Surgery /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,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Surgery /certified fixed orthodontic courses by Indian dental academy

  1. 1. Diagnosis & treatment planning in orthognathic surgery INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com 1
  2. 2. Contents • • • • • • Introduction Indications Collection of records Diagnosis Treatment plan Different surgeries - maxilla - mandible www.indiandentalacadem y.com 2
  3. 3. Introduction www.indiandentalacadem y.com 3
  4. 4. Envelope of discrepancy 3 ranges of correction for any kind of malocclusion • Orthodontic tooth movement alone • Tooth movement plus functional or orthopedic treatment • Surgical orthodontics www.indiandentalacadem y.com 4
  5. 5. Envelope of discrepancy www.indiandentalacadem y.com 5
  6. 6. Indications A skeletal or dento-facial deformity is so severe that the magnitude of the problem lies outside the envelope of possible correction by orthodontics alone proffit www.indiandentalacadem y.com 6
  7. 7. Indications Severe dento-facial deformities www.indiandentalacadem y.com 7
  8. 8. Indications Syndromes www.indiandentalacadem y.com 8
  9. 9. Indications Cleft patients www.indiandentalacadem y.com 9
  10. 10. Indications Asymmetries www.indiandentalacadem y.com 10
  11. 11. Collection of records Interview data Clinical examination Data Data base Diagnostic records www.indiandentalacadem y.com 11
  12. 12. Collection of records Interview data • Patient’s chief complaint • Interview related to the patient’s social psychological status • Information related to the patient’s physical status www.indiandentalacadem y.com 12
  13. 13. Collection of records Patient’s chief complaint 2 groups 1. who are concerned about their appearance, oral function 2. Older patients concerned about some specific health related problems www.indiandentalacadem y.com 13
  14. 14. Collection of records Social psychological status An extension of chief complaint • Motivation • Expectation personality exceptional Personality inadequate no problem pathologic personality www.indiandentalacadem y.com 14
  15. 15. Psychological considerations in orthognathic surgery “The area around mouth is both emotionally charged and strongly connected with one’s self image” - MACGREGOR The face is the area of one’s body that produces the greatest concern regarding physical attraction A survey of over 100 adults ( Berschied et al ) - The people who are satisfied with their facial features expressed greater self confidence www.indiandentalacadem y.com 15
  16. 16. Psychological considerations in orthognathic surgery Dento- facial defects are extremely prominent Study done by Richardson (a normal child, a child with crutches and a brace on the legs, 1 child with hand missing, a child in a wheel chair, a child with a facial deformity and an obese child) It is impossible and foolish to treat the patient’s physical condition without adequate understanding and regard for the emotional frame work www.indiandentalacadem y.com 16
  17. 17. Psychological considerations in orthognathic surgery CONCEPT OF BODY IMAGE ( Individual’s self concept ) 2 COMPONENTS • BODY SENSE – The actual appearance the person sees when viewing himself in a mirror / photograph - SCHILDER & SCHONFELD • BODY CONCEPT - The internal process of how the patient feels about his appearance www.indiandentalacadem y.com 17
  18. 18. Psychological considerations in orthognathic surgery • Internal motivation – originating within the patient • External motivation - a desire to overcome others The patient motivated by external pressures were very poor candidates compared to the patients responding to internal pressures - EDGERTON & KNOOR www.indiandentalacadem y.com 18
  19. 19. Psychological considerations in orthognathic surgery Structured interview technique Prevent some of the pitfalls of cosmetic surgery that result in postoperative dissatisfaction Post operative dissatisfaction is usually as a result of lack of understanding between the patient and surgeon www.indiandentalacadem y.com 19
  20. 20. Psychological considerations in orthognathic surgery Structured interview technique 1. How does the patient perceive the deformity ? 2. How does the deformity affect the patient’s personality ? 3. Why did the patient decide to have the problem corrected ? 4. What does patient expect from surgery ? 5. Has the patientwww.indiandentalacadem ? had previous surgery y.com 20
  21. 21. Psychological considerations in orthognathic surgery • Positive reactors / group I • Neutral reactors / group II • Negative reactors / group III www.indiandentalacadem y.com 21
  22. 22. Psychological considerations in orthognathic surgery Is the deformity developmental or acquired ? • Greater emotional stability is seen in patients with congenital deformity • No concept of NORMAL • Patients with an acquired deformity will have a distorted image of their former appearance • Clinician should be frank about the possibilities of treatment Age • Adolescents would be expected to have fewer www.indiandentalacadem postoperative emotional problems y.com 22
  23. 23. Psychological considerations in orthognathic surgery Supportive measures • Explaining the surgical goal - Show the pictures of other patients - encourage the patient - limitations & risks must be explained - should not promise • Anticipating post operative depression • Seeking psychiatric consultation www.indiandentalacadem y.com 23
  24. 24. Collection of records Physical status • • • • Medical history Dental history Family history Evaluation of the physical growth status chronic conditions are of great concern www.indiandentalacadem y.com 24
  25. 25. Medical history www.indiandentalacadem y.com 25
  26. 26. Family history • Hapsburg jaw www.indiandentalacadem y.com 26
  27. 27. Collection of records Clinical examination data To determine what diagnostic records are required 1. Health of the hard and soft tissues 2. Oral function including TMJ 3. Facial proportions and esthetics www.indiandentalacadem y.com 27
  28. 28. Collection of records Health of the hard and soft tissues • • • • OPG – overall dentition Bitewing – inter-proximal caries Occlusal - palate & impacted teeth Midline IOPAs ex; diastema www.indiandentalacadem y.com 28
  29. 29. Collection of records Periodontal health • • • • Bleeding on probing Periodontal breakdown Pockets Adequacy of attached gingiva www.indiandentalacadem y.com 29
  30. 30. Collection of records Oral function • • • • Speech - lisping Mastication Cheek & lip biting TMJ problems - symptoms - muscle examination - Range of motion www.indiandentalacadem y.com 30
  31. 31. Collection of records TMJ radiographs 1. Trans-cranial radiographs – lataeral 1/3 of the condyle 2. Tomographs / laminographs - multiple views 3. Computed tomography - anteroposterior and lateral views 4. Arthrography - disk morphology & position 5. Magnetic resonance images ( MRI ) - precise method - hard & soft tissues www.indiandentalacadem y.com 31
  32. 32. CT scan of right TMJ www.indiandentalacadem y.com 32
  33. 33. PHOTOGRAPHS FACIAL • Frontal with relaxed lip position • Frontal with smile • Three quarter view • Profile view • Submental view INTRAORAL frontal • Teeth on occlusion right lateral left lateral upper • Occlusal views lower www.indiandentalacadem y.com 33
  34. 34. Photographs Submental views www.indiandentalacadem y.com 34
  35. 35. proportions Facial & esthetics www.indiandentalacadem y.com 35
  36. 36. Facial keys to orthodontic diagnosis and treatment planning: PART 1 - W. Arnett, T. Bergman AJODO 1993 April • Head orientation - Natural Head position • Condyle position - Centric Relation • Lip posture - Ralaxed Lip Posture www.indiandentalacadem y.com 36
  37. 37. NATURAL HEAD POSITION • Orientation of the head assumed naturally • 2 degree standard deviation www.indiandentalacadem y.com 37
  38. 38. CENTRIC RELATION To produce precise function Upper most position - DAWSON www.indiandentalacadem y.com 38
  39. 39. CENTRIC RELATION • TOMOGRAPHY • BASE PLATE WAX METHOD - Double thickness - guided closure - first tooth contact www.indiandentalacadem y.com 39
  40. 40. RELAXED LIP POSITION • CASUAL OBSERVATION www.indiandentalacadem y.com 40
  41. 41. Facial keys to orthodontic diagnosis and treatment planning: PART 2 - W. Arnett, T. Bergman AJODO 1993 MAY I. Frontal view a.. Relaxed lip b. Functional analysis 1. Closed lip 2. Smile II. Profile a. Relaxed lip www.indiandentalacadem y.com 41
  42. 42. Frontal view Outline form & symmetry Height : width • Females – 1.3 : 1 • Males - 1.35 : 1 Asymmetry Common sites – chin, gonial angles, & cheek bones www.indiandentalacadem y.com 42
  43. 43. Facial level • • • • Pupil plane Upper dental arch Lower dental arch Chin- jaw line constructed frontal horizontal reference line www.indiandentalacadem y.com 43
  44. 44. Midline arrangements Uppermost condyle position and first tooth contact Soft tissue landmarks • Nasal bridge • Nasal tip • Philtrum • Chin point Dental land marks • Upper incisor midline • Lower incisor midline www.indiandentalacadem y.com 44
  45. 45. Frontal vertical facial relations Facial one thirds www.indiandentalacadem y.com 45
  46. 46. Long face problems Vertical maxillary excess www.indiandentalacadem y.com 46
  47. 47. Long face problems Increased chin height www.indiandentalacadem y.com 47
  48. 48. Short face problems Short vertical chin height www.indiandentalacadem y.com 48
  49. 49. Lower one third evaluation Relaxed position Upper lip : lower lip = 1:2 Upper lip 19 – 22mm Short upper lip ( 18mm or less ) • Increased interlabial gap • Incisor exposure Lower lip 38 – 44mm • Anatomic short lower lip – class II malocclusions • Secondary to posture www.indiandentalacadem y.com • Anatomic long lower lip – class III malocclusions 49
  50. 50. Lower one third evaluation Upper tooth to lip relation Normal range is 1-5mm women show more within this range Disharmony is due to 1. 2. 3. 4. Upper lip length Lower lip length Thickness of the lips The angle of the view www.indiandentalacadem y.com 50
  51. 51. Incisor to lip relations Interlabial gap Lip incompetence • Short philtrum/anatomic short upper lip • Vertical maxillary excess • Excessive overjet – upper lip blocks the lower lip www.indiandentalacadem y.com 51
  52. 52. Lower one third evaluation Closed lip position Mentalis contraction, lip strain, alar base narrowing www.indiandentalacadem y.com 52
  53. 53. Smile position with lip level • 2mm of gingival exposure • If the patient has normal crown exposure at repose and gummy smile maxilla should not be impacted • The gingival smile is never treated to ideal at the expense of underexposing the incisors in the relaxed lip position www.indiandentalacadem y.com 53
  54. 54. Incisor to lip relations Anesthetic reverse resting maxillary lip line www.indiandentalacadem y.com 54
  55. 55. Incisor to lip relations Commissure height A line connected from the alar bases through subspinale is perpendicular to the commissural Line Drooping of commissures - ageing, facial jowling www.indiandentalacadem y.com 55
  56. 56. Incisor to lip relations Maxillary lip to upper incisor at rest Age differentials Excess incisor show at rest • • • • Short upper lip Vertical maxillary excess Excessive crown height Detorqued max. incisors www.indiandentalacadem y.com 56
  57. 57. Incisor to lip relations Inadequate incisor show at rest • • • • Excessive upper lip height Vertical max. deficiency Inadequate crown height Flared maxillary incisors Dental characteristic of ageing is to show less upper incisor exposure and more lower incisor exposure www.indiandentalacadem y.com 57
  58. 58. Inadequate incisor show in growing patient www.indiandentalacadem y.com 58
  59. 59. Incisor to lip relations Gingival display on smile Gummy smile • • • • • Short philtrum Vertical max. excess Excessive curtain on smile Gingival hyperplasia Upright max.incisors www.indiandentalacadem y.com 59
  60. 60. Incisor to lip relations Crown length Vertical height of max. central incisors Adults Children - 9-12mm (males ) 9.5mm (females ) 4.5 mm www.indiandentalacadem y.com 60
  61. 61. Incisor to lip relations Lip incompetence in children www.indiandentalacadem y.com 61
  62. 62. Incisor to lip relations Periodontal contribution in adolescents - kokich Gingival margin is 1mm coronal to the Cemento-enamel junction www.indiandentalacadem y.com 62
  63. 63. Incisor to lip relations Excessive smile curtain www.indiandentalacadem y.com 63
  64. 64. Incisor to lip relations “Smile arc” Consonant smile arc Nonconsonent smile arc www.indiandentalacadem y.com 64
  65. 65. Incisor to lip relations Flattening of the smile due to attrition of incisors www.indiandentalacadem y.com 65
  66. 66. Incisor to lip relations Inadequate incisor show on smile • Long philtrum height • Vertical max. deficiancy • Inadequate smile curtain • Flared max. incisors • Diminished dento alveolar development Secondary to thumb sucking habit www.indiandentalacadem y.com 66
  67. 67. Incisor to lip relations Diminished lip mobility due to low frenal attachment www.indiandentalacadem y.com 67
  68. 68. Incisor to lip relations Assessment of “negative space” www.indiandentalacadem y.com 68
  69. 69. Profile examination www.indiandentalacadem y.com 69
  70. 70. Soft tissue Profile angle General harmony of the forehead, mid face, and lower face Class I occlusion – 1650 to 1750 Extremes of the angle are usually due to skeletal disharmony www.indiandentalacadem y.com 70
  71. 71. Lower face analysis on profile view www.indiandentalacadem y.com 71
  72. 72. Profile view Nasolabial angle • Range is 850 – 1050 ( 1000) • Females show more obtuse angle • Indicate the position of the maxillary teeth and the contour of the lower border of the nose www.indiandentalacadem y.com 72
  73. 73. Nasolabial angle www.indiandentalacadem y.com 73
  74. 74. Profile view Factors to be considered in treatment plan • • • • • • Existing angle Estimation of the lip tension Antero-posterior lip thickness Magnitude of the mandibular retrusion Extraction versus non-extraction Surgical movement of the maxilla Maxillary setback – nasal elongation, alar base depression, opening of the nasolabial angle ( premature ageing ) www.indiandentalacadem y.com 74
  75. 75. Profile view Maxillary sulcus contour • Gently curved • upper lip tension www.indiandentalacadem y.com 75
  76. 76. Profile view Mandibular sulcus contour Deeply curved - class II, vertical maxillary deficiancy www.indiandentalacadem y.com 76
  77. 77. Profile view Orbital rim • Anteroro-posterior indicator of Maxillary position • The globe is positioned 2-4mm anterior to the orbital rim www.indiandentalacadem y.com 77
  78. 78. Cheek bone contour Deficient in combination with maxillary retrusion www.indiandentalacadem y.com 78
  79. 79. Profile view Nasal base lip contour Mand. Protrusion Max.Retrusion www.indiandentalacadem y.com 79
  80. 80. Nasal & paranasal relations www.indiandentalacadem y.com 80
  81. 81. Profile view Nasal projection Subnasale to nasal tip Normal is 16-20mm Important in contemplating anterior movement of the maxilla www.indiandentalacadem y.com 81
  82. 82. Profile view Throat length & contour Neck throat junction soft tissue menton Mandibular setback is contraindicated in case of a short, sagging neck www.indiandentalacadem y.com 82
  83. 83. Lower face analysis on profile view Chin neck angle www.indiandentalacadem y.com 83
  84. 84. Lower face analysis on profile view Labiomental sulcus www.indiandentalacadem y.com 84
  85. 85. Profile view Subnasale –pogonion line - Burstone Upper lip – 3.5+/- 1.4mm Lower lip - 2.2+/- 1.6mm www.indiandentalacadem y.com 85
  86. 86. Transverse facial & dental proportions Rule of fifths Middle fifth of the face www.indiandentalacadem y.com 86
  87. 87. Transverse facial & dental proportions The middle fifth of the face The distance between 2 inner canthi of the eye www.indiandentalacadem y.com 87
  88. 88. Transverse facial & dental proportions The medial fifths of the face A line from outer canthus of the eyes should be coincident with the gonial angles of the mandible www.indiandentalacadem y.com 88
  89. 89. www.indiandentalacadem y.com 89
  90. 90. Transverse facial & dental proportions The outer fifth of the face outer canthus of the eye to the helix of the ear www.indiandentalacadem y.com 90
  91. 91. www.indiandentalacadem y.com 91
  92. 92. Transverse facial & dental proportions Transverse nasal proportions 3 major categories of nasal features - Forman & Bell 1. Leptorrhine 2. Mesorrhine 3. Platyrrhine www.indiandentalacadem y.com 92
  93. 93. Transverse facial & dental proportions Leptorrhine – Long narrow nose ( whites ) www.indiandentalacadem y.com 93
  94. 94. Transverse facial & dental proportions Mesorrhine – lack of columellar support & dorsal height ( Asians ) www.indiandentalacadem y.com 94
  95. 95. Transverse facial & dental proportions Platyrrhine – Broad, flat nose ( blacks ) www.indiandentalacadem y.com 95
  96. 96. Asymmetry – facial and dental Etiologies • • • • • • Congenital malformations Environmental factors Functional Tumours of hard & soft tissues Condylar pathology Masseteric hypertrophy www.indiandentalacadem y.com 96
  97. 97. Systematic evaluation of dental & facial asymmetry • Nasal tip to midsagittal plane • Maxillary dental midline to midsagittal plane • Max.dental midline to mand.dental midline • Mand. Dental midline to midsymphysis • Midsymphysis to mid sagittal plane www.indiandentalacadem y.com 97
  98. 98. Systematic evaluation of dental & facial asymmetry Nasal tip to midsagittal plane The position of the nasal tip is best evaluated by having the patient elevate the head slightly and visualizing the position of the tip to the midsagittal plane Maxillary dental midline to midsagital plane Deviations of the maxillary dental midline from the midsagittal plane www.indiandentalacadem y.com 98
  99. 99. Maxillary dental midline to mid sagittal plane • Dental midline discrepancy • Max. rotation www.indiandentalacadem y.com 99
  100. 100. A METHOD TO CHECK MAXILLOMANDIBULER ASYMMETRY www.indiandentalacadem y.com 100
  101. 101. Maxillary dental midline to mandibular dental midline Midsymphysis to midsagittal plane • True mandibular asymmetry • Functional shift & mandibular asymmetry Lateral shift is not indicative of true mandibular asymmetry but the transverse maxillary deficiency www.indiandentalacadem y.com 101
  102. 102. Maxillo- madibular asymmetry Transverse cant of the maxilla – canine show www.indiandentalacadem y.com 102
  103. 103. mandibular asymmetry alone www.indiandentalacadem y.com 103
  104. 104. Chin asymmetry Measurement of the midsymphysis to the midsagittal plane www.indiandentalacadem y.com 104
  105. 105. Radiographic analysis www.indiandentalacadem y.com 105
  106. 106. Radiographic analysis • Hand wrist radiographs • Lateral cephalograms • Postero- anterior / frontal cephalograms • TMJ radiographs www.indiandentalacadem y.com 106
  107. 107. Analysis of hand wrist radiograph • To estimate the patient’s skeletal age • poor correlation with jaw growth www.indiandentalacadem y.com 107
  108. 108. Radiographic analysis Lateral cephalograms • Relationship of the jaws to the cranium • Relationship of the both the jaws • Relationship of the teeth to the jaw bases www.indiandentalacadem y.com 108
  109. 109. Radiographic analysis Postero-anterior films Vertical lines – transverse asymmetries Horizontal planes - vertical position of structures Different analyses • Rickett’s analysis • Grummons analysis • Grayson’s analysis • Hewittt’ analysis • Chierici’ method www.indiandentalacadem y.com 109
  110. 110. Cast analysis Occlusal view • • • • Symmetry Crowding Malalignment Undercuts www.indiandentalacadem y.com 110
  111. 111. Cast analysis Casts in occlusion • Antero-posterior • Vertical • Transverse Class I canine relation www.indiandentalacadem y.com 111
  112. 112. Special considerations • Surgical possibilities • Logical sequence in planning surgical orthodontic treatment • Techniques of prediction www.indiandentalacadem y.com 112
  113. 113. Treatment planning Surgical possibilities – transverse plane changes in the width of the maxilla I0 mm of average changes www.indiandentalacadem y.com 113
  114. 114. Surgically assisted orthopedic expansion • RME screw should be placed immeadiately after osteotomy to enhance the orthopedic force • Osteotomy through the lateral maxilla, including the separation at pterigomaxillary region www.indiandentalacadem y.com 114
  115. 115. Mandible 2 major limitations 1. Soft tissue envelope 2. Temporo-mandibular joint www.indiandentalacadem y.com 115
  116. 116. Antero-posterior & vertical changes of the maxilla Forward movement – 10mm Upward movement – 10 to 15mm www.indiandentalacadem y.com 116
  117. 117. Limitations of forward Movement 1.Upper lip 2.Velopharyngeal Closure Upward movement www.indiandentalacadem y.com 117
  118. 118. Backward movement • Very limited movement ( 3-5mm ) Downward movement • Technically possible but anatomically less stable • Interpositional bone grafts provide mechanical stability • Stretch of the soft tissues www.indiandentalacadem y.com 118
  119. 119. Mandible • Any movements but not downward movements at Gonial region • Mandibular plane changes • Soft tissue stretch • Condylar position in the fossa www.indiandentalacadem y.com 119
  120. 120. Implications of incomplete growth • Growth following surgery • Need for second surgery • Early surgery is contraindicated for excess growth www.indiandentalacadem y.com 120
  121. 121. Logical sequence of treatment planning • Pathologic versus developmental problems • Pathologic - chronic systemic diseases - local conditions - psychologic conditions www.indiandentalacadem y.com 121
  122. 122. • Prioritizing the developmental problem list • Orthodontic risks • Surgical risks - Predictable sequelae - Unanticipated complications - Catastrophic events www.indiandentalacadem y.com 122
  123. 123. CEPHALOMETRIC PREDICTION Manual prediction • Tracing overlay method • Moving templates Computer prediction www.indiandentalacadem y.com 123
  124. 124. Tracing overlay method • Simplest way to simulate the effects of the mandibular surgery • Limited to surgery that does not affect the vertical position of the maxilla www.indiandentalacadem y.com 124
  125. 125. Tracing overlay method www.indiandentalacadem y.com 125
  126. 126. Tracing overlay method www.indiandentalacadem y.com 126
  127. 127. Template method • Intermediate tracings • Used for any kind of prediction • Time consuming www.indiandentalacadem y.com 127
  128. 128. Template method www.indiandentalacadem y.com 128
  129. 129. Template method www.indiandentalacadem y.com 129
  130. 130. Computer prediction www.indiandentalacadem y.com 130
  131. 131. www.indiandentalacadem y.com 131
  132. 132. www.indiandentalacadem y.com 132
  133. 133. www.indiandentalacadem y.com 133
  134. 134. Advantages • Patient counseling • Comparison of diff. Treatment plan options • Less risk of post operative dissatisfaction Disadvantages • Dental relations are unknown • Distortions with some soft wares www.indiandentalacadem y.com 134
  135. 135. Surgeries of mandible www.indiandentalacadem y.com 135
  136. 136. Classification • Ramus osteotomies vertical subsigmoidal osteotomy sagittal split oteotomy inverted ‘L’ & ‘C’ osteotomies condylectomy • Osteotomies of the body of the mandible • Segmental procedures • Genioplasties www.indiandentalacadem y.com 136
  137. 137. Ramus osteotomies • To move the whole arch • Best for large movements • Both extraoral & intraoral approaches www.indiandentalacadem y.com 137
  138. 138. Ramus osteotomies Vertical subsigmoid osteotomy www.indiandentalacadem y.com 138
  139. 139. Ramus osteotomies Sagittal split osteotomy www.indiandentalacadem y.com 139
  140. 140. Ramus osteotomies Inverted ‘L’ osteotomy www.indiandentalacadem y.com 140
  141. 141. Ramus osteotomies ‘C’ osteotomy www.indiandentalacadem y.com 141
  142. 142. Ramus osteotomies Condylectomy www.indiandentalacadem y.com 142
  143. 143. Body osteotomies • In cases where satisfactory dental relations are to be established • Short bodies, Asymmetries, Open bite • Changes in arch width www.indiandentalacadem y.com 143
  144. 144. Segmental & symphyseal osteotomies Total subapical osteotomy www.indiandentalacadem y.com 144
  145. 145. Segmental osteotomies Anterior posterior www.indiandentalacadem y.com 145
  146. 146. Genioplasties www.indiandentalacadem y.com 146
  147. 147. Surgeries of maxilla www.indiandentalacadem y.com 147
  148. 148. Segmental surgery Single tooth osteotomies www.indiandentalacadem y.com 148
  149. 149. Anterior segmental osteotomies www.indiandentalacadem y.com 149
  150. 150. Corticotomy www.indiandentalacadem y.com 150
  151. 151. LeFort I osteotomy www.indiandentalacadem y.com 151
  152. 152. In open bite cases www.indiandentalacadem y.com 152
  153. 153. LeFort II osteotomy www.indiandentalacadem y.com 153
  154. 154. Diagnosis & Treatment planning www.indiandentalacadem y.com 154
  155. 155. CLASS II PROBLEMS www.indiandentalacadem y.com 155
  156. 156. Mandibular deficiency - Short face Extra-oral • • • • • Well developed chin button Low mandibular plane angle Square gonial angles Lack of prominence of lips Curled or elevated lower lip Intra-oral • • • • Class II molar & canine relation Increased overjet Anterior deep bite Excessive curve of spee www.indiandentalacadem y.com 156
  157. 157. Mandibular deficiencyTreatment planning • Preadolescents with growth potential - Bite opening - Functional jaw orthopedics - Eruption of the posterior teeth • Adolescents - Camouflage - Fixed functional appliance www.indiandentalacadem y.com 157
  158. 158. TREATMENT PLANNING FOR ADULTS • Camouflage • Surgery Short face – Subapical osteotomy - Ramus osteotomy www.indiandentalacadem y.com 158
  159. 159. TREATMENT PLANNING FOR ADULTS Mandibular vertical & antero-posterior deficiency www.indiandentalacadem y.com 159
  160. 160. TREATMENT PLANNING FOR ADULTS Chin prominence – Genioplasty with angulated osteotomy www.indiandentalacadem y.com 160
  161. 161. MANDIBULAR DEFICIENCY- LONG FACE Extra-oral • • • • Excessive ant.face height Lip incompetence Skeletal class II malocclusion Hypo-plastic upper lip Intra oral • • • • • • Class II malocclusion Crowding in the lower Over eruption of posterior teeth Tendency towards ant.open bite Narrow maxilla & posterior cross bite www.indiandentalacadem Tipping of palatal plane down posteriorly y.com 161
  162. 162. .Treatment planning – adults Decreasing the lower face height • Superior positioning of the maxilla ( LeFort I total / Segmental osteotomy ) • Mandibular surgery ( Ramus osteotomy ) • Superior repositioning of the chin ( Inferior border osteotomy ) www.indiandentalacadem y.com 162
  163. 163. www.indiandentalacadem y.com 163
  164. 164. www.indiandentalacadem y.com 164
  165. 165. CLASS III PROBLEMS www.indiandentalacadem y.com 165
  166. 166. Class III problems • More mand. Growth than normal • Growth continues after adolescence longer than Normal Heavy forces for longtime wear – Restrict maxillary growth Shorter periods of wear - Rotation the mandible down & back www.indiandentalacadem y.com 166
  167. 167. Class III problems Maxillary deficiency – Face mask therapy Age- 8 yrs or children Patients with transverse discrepancy - RME www.indiandentalacadem y.com 167
  168. 168. Class III problems Surgical camouflage - Reduction genioplasty • Increase the face height • Flassidity of soft tissue www.indiandentalacadem y.com 168
  169. 169. Class III problems Onlay grafts • Mid face deficiencies • Grafts in the paranasal, alar base and zygomatic areas www.indiandentalacadem y.com 169
  170. 170. Class III problems Maxillary versus maxillary surgery • Volume of the oral cavity • Unesthetic “Turkey gobbler” appearance Suction lipectomy www.indiandentalacadem y.com 170
  171. 171. Class III problems Timing of orthognathic surgery Excess mandibular growth Relapse tendencies Maxillary deficiency • Favorable maxillary growth • Prolonged mandibular growth www.indiandentalacadem y.com 171
  172. 172. Class III problems www.indiandentalacadem y.com 172
  173. 173. Class III problems- cleft patients Bone grafts Timing of the graft – before the eruption of the tooth • To establish bone continuity • Acts as a matrix www.indiandentalacadem y.com 173
  174. 174. Class III problems - cleft patients Comprehensive orthodontics Secondary esthetic procedures 1. Nose-lip revision 2. Pharyngeal surgery • Compensation from lat. Pharyngeal wall • Enlarged tonsils www.indiandentalacadem y.com 174
  175. 175. Class III problems - cleft patients Orthognathic surgery After conclusion of active growth Maxillary surgery • Lip scars • Palatal scar • Cleft palate speech www.indiandentalacadem y.com 175
  176. 176. Dento facial asymmetry www.indiandentalacadem y.com 176
  177. 177. Dento facial asymmetry In preadolescent children Growth modification with asymmetric functional appliances ( hybrid appliances ) www.indiandentalacadem y.com 177
  178. 178. Dento facial asymmetry In adolescents Avoid surgery until adolescent growth spurt ends Ankylosed condyle Release of condyle from glenoid fossa www.indiandentalacadem y.com 178
  179. 179. Dento facial asymmetry In adults Can not be managed orthodontically or orthopedically • Ramus osteotomy • Maxillary surgery / asymmetric onlay grafts • Inferior border osteotomy www.indiandentalacadem y.com 179
  180. 180. References • Surgical orthodontic treatment - R.P.WHITE & W.R.PROFFIT • Esthetic orthodontics & orthognathic surgery - DAVID.M.SARVER • Surgical correction of dentofacial deformities – W.H.BELL, W.R.WHITE & R.P.PROFFIT • Orthodontics ; current principles & techniques – T.M.GRABER & R.I.VANARSDALL.Jr • Dentofacial deformities ; integrated orthodontic & surgical correction – B.N.EPKER & L.C.FISH www.indiandentalacadem • Contemporary orthodontics y.com PROFFIT – W.R. 180
  181. 181. References • Contemporary treatment of dentofacial deformity - R.P.WHITE.W.R.PROFFIT & DAVID.M.SARVER • A text book of oral surgery - MOORE • Introduction to orthognathic surgery – color atlas - J.P.REYNEKE & W.G.EVANS • LEE HELDT & ERNEST A.HAFFKE –The psychological and social aspects of orthognathic surgery - AMJ.ORTHOD vol.82, 1992 • G.W.ARNETT & ROBERT.T.BERGMAN – Facial keys to orthodontic diagnosis ; Part I - AJODO April, 1993 • G.W.ARNETT & ROBERT.T.BERGMAN – Facial keys to www.indiandentalacadem orthodontic diagnosis ; Part II – AJODO MAY, 1993 y.com 181
  182. 182. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacadem y.com 182

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