com
  29. 29. Pre-Surgical Orthodontics Ant – post positioning of the incisors • Affects the sagittal placement of the jaws during surgery • dental compensations must be removed • Movements opposite to camouflage www.indiandentalacademy.com
  30. 30. Pre-Surgical Orthodontics • Extraction pattern in surgical patients – Opposite to camouflage – Worsening of the occlusion – Extraction of teeth during the surgery itself www.indiandentalacademy.com
  31. 31. Pre-Surgical Orthodontics www.indiandentalacademy.com
  32. 32. Pre-Surgical Orthodontics Segmental surgeries • Establish torque of incisors pre surgically • ½ extraction site left open www.indiandentalacademy.com
  33. 33. Pre-Surgical Orthodontics Anchorage consideration • Opposite directions of movement • Intermaxillary elastics • Extra oral forces rarely needed • Small amount of space can be left open www.indiandentalacademy.com
  34. 34. Pre-Surgical Orthodontics Arch compatibility • Shape and width • Co-ordinated arch wire www.indiandentalacademy.com
  35. 35. Pre-Surgical Orthodontics • Torquing of roots • Not more than 5 mm of dental expansion • ½ cusp cross-bite can be corrected postsurgically www.indiandentalacademy.com
  36. 36. Pre-Surgical Orthodontics • At the end of the pre-surgical phase, the patient should be in a full sized rectangular steel wire which will help stabilize the teeth during surgery www.indiandentalacademy.com
  37. 37. Stabilizing wires • Full dimension, filling the slot – 17 x 25 ss for 18 slot – 21 x 25 ss or TMA for 22 slot – 19 x 25 wire in a 22 slot is acceptable • The stabilizing wire must be passive www.indiandentalacademy.com
  38. 38. Stabilizing wires www.indiandentalacademy.com
  39. 39. Final surgical Planning 2 weeks before surgery • OPG • Lat. Ceph • Casts • Photos – intra and extra-oral • PA ceph – if there is facial asymmetry • IOPAs and occlusal view if needed. • Face bow transfer onto an articulator if needed www.indiandentalacademy.com
  40. 40. Final surgical Planning • OPG – Root proximity at osteotomy site – Confirm with IOPAs • Lateral Ceph. – For pre surgical prediction • Models – Model surgery – Preparation of the splint www.indiandentalacademy.com
  41. 41. Final surgical Planning Need for a facebow transfer 1.Mand. dentition – condylar relation maintained Mand. is required to auto-rotate Segmental subapical procedures of the mandible. 2.In case of 2 jaw surgeries www.indiandentalacademy.com
  42. 42. Final surgical Planning • Condyle - mandibular dentition relation is to be chanced during surgery, a facebow transfer is not needed. • Mounting on a simple articulator will do. www.indiandentalacademy.com
  43. 43. Model Surgery 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. www.indiandentalacademy.com
  44. 44. Model Surgery Model surgery – 4 weeks after stabilizing wire is placed www.indiandentalacademy.com
  45. 45. Model Surgery - 2 jaw surgery Impressions Wax bite to record Pre surgical occlusion Face-bow record www.indiandentalacademy.com
  46. 46. Model Surgery - 2 jaw surgery Casts mounted on semi-adjustable articulator www.indiandentalacademy.com
  47. 47. Model Surgery - 2 jaw surgery Mounting of maxillary cast with spacer www.indiandentalacademy.com
  48. 48. Model Surgery - 2 jaw surgery www.indiandentalacademy.com
  49. 49. Model Surgery - 2 jaw surgery Intermediate splint www.indiandentalacademy.com
  50. 50. Model Surgery - 2 jaw surgery Mandible advanced to desired position www.indiandentalacademy.com
  51. 51. Model Surgery - 2 jaw surgery Final Splint www.indiandentalacademy.com
  52. 52. Model Surgery – ‘Piggy-back’ splint Mandibular cast positioned – hinge articulator www.indiandentalacademy.com
  53. 53. Model Surgery – ‘Piggy-back’ splint Wires made as required www.indiandentalacademy.com
  54. 54. Model Surgery – ‘Piggy-back’ splint Final splint placed back on original mounting www.indiandentalacademy.com
  55. 55. Model Surgery – ‘Piggy-back’ splint Intermediate splint made with final splint in place www.indiandentalacademy.com
  56. 56. Model Surgery – ‘Piggy-back’ splint Intermediate and final splints www.indiandentalacademy.com
  57. 57. Model Surgery – ‘Piggy-back’ splint Piggy – back splint on the casts www.indiandentalacademy.com
  58. 58. Requirements of the splint • Fit the teeth accurately • Minimum thickness – not more than 2 mm www.indiandentalacademy.com
  59. 59. Requirements of the splint • Excess acrylic should be trimmed off the buccal aspect, to allow for proper visual verification during surgery and oral hygiene maintenance. www.indiandentalacademy.com
  60. 60. Model Surgery - Problems • Condylar distraction • Trim cusp or prolong pre-surgical orthodontics www.indiandentalacademy.com
  61. 61. Model Surgery - Problems • Incompatibility of canine widths – Easy to check in Class II – not Class III – Can result in ant. Open-bite – Go back to lighter wire • Lack of space between roots to place osteotomy cuts www.indiandentalacademy.com
  62. 62. During Surgery • Splint used to help attain final occlusion • Segmental osteotomies – wire placement • IMF with splint in place • Teeth might penetrate thro splint • Splint should be in place until start of post surgical orthodontics www.indiandentalacademy.com
  63. 63. Post Operative Events • Hospitalization – 2-3 days for single jaw – 4-5 days for double jaw • • • • Facial edema – 2-3 weeks Resumes partial function in 2 weeks Mastication after 6-8 weeks Complete bone healing – 6 months www.indiandentalacademy.com
  64. 64. Post Operative Care • 1 week soft diet – Milk, mashed potatoes, scrambled eggs • After 2 weeks – more chewing – Chapattis, vegetables, and meat in small pieces • Progress to normal diet • Normal diet in 6-8 weeks www.indiandentalacademy.com
  65. 65. Post Operative Physiotherapy • As soon as the initial intracapsular joint edema has resolved – after about 1 week. – 1st week after surgery – open and close mouth gently within comfortable limits – Over next 2 weeks – 3 10-15 minute sessions of opening and closing and lateral movements. – 3rd – 8th weeks, range of motion is increased, and should be normal in 8 weeks. www.indiandentalacademy.com
  66. 66. Post Operative Care • Orthodontist should see the pt within the 1st week – review the occlusal status and check the status of the orthodontic appliance. • Post surgical orthodontics – adequate bone healing – adequate mouth opening www.indiandentalacademy.com
  67. 67. Post Operative Care • Rigid internal fixation and jaw exercises ➫ 2-3 weeks • Wire fixation and IMF ➫ 3-4 weeks after the IMF is released. • Splint and light elastics to guide occlusion www.indiandentalacademy.com
  68. 68. Post Surgical Orthodontics • Working archwires placed – 0.016” steel – 21 x 25 NiTi or Braided Steel – Stabilizing wire left in place in 1 arch www.indiandentalacademy.com
  69. 69. Post Surgical Orthodontics • Good amount of settling in first month • Step bends in archwires www.indiandentalacademy.com
  70. 70. Post Surgical Orthodontics • Headgears and extra oral forces • Heavy intermaxillary elastics • Overlay wire for transverse stabilization www.indiandentalacademy.com
  71. 71. Post Surgical Orthodontics • Finishing with positioners – Parasthesia after surgery – Variable biting force • At the end – Proper settling – Root parallelism – esp. osteotomy site www.indiandentalacademy.com
  72. 72. Retention • Not very different from routine orthodontics. • Transverse retention • Fixed retainers www.indiandentalacademy.com
  73. 73. Summary Before surgery Alignment Leveling – by intrusion Arch compatibility Preparation of osteotomy site Before and/or Post. crossbite correction – if after surgery orthodontic expansion is planned Leveling by extrusion After surgery Settling and leveling by extrusion Root paralleling at osteotomy sites www.indiandentalacademy.com Detailed tooth positioning
  74. 74. Clinical Management Of Some Commonly Encountered Orthognathic Surgical Patients 1.Mand. Deficiency with normal or reduced facial height 2.Excessive face height (long face) 3.Class III problems 4.Facial asymmetry 5.Crossbite and open bite www.indiandentalacademy.com
  75. 75. Mand Deficiency with normal or reduced facial height • Horizontal growth pattern • Class II molar and Canine relationship – often with a div. 2 pattern. • Excessive curve of spee in the lower arch. • Incisor crowding • Deep bite – usually causing some gingival irritation www.indiandentalacademy.com
  76. 76. Mand Deficiency with normal or reduced facial height • Chin button well developed • Deficiency near the lower lip region – seen as a deep mentolabial sulcus, a curl of the lower lip and an aged appearance. • TMJ disorders – www.indiandentalacademy.com
  77. 77. Mand Deficiency with normal or reduced facial height Surgical plan • In most of these patients, – Mandibular deficiency needs to be corrected – Height of the face must be increased. www.indiandentalacademy.com
  78. 78. Mand Deficiency with normal or reduced facial height Mandibular subapical procedure vs. BSSO Subapical procedure – When face ht. is not to be increased BSSO – To increase face height www.indiandentalacademy.com
  79. 79. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  80. 80. Mand Deficiency with normal or reduced facial height • Rotation of mandible – chin moved back and incisors forward • Genioplasty if needed – Reduce chin prominence – Further increase face height • No maxillary surgery to increase face height www.indiandentalacademy.com
  81. 81. Mandibular Deficiency with normal or reduced facial height Pre surgical Orthodontics Position of the incisors – vertically and sagittally Vertical – Determines final face height Sagittal – Determines amount of movement www.indiandentalacademy.com
  82. 82. Mand Deficiency with normal or reduced facial height • Expansion of arch may be necessary – Wider part of mandible comes forward – Can be done orthodontically or surgically – Extractions may not be required www.indiandentalacademy.com
  83. 83. Mand Deficiency with normal or reduced facial height • Considerations during model surgery – Face bow transfer rarely required – Maintain bilateral symmetry – even if crossbite develops – Keep skeletal midlines matching • Post surgical orthodontics – – Level COS by extrusion www.indiandentalacademy.com
  84. 84. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  85. 85. Pre and Post Surgical Orthodontics Dr. Punit Thawani www.indiandentalacademy.com
  86. 86. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  87. 87. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  88. 88. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  89. 89. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  90. 90. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  91. 91. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  92. 92. Mand Deficiency with normal or reduced facial height www.indiandentalacademy.com
  93. 93. Long Face Problems • Vertical excess of post maxilla • ↑mand plane angle • Incisor exposure • Incompetent lips www.indiandentalacademy.com
  94. 94. Long Face Problems • Gummy smile • Narrow maxilla • Cross-bite www.indiandentalacademy.com
  95. 95. Long Face Problems Surgical considerations • impacting to maxilla – mandibular autorotation • Rotating the mandible upwards and forwards after a BSSO • Chin procedures www.indiandentalacademy.com
  96. 96. Long Face Problems • Maxillary procedure – Stable – Corrects most of the problem • BSSO with rotation – Soft tissue stretch – Unstable • Chin procedures – used as adjuncts www.indiandentalacademy.com
  97. 97. Long Face Problems Pre surgical Orthodontics • Orthodontist must know 2 things – – Maxilla in 1 piece or segmented? – how many pieces, and where – Chin position? - or is proper lip – chin balance going to be achieved by orthodontic treatment www.indiandentalacademy.com
  98. 98. Long Face Problems • Segmented procedures – Align within the segment – Stabilize with a wire with step, or segments of 21 x 25 SS wire – Roots of adjescent teeth • Leveling – If mild, by intrusion – If severe - surgically www.indiandentalacademy.com
  99. 99. Long Face Problems • Expansion – Orthodontically – Surgically – But not both – Causes more relapse www.indiandentalacademy.com
  100. 100. Long Face Problems • Maxillary impaction – ↑ wrinkles on the cheek – Drastic reduction in incisor exposure – Widening of alar bases – Aged appearance – More tolerated in younger individuals than adults www.indiandentalacademy.com
  101. 101. Long Face Problems • If maxilla is moved back - ↓lip support • Maxilla may have to be moved forward to get good lip support • Genioplasty – avoid major jaw surgery www.indiandentalacademy.com
  102. 102. Long Face Problems Before model surgery • How much is the maxilla going to be moved • How to reduce residual overjet (if any) • Surgical expansion? – Prepare overlay wire www.indiandentalacademy.com
  103. 103. Long Face Problems Post surgical Orthodontics • Segmental procedures – torque on anteriors – Flexible rectangular wires in upper – 0.016” SS in lower • Stabilizing transverse corrections www.indiandentalacademy.com
  104. 104. Long Face Problems www.indiandentalacademy.com
  105. 105. Long Face Problems www.indiandentalacademy.com
  106. 106. Long Face Problems www.indiandentalacademy.com
  107. 107. Long Face Problems www.indiandentalacademy.com
  108. 108. Long Face Problems www.indiandentalacademy.com
  109. 109. Class III patients • Flatness in the lower 1/3rd of the face – especially in the labio-mental fold. • Soft tissues seem to be tight. • Midface deficiency –“sunken in” appearance is seen. • Thin vermillion border, and reduced maxillary incisor exposure at rest. www.indiandentalacademy.com
  110. 110. Class III patients • Natural compensation – Flared upper incisors, retroclined lower incisors. – Spacing between lower teeth – should think of large tongue – Maxilla may have small or even missing teeth. – Check for attached gingiva in lower anterior – labial region. www.indiandentalacademy.com
  111. 111. Class III patients • Surgical techniques 1.Mandibular – 1.(BSSO) 2.Mandibular sub apical procedures 2.Maxillary – 1.Lefort I osteotomy - high level 2.Expansion 3.Genioplasty www.indiandentalacademy.com
  112. 112. Class III patients • Jaw at fault should be operated • If mandible too prognathic – both jaws – Too much setback ➫ Double chin • Maxillary impaction in case of hyperdivergent jaws www.indiandentalacademy.com
  113. 113. Class III patients • Jacobs – ‘two patient’ concept • Incisors should be positioned as ideally as possible to their respective jaw bases, without concern for inter-arch occlusion. • Maxilla – require extractions and significant retraction • Mandible – Non extraction or extraction for molar correction – Molar inclination correction www.indiandentalacademy.com
  114. 114. Class III patients • If upper expansion is needed – Teeth should be aligned within the segments – Arches should NOT be co-ordinated presurgically – Gross coordination surgically – Final coordination post surgically www.indiandentalacademy.com
  115. 115. Class III patients • Frequent progress models • Before surgery, patients should be informed about – – Possibility of late mandibular growth – Large amount of setback – double chin, may require second soft tissue surgery – Possibility of nasal changes – alar base widening and upturning of the nose. www.indiandentalacademy.com
  116. 116. Class III patients Post surgical orthodontics Basic principles to be followed Check for relapse tendency www.indiandentalacademy.com
  117. 117. Class III patients Tendency towards relapse • Moderate class III elastics (200-300 gms)– heavier rectangular wires needed • Upper incisors can be flared to an extent • Interproximal reduction, and retroclination of lower incisors • Leave larger overjet and overbite www.indiandentalacademy.com
  118. 118. Class III patients • If relapse is still expected, the retention appliance can be made with hooks for attachment of light class III elastics while sleeping www.indiandentalacademy.com
  119. 119. Class III patients www.indiandentalacademy.com
  120. 120. Class III patients www.indiandentalacademy.com
  121. 121. Class III patients www.indiandentalacademy.com
  122. 122. Class III patients www.indiandentalacademy.com
  123. 123. Class III patients www.indiandentalacademy.com
  124. 124. Class III patients www.indiandentalacademy.com
  125. 125. Class III patients www.indiandentalacademy.com
  126. 126. Class III patients www.indiandentalacademy.com
  127. 127. Dento-facial Asymmetry • More through diagnosis – PA view – Submento-vertex – CT scan www.indiandentalacademy.com
  128. 128. Dento-facial Asymmetry Surgery in children • Severe or progressive asymmetry – Hemifacial microsomia – mandibular ankylosis due to condylar fracture www.indiandentalacademy.com
  129. 129. Dento-facial Asymmetry • Principle of treatment – – Modify growth to its full potential so that the child grows out of the deformity • Initial functional appliance treatment – Eliminate need for surgery – Make surgery easier – Help in muscular adaptation www.indiandentalacademy.com
  130. 130. Dento-facial Asymmetry • Role of orthodontist – – Growth guidance after surgery – Maintenance of normal joint function – Alignment of permanent teeth www.indiandentalacademy.com
  131. 131. Dento-facial Asymmetry Asymmetry problems in adolescents • Continue growth guidance – prevents bimaxillary problems • Problems of excessive growth – Hemifacial hypertrophy • Orthognathic surgery at the end of growth www.indiandentalacademy.com
  132. 132. Dento-facial Asymmetry Problems of excessive growth • Diagnosis – 99mTc scan • After growth – surgical correction www.indiandentalacademy.com
  133. 133. Dento-facial Asymmetry • In severe cases – surgical correction before growth is completed – Only mandibular surgery – cant of occlusal plane corrected by functional appliances www.indiandentalacademy.com
  134. 134. Dento-facial Asymmetry Asymmetry in adults • Extent of surgery – – Correct asymmetry at its source – Camouflage • Pre and post surgical orthodontics – similar to any other case www.indiandentalacademy.com
  135. 135. Dento-facial Asymmetry Guidelines – • More concern about transverse than vertical asymmetry • More concern about chin position than mandibular angles • Maxillary midline more critical than mandibular midline www.indiandentalacademy.com
  136. 136. Dento-facial Asymmetry • If nose and jaw are deviated to the same side, both should be corrected • Asymmetry of higher structures - infra-orbital rims, Zygomatic arch – onlay grafts should be considered www.indiandentalacademy.com
  137. 137. Dento-facial Asymmetry • Pre-surgical orthodontics – Matching skeletal and dental midlines • Asymmetric extractions • Asymmetric elastics and cross elastics • Loops and springs – Know the type of surgery • Genioplasty • Ramus osteotomy www.indiandentalacademy.com
  138. 138. Dento-facial Asymmetry • Post surgical orthodontics – Leveling by extrusion – May be longer in such patients www.indiandentalacademy.com
  139. 139. Dento-facial Asymmetry www.indiandentalacademy.com
  140. 140. Surgery in Patients with TMJ Problems • General guideline for management www.indiandentalacademy.com
  141. 141. Surgery in Patients with TMJ Problems • Orthodontics and/or surgery to correct occlusion • TMJ surgery – Not responding to reversible therapy – Progressive internal joint pathologies www.indiandentalacademy.com
  142. 142. Stability of Surgical Corrections The stability of orthognathic surgical procedures depends on the following – 1.Direction of movement 2.Type of fixation used 3.Surgical technique employed www.indiandentalacademy.com
  143. 143. Hierarchy of Stability Maxillary impaction • Most stable procedure • Mandible auto-rotates to maintain the freeway space • Wire/IMF vs RIF equally good results • Wire/IMF – 6 weeks after the surgery - 20% of patients showed 2-4 mm of change in the upward direction – 6weeks to 1 year - that much downward movement of the max www.indiandentalacademy.com
  144. 144. Hierarchy of Stability www.indiandentalacademy.com
  145. 145. Hierarchy of Stability RIF or wire/IMF seemed to make no significant differences in stability. More than 90% chance of max being within 2 mm of post surgical position after 1 year » Bishara et al 1988 » Denison et al 1989 » Proffit et al 1992 www.indiandentalacademy.com
  146. 146. Hierarchy of Stability Mandibular advancement (BSSO) • normal or short face height is considered Wire/IMF • first 6 weeks post surgery – the mand had a tendency to move slightly back. • 6 weeks to one year – the changes seemed to be recovered • function www.indiandentalacademy.com
  147. 147. Hierarchy of Stability RIF • smaller tendency to move back • greater chance of slight forward movement 90% chance of stability » Proffit et al 1990 » Kouma et al 1991 » Gomes et al 1993 » Ingervall et al 1994 www.indiandentalacademy.com
  148. 148. Hierarchy of Stability • BSSO with rotation to close an open bite – Soft tissue stretch – RIF more stable than wire/IMF – Interpositional bone grafts and heavy plates » Ritzik et al 1990 www.indiandentalacademy.com
  149. 149. Hierarchy of Stability By the end of 1 year, only 60% of the patients were judged to have excellent clinical results • Post surgical bite opening tendency is seen www.indiandentalacademy.com
  150. 150. Hierarchy of Stability Maxillary advancement • If moved only anteriorly – 80% stable • If simultaneous downward movement – unstable » Proffit et al – 1991 » Bishara , Chi - 1992 www.indiandentalacademy.com
  151. 151. Hierarchy of Stability Mandibular setback • BSSO and Trans-oral vertical ramus osteotomy (VRO). • VRO seemed to be more stable than BSSO www.indiandentalacademy.com
  152. 152. Hierarchy of Stability VRO • chance of further backward • but forward relapse also occurred With BSSO • no post surgical backward movement, but forward relapse occured • RIF with BSSO seemed to make relapse tendencies worse www.indiandentalacademy.com
  153. 153. Hierarchy of Stability VRO • improper positioning of condyles in fossa resulted in backward movement Both procedures • Change in ramus inclination resulted in forward relapse » Proffit et al (1991) www.indiandentalacademy.com
  154. 154. Hierarchy of Stability Widening of the maxilla • 1 year later, almost 50% of the expansion was lost in the second molar region • Reduction in post surgical width of about 2 mm in 2/3rd of the patients. » Proffit et al 1992. • Stretching of the palatal mucosa • Modest overcorrection and stringent www.indiandentalacademy.com
  155. 155. Hierarchy of Stability 3 Basic principles that influence post surgical stability – • Stability is greatest when soft tissues are relaxed during surgery and least when they are stretched. • Neuromuscular adaptation • Neuromuscular adaptation affects muscle length and not muscle orientation. www.indiandentalacademy.com
  156. 156. Euryprosopic Mesoprosopic www.indiandentalacademy.com
  157. 157. Surgeries are only treatment in • Congenital anomalies affecting (cranio-)facial regions. • Excessively large or small jaw dimensions on account of abnormal growth coupled with abnormal placement (in one or more planes namely, sagittal, vertical and transverse) in adult patients. • Asymmetrical jaw growth. Pre and Post Surgical Orthodontics Dr. Punit Thawani www.indiandentalacademy.com
  158. 158. • Anatomic limitations, which hinder the orthodontic tooth movement. Pre and Post Surgical Orthodontics Dr. Punit Thawani www.indiandentalacademy.com
  159. 159. References • Contemporary treatment of Dentofacial Deformity – Proffit, White & Sarver • Surgical Orthodontic Treatment – Proffit and White • Contemporary Orthodontics – Proffit • Orthognathic surgery: A hierarchy of Stability – Proffit et al - Int. J or Adult Orthod Orthognath Surg 1996 www.indiandentalacademy.com
  160. 160. References • Lingual Orthodontics and Orthognathic surgery – Int. J or Adult Orthod Orthognath Surg 2000 • Stability of Le Fort I osteotomy in maxillary inferior positioning: Review of the literature Costa et al - Int. J or Adult Orthod Orthognath Surg 2000 • Long term stability of mandibular setback surgery: A follow-up of 80 bilateral sagittal split osteotomy patients - Mobarak, et al - Int. J or Adult Orthod Orthognath Surg 2000 www.indiandentalacademy.com
  161. 161. References • Long Term stability of Surgical Open bite Correction by Le Fort I osteotomy - Proffit, Bailey, Phillips, Turvey – AO Feb 2000 • Long term Prognosis of BSSO Mandibular Relapse and its Relation to Different Facial Types - Yoshida et al - AO March 2000 • Mandibular advancement surgery in high angle and low angle Class II patients: Different long term skeletal responses - Mobarak, Espeland, Krogstad and Lyberg – AJO 2001 www.indiandentalacademy.com
  162. 162. Thank you For more details please visit www.indiandentalacademy.com Pre and Post Surgical Orthodontics Dr. Punit Thawani www.indiandentalacademy.com

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