orthognathic surgery/ fixed orthodontics courses

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orthognathic surgery/ fixed orthodontics courses

  1. 1. Orthognathic Surgery INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Contents          Definition, Team, Objectives History of Orthognathic Surgery Grading of patients Envelope of discrepancy Overview of Facial Planning Process STO/CTP Pre-surgical Orthodontic goals Definitive Surgical Treatment Plan Model Surgery www.indiandentalacademy.com
  3. 3. Contents         Basis/Concept of Orthognathic Surgery Patient preparation Surgical Procedures Rigid Internal Fixation Special Considerations Rehabilitation Post Surgical Orthodontics Retention and Relapse www.indiandentalacademy.com
  4. 4. Definition  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 deformities of the jaws and associated structures.  Fonseca www.indiandentalacademy.com
  5. 5. Team    Oral and maxillofacial surgeon Orthodontist General dentist Periodontist Prosthodontist Endodontists Neurosurgeons Opthamologists Otolaryngologists Plastic surgeon Speech pathologist www.indiandentalacademy.com
  6. 6. Objectives Basic therapeutic goals: Function Aesthetics Stability Minimizing the treatment time  Fonseca www.indiandentalacademy.com
  7. 7. Objectives Specific therapeutic goals: Masticatory / Swallowing Functional occlusion Opening and closing of jaws TMJ dysfunction Structural abnormalities Myofascial pain Speech Stability of orthodontic results Improve dental and periodontal health Improve psychosocial impairments  Fonseca www.indiandentalacademy.com
  8. 8. History of Orthognathic Surgery  1849 - Simon Hullihen - Mandibular subapical osteotomy  1859 – von Langenbeck – First orthognathic surgical procedure  1864 - Cheever - LeFort I  1907 - Dingman - Mandibular body osteoectomy  1921 – Cohn-Stock – Anterior maxillary osteotomy  1927 - Wassmund - Maxillary osteotomy www.indiandentalacademy.com
  9. 9. History of Orthognathic Surgery  1934 - Auxhausen - Maxillary osteotomy  1934 - Bell - Biologic basis of osteotomy  1942 - Gillies & Harrison - LeFort II &III  1942 - Schuchardt - similar to BSSO  1950 - Tessier - LeFort III &IV  1952 - Converse - Maxillary osteotomy www.indiandentalacademy.com
  10. 10. History of Orthognathic Surgery  1954 - Caldwell & Letterman - Vertical subcondylar osteotomy  1960’s - Stoker, Epker, Bell, Wilmar & Obwegeser LeFort I down fracture  1965 - Trauner & Obwegeser - BSSO www.indiandentalacademy.com
  11. 11.  1970 - Turvey, Epker, Fish & LaBanc - Bijaw surgeries  1973 - Henderson & Jackson - Pyramidal LeFort II  1992 - McCarthy - Distraction osteogenesis in congenitally hypoplastic mandible www.indiandentalacademy.com
  12. 12.  Group I Group II Group III  Arnett . McLaughlin www.indiandentalacademy.com  
  13. 13. Sagittal Envelope of Discrepancy  Proffit www.indiandentalacademy.com
  14. 14. Transverse Envelope of Discrepancy www.indiandentalacademy.com
  15. 15. IOTN Treatment Grades   Shaw and coworkers Proffit . White . Sarver www.indiandentalacademy.com
  16. 16.  Proffit www.indiandentalacademy.com
  17. 17. State of art care  Correctly diagnose existing deformities  Establish a proper treatment plan  Execute the recommended treatment  Arnett . McLaughlin www.indiandentalacademy.com
  18. 18. Criteria for success         Healthy musculature and temporomandibular joints Facial balance Correct static and functional occlusion Periodontal health Resolving the patient’s chief complaints Stability of dental, skeletal, and growth changes Maintaining or increasing airway Arnett . McLaughlin www.indiandentalacademy.com
  19. 19. Criteria for success 1. Healthy musculature and temporomandibular joints  Normal range of movement  Structural stability  Free from pain  Remodeling   Local remodeling Total remodeling www.indiandentalacademy.com
  20. 20. Criteria for success 2. Facial balance  Tweed, Down, Steiner, McNamara – Averages for general population  Assumption that if the dental and skeletal values are normal the face would be normal   STCA – 45measurements CTP www.indiandentalacademy.com
  21. 21. Criteria for success 3. Correct static and functional occlusion    Andrews six keys Overjet, overbite and symmetrical midlines Condyles in glenoid fossa 4. Periodontal health   Alveolar bone Gingival tissue www.indiandentalacademy.com
  22. 22. Criteria for success 5. Resolving the patient’s chief complaints 6. Stability  Magnitude of tooth movement in three dimensions    Excessive compensation Disproportionate growth Stability of TMJ  Surgical technique – condyles should be seated without compression 7. Maintaining or increasing airway www.indiandentalacademy.com
  23. 23. Overview of Facial Planning Process       Patient concerns History Clinical examination Radiographic and imaging analysis Dental model analysis Arnett . McLaughlin  Fonseca www.indiandentalacademy.com
  24. 24. Patient concerns     What are your concerns or problems? Have you had previous treatment for this condition, and what was the outcome? Why do you want treatment? What do you expect from treatment? www.indiandentalacademy.com
  25. 25. Patient History        Personal information Chief complaint - Motivation questionnaires Medical Dental and orthodontic history History of the TMJ and musculature Pre-surgical growth assessment Arnett . McLaughlin www.indiandentalacademy.com
  26. 26. Questionnaires  Basic - general screening  In-depth - complex problems www.indiandentalacademy.com Patient History
  27. 27. Personal information www.indiandentalacademy.com Patient History
  28. 28. Chief complaint - Motivation questionnaires    Dental changes Facial changes Relief of symptoms www.indiandentalacademy.com Patient History
  29. 29. Medical history www.indiandentalacademy.com Patient History
  30. 30. Dental and orthodontic history www.indiandentalacademy.com Patient History
  31. 31.  History of the TMJ and musculature www.indiandentalacademy.com Patient History
  32. 32. Pre-surgical growth assessment www.indiandentalacademy.com
  33. 33. Psychological ramifications of orthognathic surgery       Self-image Motivations and patient expectations Patient interviews Patient preparation Response to treatment Fonseca www.indiandentalacademy.com
  34. 34. Psychological ramifications Self-image  Class III – Masculine, leadership, aggression, dominance, strength etc.  Class II profile – Feminine, submissive, naive etc.  Round face – Child like, warm, honest, trustworthy etc. www.indiandentalacademy.com
  35. 35. Psychological ramifications Motivations and patient expectations  What reasons do patients give for seeking treatment?        Enhancement of self-image Oral function Social well being Future dental health TMJ Nasal function Psychological well being www.indiandentalacademy.com
  36. 36. Psychological ramifications Motivations and patient expectations  Psychological well being   Psychological health before surgery Assessing patients emotional distress www.indiandentalacademy.com
  37. 37. Psychological ramifications Patient interview  Social support system  Assessment of personality   Open ended question Silence  www.indiandentalacademy.com Proffit
  38. 38. Psychological ramifications Patient preparation  Explain diagnosis  Treatment options  Risk / benefits  Prepare the supporting people www.indiandentalacademy.com
  39. 39. Psychological ramifications Response to treatment  Post surgical perception or problems with         Swelling Bruising Nasal congestion Dry lips Facial abrasion Dribbling Sleeping – sitting for 2-3 weeks Murphy T. 2005 Jr of Orthod         Sleep discomfort Numbness Tingling Pain in jaw joints Possibility of altered speech Low feeling Soft diet Possible acne www.indiandentalacademy.com
  40. 40. Clinical examination   TMJ examination Clinical facial examination   Frontal view Profile view      High midface profile Maxillary area profile Mandibular area profile Intra-oral examination Arnett . McLaughlin www.indiandentalacademy.com
  41. 41. TMJ examination     The range of movements Deviation from normal movements Any pain during movement The joint sounds www.indiandentalacademy.com
  42. 42. Clinical facial examination - Frontal view   General outline Midline assessment www.indiandentalacademy.com
  43. 43. Clinical facial examination - Frontal view  Horizontal reference lines www.indiandentalacademy.com
  44. 44. Clinical facial examination - Frontal view  Mandibular deviations and cants www.indiandentalacademy.com
  45. 45. Clinical facial examination - Frontal view  Vertical assessment - the facial thirds www.indiandentalacademy.com
  46. 46. Clinical facial examination - Frontal view  Vertical assessment of the lower third of the face www.indiandentalacademy.com
  47. 47. Clinical facial examination - Frontal view  Upper lip length  Inter-labial gap www.indiandentalacademy.com  Lower lip length
  48. 48. Clinical facial examination - Frontal view  Upper incisor crown length and overbite www.indiandentalacademy.com
  49. 49. Clinical facial examination - Frontal view  Upper incisor exposure – lips at rest www.indiandentalacademy.com
  50. 50. Clinical facial examination - Frontal view  Exposure of the upper incisor and gingival tissue when smiling www.indiandentalacademy.com
  51. 51. Clinical facial examination - Frontal view  Closed lip position www.indiandentalacademy.com
  52. 52. Clinical facial examination - Frontal view  Upper and lower vermilion borders www.indiandentalacademy.com
  53. 53. Frontal view - Summary www.indiandentalacademy.com
  54. 54. Frontal view - Summary www.indiandentalacademy.com
  55. 55. Clinical facial examination - Profile view  High midface     Glabella Orbital rim Cheek bone Subpupil area www.indiandentalacademy.com
  56. 56. Clinical facial examination - Profile view  Maxillary area     Nasal base Upper lip prominence Upper lip support Nasal projection www.indiandentalacademy.com
  57. 57. Clinical facial examination - Profile view  Mandibular area     Lower lip prominence Soft tissue pogonion prominence Throat length contour Overjet www.indiandentalacademy.com
  58. 58. Profile view - Summary www.indiandentalacademy.com
  59. 59. Intra-oral examination       Soft tissues Finger or thumb sucking Tongue size, position and activity Mentalis muscle activity Dental assessment Molar relationship www.indiandentalacademy.com
  60. 60.        Canine relationship Midlines Overjet and overbite Crossbites Crowding or spacing Lower curve of spee Periodontal health www.indiandentalacademy.com
  61. 61. Records www.indiandentalacademy.com
  62. 62. Imaging and radiographic analysis  Facial photographs    Routine facial photographs In-depth facial photographs Intra-oral photographs www.indiandentalacademy.com
  63. 63. www.indiandentalacademy.com
  64. 64. Routine facial photographs www.indiandentalacademy.com
  65. 65. In-depth facial photographs www.indiandentalacademy.com
  66. 66. Intra-oral photographs www.indiandentalacademy.com
  67. 67. Radiographic and Imaging Analysis  Radiographs      Lateral cephalometry Panoramic radiographs Intra-oral radiographs Tomograms MRI www.indiandentalacademy.com
  68. 68. Metallic midface markers      Cheek bone Soft tissue orbital rim Nasal base Subpupil Neck-throat junction www.indiandentalacademy.com
  69. 69. Dental Models    Impression taking Wax bite construction Model analysis www.indiandentalacademy.com
  70. 70. Importance of wax bite    First tooth contact Maximum intercuspation Relates the mandible to maxilla during      facial examination, facial photography, cephalometry, tomography and model articulation www.indiandentalacademy.com
  71. 71. Wax bite construction  First wax bite www.indiandentalacademy.com
  72. 72. Wax bite construction  Second wax bite  Third wax bite www.indiandentalacademy.com
  73. 73. Model analysis          Arch length Tooth size analysis Tooth position Arch width analysis Curve of spee Cuspid-molar relation Tooth arch symmetry Buccal tooth tipping (Curve of wilson) Missing, broken down or crowned teeth www.indiandentalacademy.com
  74. 74. Diagnosis in three areas    Musculature and TMJ Face Dentition www.indiandentalacademy.com
  75. 75. 1. Musculature and TMJ   Head, neck and TMJ pain and dysfunction TMDs    Masticatory muscle disorders Temporomandibular joint articular disorders Condylar remodelling   Local Total www.indiandentalacademy.com
  76. 76. 2. Face     Clinical examination STCA Frontal - Grummons and Ricketts Profile - COGS - skeletal and soft tissue – Burstone et al. www.indiandentalacademy.com
  77. 77. Orthognathic Surgery -II Dr Sangamesh B. www.indiandentalacademy.com
  78. 78. Contents          Definition, Team, Objectives History of Orthognathic Surgery Grading of patients Envelope of discrepancy Overview of Facial Planning Process STO/CTP Pre-surgical Orthodontic goals Definitive Surgical Treatment Plan Model Surgery www.indiandentalacademy.com
  79. 79. Contents         Basis/Concept of Orthognathic Surgery Patient preparation Surgical Procedures Rigid Internal Fixation Special Considerations Rehabilitation Post Surgical Orthodontics Retention and Relapse www.indiandentalacademy.com
  80. 80. STCA         Arnett etal 1999 AJO DO Sample 46 adult caucasian– 20/M 26/F Class I Occlusion Balanced facial appearance All records – NHP If not in NHP – TVL TVL – Subnasale perpendicular to NHP Arnett . McLaughlin www.indiandentalacademy.com
  81. 81. STCA Following areas were evaluated;  Dental and skeletal factors  Soft tissue components  Vertical facial heights or lengths  TVL projections  Facial harmony www.indiandentalacademy.com
  82. 82. STCA - Dental and skeletal factors www.indiandentalacademy.com
  83. 83. STCA – Soft tissue thickness www.indiandentalacademy.com
  84. 84. STCA - Vertical facial heights or lengths www.indiandentalacademy.com
  85. 85. STCA - Vertical facial heights or lengths www.indiandentalacademy.com
  86. 86. STCA - TVL projections www.indiandentalacademy.com
  87. 87. STCA - TVL projections   The A/P position of the TVL will be frequently through subnasale TVL must be moved forward 1-3mm in case of maxillary retrusion    Long nose Depressed or flat orbital rims, cheek bones, subpupils, alar bases etc. Patient clinical visualization for verification www.indiandentalacademy.com
  88. 88. STCA – Harmony values www.indiandentalacademy.com
  89. 89. STCA – Harmony values for Females www.indiandentalacademy.com
  90. 90. STCA – Harmony values for Males www.indiandentalacademy.com
  91. 91.    Middle third Lower third Clinical commentary on    Facial growth Facial imbalances Bimaxillary surgery www.indiandentalacademy.com
  92. 92. STCA – Length of the lower third of the face www.indiandentalacademy.com
  93. 93. STCA – Short upper lip www.indiandentalacademy.com
  94. 94. STCA – Normal upper to lower lip ratio www.indiandentalacademy.com
  95. 95. STCA – Upper lip prominence  Related to A/P position of the maxilla, upper incisor torque and upper lip thickness www.indiandentalacademy.com
  96. 96. STCA – Nasolabial angle and upper lip www.indiandentalacademy.com
  97. 97. STCA – Upper incisor exposure – lips at rest disharmony www.indiandentalacademy.com
  98. 98. STCA – Exposure of upper incisor and gingival tissue on smiling www.indiandentalacademy.com
  99. 99. STCA – Prominence of soft tissue pogonion  Retrusive soft tissue pogonion Protrusive soft tissue pogonion    Vertical maxillary excess Mandibular retrusion Steep occlusal plane Vertical maxillary deficiency Mandibular protrusion Flat occlusal plane www.indiandentalacademy.com
  100. 100. STCA – Throat length and contour    Long and short throat length Long straight throat length is favorable for mandibular setback Short sagging throat length is unfavorable www.indiandentalacademy.com
  101. 101. 3. Dentition and intra-oral structures  Vertical     Horizontal     Overbite Plane of occlusion Curve of spee Anatomical variation Crowding / spacing Overjet Transverse  Crossbites www.indiandentalacademy.com
  102. 102.      Maxillary retrusion Mandibular retrusion Clockwise mandibular rotation Upper and lower denture base retrusion Overjet increase www.indiandentalacademy.com
  103. 103. Video imaging technology    Acetate tracings Photograph modification Videocephalometrics  Fonseca  Proffit White Sarver www.indiandentalacademy.com
  104. 104. Video imaging technology Videocephalometrics Advantages:        Accuracy Multiple analysis in short time Individualization - gender, age, race and ethnicity Prediction by algorithmic data Incorporation of changes during treatment Fonseca www.indiandentalacademy.com
  105. 105. Video imaging technology to orthognathic surgery    How does technology work? Are the predictions generated by the computer accurate enough for the surgical team to follow precisely? Is it medicolegally safe to use;are the patients likely to litigate if they feel the outcome is not what they expected? www.indiandentalacademy.com
  106. 106. Surgical prediction  Mandibular    1989 - Hing 1993 - Schwartz - ‘Quick ceph’ Maxillary  1994 - Konstaniantos et al. – ‘Dentofacial Planner’ www.indiandentalacademy.com
  107. 107. Surgical prediction    Skeletal and soft tissue response is different for different surgical procedure and osteosynthesis Algorithms in the prediction software should be modifiable Types of procedure should be agreed by the surgeon then proceed for prediction tracing www.indiandentalacademy.com
  108. 108. Cephalometric Treatment Planning  Arnett . McLaughlin www.indiandentalacademy.com
  109. 109. CTP  Step 1 – Correct the torque of the upper incisor www.indiandentalacademy.com
  110. 110. CTP  Step 2 - Correct the torque of the lower incisor www.indiandentalacademy.com
  111. 111. CTP  Step 3 – Position of maxillary incisors www.indiandentalacademy.com
  112. 112. CTP  Step 4 – Auto-rotate the mandible to 3mm of overbite www.indiandentalacademy.com
  113. 113. CTP  Step 5 – Move the mandible to 3mm of overjet A/P movement www.indiandentalacademy.com
  114. 114. CTP  Step 6 – Set the maxillary occlusal plane www.indiandentalacademy.com
  115. 115. CTP  Step 7 – Assess the chin height and AP projection to TVL www.indiandentalacademy.com
  116. 116. CTP Omitting steps  If any of the steps are correct then they are omitted  Steps 1,2,4,7 provide a facially correct class I occlusion  Step 3 is for LeFort I – Upper incisor AP and vertical change  Step 6 – Occlusal plane modification  Step 7 – Chin osteotomy www.indiandentalacademy.com
  117. 117. STO  Initial surgical treatment objectives    To establish orthodontic goals To develop surgical objectives To create the predicted facial profile www.indiandentalacademy.com
  118. 118. Pre-surgical Orthodontics      Selection of appliance Alignment Vertical positioning of teeth Anteroposterior position of teeth Arch compatibility www.indiandentalacademy.com
  119. 119. Pre-surgical Orthodontic goals  Fonseca www.indiandentalacademy.com
  120. 120. Pre-surgical Orthodontic goals  Sagittal dimension www.indiandentalacademy.com
  121. 121. Pre-surgical Orthodontic goals   Vertical dimension Fonseca www.indiandentalacademy.com
  122. 122. Pre-surgical Orthodontic goals  Transverse dimension  Fonseca www.indiandentalacademy.com
  123. 123. Definitive Surgical Treatment Plan  Final surgical treatment objectives  Definitive treatment plan    Dental and periodontal treatment Extractions Surgery www.indiandentalacademy.com
  124. 124. Model Surgery       Traditional Method Analytical model surgery Maxillary surgeries Mandibular surgeries Double-jaw surgeries Fonseca www.indiandentalacademy.com
  125. 125. Maxillary surgeries       Impressions Wax-bite Face-bow transfer Mounting of the casts on a semiadjustable articulator Vertical reference lines are drawn – A/P positioning or arch rotation Horizontal reference lines www.indiandentalacademy.com
  126. 126. Model Surgery www.indiandentalacademy.com
  127. 127. Model Surgery www.indiandentalacademy.com
  128. 128. Model Surgery www.indiandentalacademy.com
  129. 129. Isolated maxillary surgery     Provide clearance in the mounting plaster for the superior repositioning of the maxilla Adjust the incisal guidance pin Acrylic splints are fabricated Final vertical position of the maxilla is confirmed using the external reference point www.indiandentalacademy.com
  130. 130. Segmental maxillary surgery  Additional measurements at dental landmarks in each dentoalveolar segment are required www.indiandentalacademy.com
  131. 131. Mandibular surgery   Maxilla used as a template As maxillary position is constant – use of semiadjustable articulator or face-bow not always required www.indiandentalacademy.com
  132. 132. Double-jaw surgeries     Determine the final position of maxilla Intermediate splint Mandibular repositioning Final splint www.indiandentalacademy.com
  133. 133. Splints www.indiandentalacademy.com
  134. 134. Analytical model surgery        1992 – Bell Three-dimensional surgical movements of jaws Common reference plane - FH Semiadjustable articulator Dental models : Patient‘s facial structures – 1:1 Cephalometric radiographs – 10% enlargement CT scans – 1:1 www.indiandentalacademy.com
  135. 135. Analytical model surgery  Common reference plane - FH www.indiandentalacademy.com
  136. 136. Analytical model surgery  Model platform and the model block www.indiandentalacademy.com
  137. 137. Analytical model surgery  Measuring final models for dentofacial surgery www.indiandentalacademy.com
  138. 138. Analytical model surgery www.indiandentalacademy.com
  139. 139. Analytical model surgery www.indiandentalacademy.com
  140. 140. Analytical model surgery  Technique    Record space available measurements on a model surgery worksheet Trim the cast to simulate normal anatomic characteristics at the oestotomy site Scribe the long axis and the proximal root surface anatomic features of each tooth on the stone www.indiandentalacademy.com
  141. 141. Analytical model surgery  Technique   Scribe an X over each tooth at the alveolar crest and at the level of the apex of the longest tooth; both labially and lingually Measure the distance between the marks on the buccal and lingual surface of the model at the apical and crestal aspects; these are presurgical interdental records www.indiandentalacademy.com
  142. 142. Analytical model surgery www.indiandentalacademy.com
  143. 143. Basis/Concept of Orthognathic Surgery      Orthognathic surgeries – described in European literature – 70 years 1960’s - Kole and Bell – Scientific basis of Orthognathic surgery 1970’s – Modification of various surgical procedures 1969-1975 – Bells’s research established the biological basis of Orthognathic surgery Fonseca www.indiandentalacademy.com
  144. 144. Basis/Concept of Orthognathic Surgery  Revascularization studies of Bell and Fonseca:  Vascular ischemia and tissue necrosis –      Improper design of the soft tissue incision Excessive stretching of the palatal soft tissue pedicle Segmentalization of the maxilla Extensive hypotension Severance of the descending palatine vessels www.indiandentalacademy.com
  145. 145. Revascularization studies of Bell and Fonseca Findings I Palatal soft tissue pedicle and the labial buccal gingiva provide a adequate nutrient pedicle for single stage osteotomy II Bilateral transection of the descending palatine vessels did not adversely affect the LeFort I osteotomy procedure if the basic surgical principles were followed III Investigated the limits of LeFort I osteotomy using standard circumvestibular incision, segmentalizing the maxilla, stretching the vascular pedicle and transecting the descending palatine arteries – result was uncomplicated post-operative healing with transient vascular ischemia www.indiandentalacademy.com
  146. 146. Revascularization studies IV 1994 – Dodson et al. - Measured the blood flow to the maxillary gingiva using laser doppler flowmetry following LeFort I osteotomy with sacrifice of bilateral descending palatine arteries – Only transient vascular ischemia and restored blood flow in the anterior maxilla one week post operatively V 1991 – You et al. - Showed no histological osteonecrosis and restored vascularity VI 1997 – Siebert et al. – Elucidated the “palatal contributions” to the blood supply to the moblized LeFort I segment. (Ascending palatine branch of facial artery and anterior branch of the ascending pharyngeal artery) www.indiandentalacademy.com
  147. 147. Basis/Concept of Orthognathic Surgery  Histological concept of blood flow in the gingival tissue      1970 – Bell - 5-6mm of osteotomy distance from the apices of the maxillary teeth 1973 – Pepersack – Confirmed the above finding Kahnberg and Engestrom – 100% teeth in the osteotomized maxilla regained their vitality within 18months Kahnberg and Engestrom – 50% had radiographically healthy sinuses after 6months – 50% had minimal mucosal swellings Di et al. – Minimal pulpal changes and normal growth of developing teeth www.indiandentalacademy.com
  148. 148. Revascularization studies in mandible      Immediately post operatively – generalized intramedullary circulation in proximal and distal segments Only avascular area – margins of the osteotomy site Boc and Peterson – decrease in pulpal and periodontal ligament blood flow immediately following surgery 1 week – vascularization at both the segments, hypervascularity at the surgical site and no evidence of soft tissue reattachment Bell and Schendel – Modified BSSO – less stripping of the pterygomassetric sling – leads to decreased necrosis www.indiandentalacademy.com
  149. 149. Revascularization studies in mandible Vascular blood supply in mandible is centrifugal – post operatively this arterial flow is from peripheral anastomosis (Mental artery and mandibular branch of the sublingual artery)  www.indiandentalacademy.com
  150. 150. Orthognathic Surgery -III Dr Sangamesh B. www.indiandentalacademy.com
  151. 151. Surgical Procedure        Maxilla Mandible Bi-jaw DO Surgery before growth OSA Adjunctive surgical procedures www.indiandentalacademy.com
  152. 152. summary www.indiandentalacademy.com
  153. 153. Mandibular excess www.indiandentalacademy.com
  154. 154. Mandibular excess www.indiandentalacademy.com
  155. 155. Mandibular excess www.indiandentalacademy.com
  156. 156. Mandibular excess www.indiandentalacademy.com
  157. 157. Mandibular excess www.indiandentalacademy.com
  158. 158. Mandibular excess www.indiandentalacademy.com
  159. 159. Mandibular excess www.indiandentalacademy.com
  160. 160. Mandibular excess www.indiandentalacademy.com
  161. 161. Mandibular excess www.indiandentalacademy.com
  162. 162. Mandibular exess www.indiandentalacademy.com
  163. 163. Mandibular excess www.indiandentalacademy.com
  164. 164. Maxillary excess www.indiandentalacademy.com
  165. 165. Maxillary excess www.indiandentalacademy.com
  166. 166. Maxillary excess www.indiandentalacademy.com
  167. 167. Maxillary excess www.indiandentalacademy.com
  168. 168. Maxillary excess www.indiandentalacademy.com
  169. 169. Mandibular excess www.indiandentalacademy.com
  170. 170. Mandibular excess www.indiandentalacademy.com
  171. 171. Mandibular excess www.indiandentalacademy.com
  172. 172. Maxillary excess ( vertical ) www.indiandentalacademy.com
  173. 173. Maxillary excess ( vertical ) www.indiandentalacademy.com
  174. 174. www.indiandentalacademy.com
  175. 175. Maxillary excess ( vertical) www.indiandentalacademy.com
  176. 176. Mandibular deficiency ( sagittal) www.indiandentalacademy.com
  177. 177. Mandibular deficiency ( vertical) www.indiandentalacademy.com
  178. 178. Genioplasty www.indiandentalacademy.com
  179. 179. Genioplasty www.indiandentalacademy.com
  180. 180. Maxillary excess www.indiandentalacademy.com
  181. 181. www.indiandentalacademy.com
  182. 182. www.indiandentalacademy.com
  183. 183. Maxillary excess www.indiandentalacademy.com
  184. 184. Maxillary excess (vertical) www.indiandentalacademy.com
  185. 185. Maxillary excess (vertical) www.indiandentalacademy.com
  186. 186. Open bite www.indiandentalacademy.com
  187. 187. Open bite www.indiandentalacademy.com
  188. 188. Open bite www.indiandentalacademy.com
  189. 189. Open bite www.indiandentalacademy.com
  190. 190. Maxilla      1859 – von Langenbeck – first Orthognathic surgical procedure for removal of Naso-pharyngeal polyp 1867 – David Cheever – for treatment of complete nasal obstruction 1921 – Cohn-Stock – Anterior maxillary osteotomy 1927 - Wassmund – LeFort I/Total maxillary osteotomy 1934 – Axhausen – for correction of healed maxillary fracture www.indiandentalacademy.com
  191. 191. Maxilla      1950 – Gillies and Harrison - 1950 – LeFort II osteotomy involving the premaxilla and nasal complex 1959 – Schuchardt – Posterior maxillary osteotomy 1965 – Obwegeser – Complete mobilization of maxilla – Major advance in stability (Haller, Hogemann & Willmar and Perko) 1973 – Henderson – Classic pyramidal LeFort II 1969-1975 – Bells’s research established the biological basis of Orhtognathic surgery www.indiandentalacademy.com
  192. 192. Maxilla – Surgically Assisted Maxillary Expansion    BROWN (1938) first described SAME Is essentially a combination of distraction osteogenesis and controlled soft tissue expansion Etiology of transverse maxillary deficiency;     Congenital Developmental Traumatic Iatrogenic www.indiandentalacademy.com
  193. 193. Maxilla- Surgically Assisted Maxillary Expansion      Diagnosis of transverse maxillary deficiency Clinically Radiographically Clinically  Unilateral or bilateral cross bite  Crowded, rotated or buccally placed teeth  Narrow or tapering maxillary arch  High or narrow palatal arch  Hour glass shaped maxillary arch  One or more teeth in cross bite is probably skeletal deficiency Radiographically  P A cephalogram is the choice www.indiandentalacademy.com
  194. 194. Maxilla - Surgically Assisted Maxillary Expansion Treatment techniques  Slow dentoalveolar expansion (SDE)  Orthopaedic rapid maxillary expansion (ORME)  Surgically assisted maxillary expansion (SAME)  Segmental maxillary osteotomy www.indiandentalacademy.com
  195. 195. Maxilla - Surgically Assisted Maxillary Expansion Indications  Skeletal maxillomandibular transverse discrepancy greater than 5mm  Significant transverse maxillary deficiency associated with narrow maxilla and wide mandible  Failed orthodontic expansion  Necessity for a large amount of expansion more than 7 mm  Extremely thin delicate gingival tissue  Presence of significant buccal gingival recession in canine bicuspid area  Significant nasal stenosis www.indiandentalacademy.com
  196. 196. www.indiandentalacademy.com
  197. 197. Maxilla - Surgically Assisted Maxillary Expansion ACTIVATION  Two types  During procedure the appliance activated 3-4 mm and then turned back to final opening of 1-1.5 mm  Following surgical procedures, after five days at a rate of 0.5mm per day (Ilizarov) www.indiandentalacademy.com
  198. 198. Segmental maxillary osteotomy      Plating at a particular expansion Higher chances of relapse More expansion in the molar region than in the canine region Widening of more than 6mm is not feasible Inelasticity of the palatal mucosa is the major limiting factor www.indiandentalacademy.com
  199. 199. Complications  Hemorrhage  Osteotomy 5mm above apices  Preserve bony coverage of the medial surface of the central incisor roots  Inadequate release of maxillae www.indiandentalacademy.com
  200. 200. Surgical Techniques    Le Fort III Le Fort I Le Fort II Le Fort III Le Fort II Le Fort I www.indiandentalacademy.com
  201. 201. LeFort I Osteotomy A. Low-level osteotomy B. Approaches the orbital rim C. Cheek prominence D. Low-level osteotomy www.indiandentalacademy.com
  202. 202. Maxilla – Anterior segmental osteotomies Indications  Marked protrusion of maxillary teeth with normal incisor axial inclination to the alveolar bone  Anterior open bite when vertical maxillary excess is not present  Patient noncompliance in anterior retraction  Root resorption, ankylosis – orthodontic tooth movement is not advisable  Improvement by reduction of prominent upper lip www.indiandentalacademy.com
  203. 203. Maxilla – Anterior segmental osteotomies    Wunderer method Wassmund method Cupar method www.indiandentalacademy.com
  204. 204. Maxilla – Posterior segmental osteotomies Indications  Posterior maxillary alveolar hyperplasia  Total maxillary hyperplasia  Distal positioning of the posterior maxillary alveolar fragment to provide space for proper eruption of impacted canine or bicuspid  Spacing in dentition  Transverse excess or deficiency  Posterior open bite www.indiandentalacademy.com
  205. 205. Maxilla – Posterior segmental osteotomies www.indiandentalacademy.com
  206. 206. Mid face osteotomy procedures   Maxillary Qudarangular LeFort I and Qudarangular LeFort II osteotomy Highlevel midface osteotomy    LeFort III Osteotomy LeFort II Osteotomy Facial malformations – Hemifacial microsomia, Crouzon’s syndrome, Apert’s syndrome etc. www.indiandentalacademy.com
  207. 207. Mid face osteotomy procedures     Maxillary-mandibular horizontal deficiency Class III skeletal malocclusion Normal nasal projection Zygoma and infraorbital deficiency www.indiandentalacademy.com
  208. 208.  Highlevel midface osteotomy    LeFort III Osteotomy LeFort II Osteotomy Indications    Total midface hypoplasia Apert’s syndrome Binder’s syndrome www.indiandentalacademy.com
  209. 209. Mandible    1849 – Hullihen – Anterior sub-apical osteotomy 1954 – Caldwell and Letterman – Intra-oral vertical ramus osteotomy – Setback procedure – could not allow advancement 1955 – Trauner and Obwegeser – BSSO www.indiandentalacademy.com
  210. 210. Mandible    1961 – Dalpont – Modification of BSSO – Advance the oblique cut to the molar region and the vertical cut to the lateral cortex 1968- Hunsuck – Shortened the cut on the medial cortex of the ramus – at the level of mandibular foramen 1970 – Bell, Schendel and Epker – Modified the technique by making a complete cut till the lower border of the mandible www.indiandentalacademy.com
  211. 211. Mandible           BSSO TVRO EVRO Combination techniques Inferior alveolar neurovascular bundle decompression Body osteotomy Midline osteotomy Inferior border osteotomy Anterior subapical osteotomy Total subapical osteotomy www.indiandentalacademy.com
  212. 212. BSSO www.indiandentalacademy.com
  213. 213. Mandibular excess www.indiandentalacademy.com
  214. 214. BSSO Indications  Horizontal mandibular excess  Horizontal mandibular deficiency  Horizontal mandibular asymmetry  Setback of 7-8mm www.indiandentalacademy.com
  215. 215. TVRO www.indiandentalacademy.com
  216. 216. IVRO Indications  Setback of more than 12mm www.indiandentalacademy.com
  217. 217. Midline osteotomy www.indiandentalacademy.com
  218. 218. Combination - Vertical ramus and sagittal osteotomy www.indiandentalacademy.com
  219. 219. Ramus and Body osteotomy www.indiandentalacademy.com
  220. 220. Anterior subapical osteotomy www.indiandentalacademy.com
  221. 221. Total subapical osteotomy www.indiandentalacademy.com
  222. 222. Distraction osteogenesis www.indiandentalacademy.com
  223. 223. Orthognathic surgery before completion of growth Assumption - Early surgery retards further growth expression  Vertical maxillary excess  Maxillary deficiency    LeFort III – Crouzon’s disease or Apert’s syndrome Mandibular prognathism Mandibular deficiency www.indiandentalacademy.com
  224. 224. Orthognathic surgery before completion of growth      Accurate diagnosis of the growth status Psychosocial concerns – social pressure and peer acceptance Surgery for excess has greater risk of unfavorable outcome than surgery for deficiency Surgical treatment done on patient request Inform the necessity to repeat the treatment at a later age www.indiandentalacademy.com
  225. 225. Obstructive sleep apnea  Non surgical       Weight loss Change in sleep position Pharmacologic options Oral devices Avoidance of sedatives CPAP OR BiPAP www.indiandentalacademy.com
  226. 226. Obstructive sleep apnea Indications  RDI > 20  Failure to tolerate CPAP  RDI < 20 in young patient with congenital facial deformity  Oxygen desaturation < 85%  Cardiac arrhythmias associated with obstruction Treatment options  Tracheostomy  Nasal/septal surgery  Uvulopalatopharyngoplasty  Genial / hyoid advancement  Maxillomandibular advancement  Tongue reduction www.indiandentalacademy.com
  227. 227. Adjunctive procedures  Chin modification      Rhinoplasty Facial soft tissue contouring Lip procedures      Chin augmentation Chin reduction Lengthening of the philtrum Management of aging changes in the lips Lip augmentation Lip reduction: reduction cheiloplasty Submental procedures  Soft tissue reduction www.indiandentalacademy.com
  228. 228. Genioplasty   1942 – Hofer – Horizontal osteotomy of the symphysis 1957 – Obwegeser – Intra-oral procedure www.indiandentalacademy.com
  229. 229. Chin modification - Genioplasty www.indiandentalacademy.com
  230. 230. Chin modification - Genioplasty www.indiandentalacademy.com
  231. 231. Chin silicone implant www.indiandentalacademy.com
  232. 232. Rhinoplasty www.indiandentalacademy.com
  233. 233. Alar cinch V-Y plasty www.indiandentalacademy.com
  234. 234. Facial soft tissue contouring www.indiandentalacademy.com
  235. 235. Lip procedures www.indiandentalacademy.com
  236. 236. Submental procedures: Soft tissue reduction www.indiandentalacademy.com
  237. 237. Fixation methods   Traditional fixation Rigid internal fixation  1992 Ellis et al. – compared rigid fixation to wire fixation methods   Predominance of indirect bone healing in wire fixation Primary healing from medullary bone in rigid fixation www.indiandentalacademy.com
  238. 238. Fixation methods Materials  Non-resorbable  SS Vitallium Titanium       Bioresorbable Polyglycolic acid L-polylactide Degraded by carbohydrate metabolism via kerbs cycle into CO2 and H2O www.indiandentalacademy.com
  239. 239. Rigid Internal Fixation  Rowe and Williams  www.indiandentalacademy.com Killeys
  240. 240. Rigid Internal Fixation      Maxilla 1.5mm and 2mm L shape T shape X shape     Mandible Lag screws Position screws Plates www.indiandentalacademy.com
  241. 241. Rigid Internal Fixation Complications/Disadvantages:  Instrumentation  Improper placement – malocclusion, TMJ pain  Infection  Plate exposure  Loose screws - necrosis  Palpable screws  Lingual plate fracture of the distal segment www.indiandentalacademy.com
  242. 242. Rehabilitation       Biologic response to surgery TMJ function and dentofacial deformities Perioperative considerations Neuromuscular rehabilitation Range-of-motion excerises Mandibular hypomobility www.indiandentalacademy.com
  243. 243. www.indiandentalacademy.com
  244. 244. Special Considerations    Functional outcomes following orthognathic surgery Soft tissue changes associated with orthognathic surgery Psychological ramifications of orthognathic surgery www.indiandentalacademy.com
  245. 245. Special Considerations  Functional outcomes following orthognathic surgery  Simple functional tasks     Maximal excursions Maximal bite forces Jaw muscle strength Analysis of mastication    Masticatory cycles Masticatory forces Masticatory performance www.indiandentalacademy.com
  246. 246. Special Considerations  Soft tissue changes associated with orthognathic surgery     Facial proportions Nasal structures Labial structures Techniques of soft tissue control         V-Y closure Alar cinch Combination of V-Y closure and alar cinch Contouring the ANS Septoplasty Double V-Y closure Chin Secondary revision of poor surgical results www.indiandentalacademy.com
  247. 247. Post Surgical Orthodontics  Upper arch     Lower arch   17x25” TMA in 0.18” slot 19x25” TMA in 0.22” slot 21x25” Nitinol in 0.22” slot 0.16” SS Elastics – 23hrs 55min – 5min for brushing www.indiandentalacademy.com
  248. 248. Post Surgical Complications www.indiandentalacademy.com
  249. 249. Post Surgical Complications www.indiandentalacademy.com
  250. 250. Post Surgical Complications    TMD Paraesthesia Decreased bite force www.indiandentalacademy.com
  251. 251. Relapse and Stability     Rigid fixation has improved stability Stability is mostly influenced by the pattern of rotation of the mandible as it is advanced Advancement of maxilla and/or mandible will stretch soft tissues promoting relapse The more advancement needed, the greater the probability for relapse www.indiandentalacademy.com
  252. 252. www.indiandentalacademy.com
  253. 253. www.indiandentalacademy.com
  254. 254. www.indiandentalacademy.com
  255. 255. Relapse and Stability www.indiandentalacademy.com
  256. 256.      Proffit. White. Sarver Proffit 3rd edition Arnett. McLaughlin Fonscea vol II Bell. Epker www.indiandentalacademy.com
  257. 257. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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