Surgical orthodontics /certified fixed orthodontic courses by Indian dental academy


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Surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Contents: Introduction Historical aspect Envelop of discrepancy Recognition of deformity Systemic evaluation of patient Pre surgical orthodontics Cephalometric evaluation Prediction tracing Mock surgery Post surgical orthodontic management
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  4. 4. "Beauty lies in the eyes of beholder" . Margaret Hungerford. Physically attractive people are generally thought to be more Friendly, sensitive and successful than others considering the face. As a primary means of identification and a source of non-verbal information, the psychological and social implication of facial disfigurement should not be underestimated.
  5. 5. Before advent of surgical procedures to correct deficiencies of maxilla the only way the orthodontists could treat patients presenting with vertical maxillary excess was by dental camouflaging the skeletal problems.
  6. 6. The term orthognathic surgery was coined by Hullihen in 1849. David Sarver will deserve much of the credit for bringing about the computer simulations. Previously cephalometric predictions of treatment outcome were necessary, but nowadays, computer imaging changed the very focus of orthodontic and orthognathic treatment.
  7. 7. A) Origin of surgical procedures B) Pre/post surgical orthodontics
  8. 8. Of the current surgical techniques for repositioning the facial bones, many were pioneered in Europe to treat trauma and gunshot wounds during 1st and 2nd world war and to lesser extent in United States.
  9. 9. Rene Le Fort in 1901 noted that the midface consistently sustained fractures at sites of weakness . Edward Angle in 1901 Commented on the patient who had treatment of this type, described how the result could have been improved . Van Eiselberg and Pehr Gadd in 1906 , were the first to conceive the idea of surgically correcting a retruded mandible by means of a step shaped osteotomy in the body of mandible.
  10. 10. In 1907 Blair introduced the first ascending ramus technique . Limberg in 1928 modified Pehr Gadd's step shaped sliding osteotomy operation by inserting a pedunculated rib graft in surgically created bony defect.
  11. 11. Wassmund in 1935 introduced a technique for retruding the : anterior maxillary alveolus and six anterior teeth. Kazanjian in 1936 modified Blair's basic design by performing an oblique sliding osteotomy.
  12. 12. Dingman performed an osteotomy in two stages. First under local anesthesia and second under general anesthesia and found that non-union and parasthesia are common complications Caldwell in 1954 adapted his vertical osteotomy technique for correction of prognathism to the correction of micrognathism. Erich in1958 believed that retrognathism is best corrected by means of overlay prosthesis on the lower anterior teeth.
  13. 13. Trauner and Obwegeser introduced sagittal split osteotomy in 1959 and it marked the beginning of new era in orthognathic surgery. This technique used an intraoral approach, which avoided the necessity of potentially disfiguring skin incision. Kole in 1959 introduced corticotomy as a surgical adjunct to orthodontic therapy. Although the foundations for present day procedures were laid in Europe, the development and refinement of orthognathic surgery occurred in United States.
  14. 14. PRE AND POST SURGICAL HISTORICAL ASPECT: William Bell in 1966 discussed different methods of orthodontic surgical correction of mandibular retrognathism. Peter B. Mills in 1969 discussed the role of orthodontists in surgical correction of dentofacial deformities.
  15. 15. Bell, Thomas and Creekmore in 1973 stated that the goal of surgical orthodontic treatment of mandibular prognathism is to correct the malocclusion of the teeth and restore facial balance and harmony. Epker and Fish in 1978 stated that pre-surgical orthodontics should be directed towards removing the existing dental compensations.
  16. 16. Dale B. Wade in1980 used modules for intermaxillary fixation. It was developed to help the orthodontists prepare his patient for surgery and provide the surgeon with the stable fixation need for proper healing.
  17. 17. Legan, Hill and Sinn in 1981 discussed role of orthodontist in diagnosis and treatment planning in dentofacial deformity cases. He suggested that the pre-surgical orthodontic treatment carried out for them included leveling of mandibular mandibular rotations occlusal anterior and plane, teeth, angulation coordination of arches. upright correct problems the minor and
  18. 18. Joe Jacobs in 1983 stated the principles of orthodontic mechanics in orthognathic surgery. Flanary, Barnwell and Alexander in 1985 investigated the pre-surgical concerns and motivations, preoperative preparation for surgery and perception of post surgical outcome.
  19. 19. Fish and Epkar in 1987 discussed the prevention of relapse after maxillary advancement. Suggested that Post surgical orthodontics include, prevention of relapse during inter-maxillary fixation where surgical occlusal splint with bilateral infra-orbital suspension wires attached.
  20. 20. ENVELOPE OF DISCREPANCY The limits of correcting a malocclusion vary both by the tooth movement that would be needed and by the patient's age as quoted by William R. proffit.
  21. 21. There are 3 possibilities of treatment; Tooth movement by orthodontic treatment. Tooth movement by orthodontic combined with growth modifications. By orthognathic surgery. treatment
  22. 22. The first envelope shows the amount of change that could produced by orthodontic tooth movement alone. Second envelope of discrepancy indicates the changes in the teeth movement can be achieved orthodontically along with growth modification. Third envelope shows, the changes can be achieved by orthognathic surgery.
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  26. 26. According to V. Mani (1995) the deformities are classified as;  Maxillary prognathism - Skeletal Dentoalveolar ]sMaxillary retrognathism- Skeletal Dentoalveolar
  27. 27. Maxillary vertical deformity-Excess Deficient Maxillary transverse deformity-Broad Narrow  Mandibular prognathism- Skeletal Dentoalveolar
  28. 28. ChinExcessive-Vertical, Horizontal Recessive-Horizontal Vertical Deep bite deformity
  29. 29. Open bite deformity or Apartognathia   Asymmetry
  30. 30. Maxillary deformity:   Epkar and Fish: Quoted that the deformities of maxilla are of several types. The deformities are either in the basal bone or in dentoalveolar segment. The most common deformity encountered can be horizontal, vertical or combined. The deformity can be associated with deep bite or open bite.
  31. 31. Schendel S.A. Quoted that in vertical excess, the exposure of the upper anterior teeth is more than 3 mm in response 2) the upper lip may be short or normal 3) the length of lower third of face is more than the middle third of face. Open bite can also occur as a result of deformity in anterior or posterior region
  32. 32. Mandibular deformity: Mandibular deformity can be present anywhere from the condyle to chin. Ankylosis of TMJ jeopardize the mandibular growth. Unilateral ankylosis causes hemi facial deformity with the midline shifted to the affected side. Mandibular prognathism is mainly due to horizontal excess. Of the body of the mandible as quoted by Opdebeeck H and Bell W.H.
  33. 33. Chin deformity: The chin can be either recessive or excessive, vertically or measurements are as follows  1) Facial axis  2) Facial depth angle horizontally The
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  35. 35. Epkar and Fish Quoted that certain examinations are necessary to evaluate the individual with dentofacial deformities and to plan treatment. These are; A) General patient evaluation: 1) Medical history 2) Dental evaluation a. Dental history b. Dental health B) Social psycologic evaluation
  36. 36. C) Esthetic facial evaluation 1. Front face analysis 2. Profile analysis D) Cephalometric evaluation 1) Soft tissue 2)Skeletal 3) Dental
  37. 37. E) Panoramic evaluation or full mouth F) Occlusal evaluation 1.     Functional 2.     Static G) Masticatory and TMJ evaluation    Masticatory muscles Mandibular movements TMJ symptoms TMJ signs periapical
  38. 38. Esthetic facial evaluation (front face): The esthetic facial evaluation is done directly on patient, with the patient standing or seated comfortably. The patient maintains head posture with the Frankfort horizontal and interpupillary lines parallel to the floor.
  39. 39. FRONT FACE ANALYSIS:  General facial characteristics:  David Sarver (1998) quoted that symmetry, balance and morphology are important in production of good front face esthetics. A) Symmetry: No face is perfectly symmetric. The absence of obvious asymmetry is necessary for good esthetics.
  40. 40. Balance: The total face height is defined by the distance from points trichion (Tr) to gnathion (Gn) and divided into facial thirds by points glabella (G) and Gnathion(Gn) . The upper, middle and lower facial thirds may be defined as the distance from trichion to glabella, glabella to Subnasal and Sub nasal to gnathion respectively. In normal attractive person the ratio of these thirds is 0.30, 0.35 and 0.35 respectively.
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  44. 44. Morphology : The morphology of any face is determined by the distance between the points fronto-temporale (Ft) - the slight elevation of the linear temporalis on either side of forehead. The width of middle third of face is defined by the distance between the points zygion (Zy) - the most lateral point of zygomatic arch. The distance between gonion (Go) bilaterally determines the width of the lower third of face.
  45. 45. Upper Third Face: Hairline to eyebrows (Tr-G) It is affected by the hairline and hair style. Morphology : It is quantified by calculating the ratio of bitemporal width'(Ft-Ft) to the height of the upper third face (Tr-G) the ratio in an attractive individual is 2.20.
  46. 46. MIDDLE THIRD FACE: Morphology is quantified by calculating the ratio of bi-zygomatic width (ZyZy) to the height of the middle third face (G-Sn). The ratio in attractive individual is 2.20. Eyes and orbits: Examination begins with measurement of intercanthal and interpupillary distances. Vertical symmetry of inner and outer canthi is recorded.
  47. 47. NOSE: When deformity exists, then glabella, dorsum tip and alar bases are noted. CHEEK: includes sequential assessment of the malar eminence, infraorbital rims and paranasal areas for symmetry. EARS : The ears are observed for symmetry level and projection.
  48. 48. Lower Third Face: Subnasal to menton: Morphology is quantified by calculating the ratio of bigonial width (Go-Go) to the height of the lower facial third(Sn-Gn). Normal ratio is1.3. LIPS: Lips are important in overall esthetics of face. At rest, the symmetry of lips relative to the face and dentition is noted. TEETH : Symmetry is single most important factor in producing an esthetic smile. It includes the symmetry of both lip movement and tooth exposure.
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  50. 50. CHIN : Often the chin may be more tapered or square. Chin is evaluated for symmetry, vertical relations and morphology and its relationship to the mandibular angles and inferior border of mandible. Sub Mental and Neck Area:This is examined by having the examiners and patients head at the same level looking directly into one another's eyes and check for any asymmetry.
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  54. 54.  PROFILE ANALYSIS: Overall facial profile is evaluated in sagittal and vertical planes. It is carried out in upper middle and lower third of face. 1)     Upper third face: The projection of supraorbital rims is evaluated as they relate to globe. They project 5-10 mm beyond the most anterior projection of globe. Distinction is made between frontal bossing and supra-orbital hypoplasia. The glabellar angle is evaluated. This angle is formed by the intersection of the lines glabella nasion and nasion - pronasale. Normal angle is 132 +- 5deg.This angle is judged as excessive, normal or deficient.
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  56. 56. Middle third face: Eyes: The lateral orbital rim normally lies 8 to 12 mm behind the most anterior projection of the globe while infra-orbital rim is normally 0 to 2 mm anterior to globe. NOSE: The nasal bridge projects 5-8 mm anteriorly to the globes. The nasal dorsum is described as normal, convex and concave in appearance. Differentiation is made between the dorsal hump and down turned nasal tip. Nasolabial angle is assessed.Normal 90-110°.
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  60. 60. Lower third of face:  Lips: The protrusion or retrusion of the upper lip is described as it relates to subnasal perpendicular an imaginary line through subnasal and perpendicular to Frankfort horizontal. The most prominent portion of the vermilion of the upper lip should lie not more than 2 mm ahead or behind the subnasale perpendicular. Normally upper lip projects slightly (2 mm) anterior to the lower lip.
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  62. 62. CHIN PROJECTION: It relates to the nose and subnasal perpendicular in the middle third face and lips in the lower third face. It should lie 2 - 6 mm behind an imaginary subnasale perpendicular line assuming normal nasal and maxillary prominence. Submental and neck area: It is subdivided into; Mandibular angle  Neck chin angle  Neck chin length.
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  64. 64. PRE SURGICAL ORTHODONTICS  INTRA ARCH OBJECTIVES  In the initial stages of treatment, orthognathic and conventional orthodontic mechanics have some similar objectives, like to position the teeth ideally relative to their apical bases through establishment of correct torque, proper elimination of rotations, flatness of the plane of occlusion and eliminating tooth- arch length discrepancies.
  65. 65. NOTE Here that these procedures may temporarily accentuate the malocclusion, where demonstrating the true magnitude of the Skeletal problem.
  66. 66. Intra-arch mechanics in orthognathic cases should be designed to achieve the ultimately desired post surgical interdigitation and allow for establishment of class I canine and molar relationship after surgical treatment. If extractions are necessary to accomplish the desired objectives, then extraction sites should be closed unless segmentalizcd surgical closure is planned. Even procedures like interdental enamel reduction must be concluded prior to surgery.
  67. 67. SKELETAL CLASS compensations mandibular II include incisor and cases, very upright dental protrusive maxillary incisor. SKELETAL CLASS III. Mandibular incisors are often found to be retroclined while maxillary incisors are commonly flared forwards.
  68. 68. A patient with a class III skeletal malocclusion may have dental compensations including retroclined mandibular incisors and proclined maxillary incisors. In class II, division 2,malocclusion with a typical retroclination of maxillary anterior teeth . Likewise a patient with these malalignment will respond to class II elastics for class III patients class III elastics for class II patients before surgery.
  69. 69. SEQUENCING OF ORTHODONTIC MECHANICS PRIOR TO SURGERY: 1) Orthognathic surgery should not be performed until the adolescent growth spurt is completed . 2) Surgical correction of maxillary and mandibular deficiency and correction of vertical maxillary excess can be carried out with a good prognosis in most patients who are in their midteens.
  70. 70. 3) However the initiation of orthodontic treatment often helps patients tolerate dentofacial deformity during their teen years even if surgery is some time in the future. The orthodontic appliance serves as a visible symbol that the dentofacial correction is being treated.
  71. 71. WHY EDGEWISE IS A CHOSEN APPLIANCE FOR SURGICAL ORTHODONTICS ?? Fixed appliance used to stabilize the teeth and the bone, at the time of surgery and during healing. Therefore, the appliance system must permit use of rectangular wire so as to achieve adequate strength and stability.
  72. 72. Extraction pattern:  Camouflage: Extraction spaces are used for dental compensations. For example - Mandibular deficiency with class II malocclusion 1)    Extract upper 1 st premolar. 2)     Avoid extraction in the lower arch. If surgery of mandibular advancement is planned for above patients 1)   Extractions in the lower arch. Only leveling and aligning in upper arch and if necessary II premolars.
  73. 73. In classIII CAMOUFLAGE: Extractions of lower 1st premolar , Upper if required the 2nd premolar SURGERY: Extractions of upper 1 st premolar necessary 2nd premolar in lower arch. and If
  74. 74. SEQUENCING OF OTHER DENTAL TREATMENT:  Dental and periodontal disease correction must be considered prior to orthodontic surgical correction has begun.
  75. 75. THREE MAIN CONSIDERATIONS:      Gingival grafting should be completed before surgery, if attached gingiva is inadequate.     Removal of 3rd molars is desirable if the surgeon anticipates using bone screws or rigid fixation. Patient with temperomandibular joint dysfunction should be made aware that TMJ problem might recur even after the surgical treatment.
  76. 76. Steps in orthodontic preparation: 1) Leveling of the maxillary and mandibular arch.  2) Establishment of incisor position.
  77. 77. STABILIZING ARCH WIRES: As presurgical phase is over, doing a model surgery is a must to check for occlusal compatibility. 2nd molars banded to increase fixation stability. Stabilizing arch wires is placed 6 weeks before surgery so that they are passive when impression is taken for surgical splint.
  78. 78. STABILIZING WIRES ARE; 1) 17 x 25 steel in 18-slot appliance. 2) 19 x 25 steel or TMA in 22-slot appliance. Full slot withstands the forces resulting from intermaxillary fixation.
  79. 79. BEFORE EVERY SURGICAL PROCEDURE: 1) Mark on the chart that he/she is a surgical patient. 2) VTO clearly illustrated on the chart determining. a) Presurgical goals (anterior retraction, extraction pattern etc.) b) Anchorage requirements.  3. Step by step chart written for reference
  80. 80. RIGID FIXATION   In this the jaw movement post surgically is in the anterior direction.    Splint causes retraction of upper anterior teeth and flaring of the lower incisor. Overcorrection is desired orthodontics. in presurgical
  81. 81. CLASSII DIVISION 1 NORMAL OVERBITE:  DEFORMITY WITH Outline of treatment:  Presurgical  1. Consider extraction usually with 15, 25, 34 and 44. 2. Place lower appliances, utility arch and begin lower canine retraction. 3. Place upper appliances, align and level, begin upper Molar advancement.
  82. 82. 4. Placement of class III elastics as necessary 5. Finish lower canine retraction. 6. Retract lower incisors. 7. Upper space closure. 8. Coordinate arches. 9. Impression to determine feasibility of surgery.
  83. 83. DETAILS OF TREATMENT: 1)     Mark on the chart in a very conspicuous manner that he/she is indicated for surgery. 2)     VTO are clearly illustrated on the chart, which is determined through the prediction tracing, which notes the presurgical goals and anchorage requirements. 3)     Finally a step-by-step plan is written on the chart for reference. This is common for all presurgical cases. Here the main goal is to place the teeth in their normal relation to their respective basal bones.
  84. 84. Our main objective in this case is to remove dental Compensations to the existing skeletal deformity that is 1) Up righting lower incisors. 2) Advancing upper molars Thus increasing the severity of class II occlusion. Note: 1)   Magnitude of class II should be same on either side. 2)   Dental midline should coincide with midline of face to avoid the production of an asymmetric chin when mandible is advanced. 3)   Consider extractions if necessary.
  85. 85. Leveling, aligning and arch coordination are done before surgery by standard approaches    Generally class II division 1 patient require extraction usually 15,25 and 34,44 so that we can get the maxillary molars in to more class II and mandibular incisor can be retracted to get them upright.    Discussing the case the lower arch is strapped up first after adequate separation
  86. 86.    Stabilizing utility = 16 x 16 arch wire with a labial root torque for incisors but without molar tip back used for Incisor intrusion.       Elastic thread may be useful for correction of rotations or in beginning the actual retraction of canine teeth.   Now the appliance is placed in the upper arch.   Leveling and aligning of upper arch with 16 x 22multistranded stainless steel wire. At this time lower sectionals are placed with retraction sectionals. Upper arch following aligning and leveling 16 x 22 boot hook arch is placed and depending on anchorage requirements the patient is instructed to wear class III elastics.
  87. 87. In this case use of lingual class III elastics can be done to prevent rotation of upper molar and lower canine while space closure continues on the buccal side. Note: Upper second molar is not banded before the complete space closure has occurred because this allows efficient mesial movement of the 1 at molar.
  88. 88. 2nd molar may be banded only for leveling and aligning and rotation correction. Once the lower extraction space is closed, an ideal buccal sectional is placed to begin the necessary root paralleling 16 x 16 wire followed by 16 x 22 wire. At this point we can take a progress cephalogram to determine the effectiveness of the mechanics. With root paralleling effective incisors retraction
  89. 89. Generally a round wire is used when lower incisors are to be tipped lingually. Use of boot hook utility arch allows the use of class I or class III elastics to produce the lower incisor retraction depending on anchorage requirements as determined by the progress cephalogram.    After lower retraction is complete 16 x 16 wire is placed as coordinated with upper arch. By now even the upper extraction site is closed and no decision for 2nd molar banding is taken.
  90. 90. Final presurgical forms.placing phase continuous, is to coordinate coordinated arch the arch wires of increasing size until desired arch form is achieved.  After the clinician feels that coordination is achieved, impressions are taken and feasibility model surgery is performed. Note: It is not necessary for all teeth to fit one another perfectly. Rather it is important to produce an occlusion at surgery that can be easily finished by routine orthodontic treatment.
  91. 91. Primary goals to achieve:      Class I molar and canine relationship with significant transverse or vertical problems.      Once these goals have been achieved the patient is ready for surgery.     The arch wires are now tied with ligatures wire to prevent inadvertent disengagement of the wires and the patient is referred for surgery.
  92. 92. If these goals cannot be achieved ?? Tooth mass discrepancy. Lower incisor angulation. Transverse discrepancy. Decision to proceed with surgery is made by 0btaining new progress models and performing feasibility model surgery on them t0 determine its plausibility. Proceed only if model surgery permits.
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  96. 96. Orthodontic Surgical maxillary expansion followed by mandibular advancement When mandibular advancement surgery is planned for patient when a transverse discrepancy of 6 mm or more exists, combined orthodontic surgical expansion of maxilla is recommended as a part of the treatment plan. The need for this is determined by observation after placing the models into the desired antero-posterior position . When the transverse discrepancy is truly skeletal, combined orthodontic surgical expansion of maxilla is indicated.
  97. 97. But however there are 3 things that we should remember regarding the appliance used: Appliance is ideally a fixed appliance.     Appliance must be capable of achieving the desired amount of expansion without need for refabrication.     Appliance is preferably tooth borne both to allow surgical access and to avoid possible palatal soft tissue necrosis.
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  99. 99. Factors affecting stability of treatment: Appliance construction and cementation:     Tightly fitting bands and well did solder joints.     Bands well cemented.     Tooth borne.
  100. 100. Appliance activation: 1) Appliance activated 5 to 6 mm at surgery to check that equal mobilization of both sides of the maxilla is occurring. 2) Regular activation as indicated must be done to avoid excess tissue tearing of palatal and alveolar mucoperiosteum which otherwise may cause a resultant periodontal or gingival defect between the maxillary central incisors which is clinically seen as loss of interdental papilla.
  101. 101. Appliance stabilization:     Stabilized minimum for 8 weeks after completion of expansion . It is preferable to maintain the appliance is place until the midline diastema is closed by the active post surgical orthodontics
  102. 102. Maintenance of arch width: Arch wires placed following expansion must be careful made to confirm to the desired arch width. Either expansion appliance or a TPA can be used to assure that the maxillary arch width is maintained.
  103. 103. Anterior Maxillary Osteotomy Augmentation Genioplasty: With     Seldom used in treatment of class II dentofacial deformity. Since results in poor esthetic results.    Used when patients has a good functional posterior occlusion.     Prominent upper lip and teeth with acute NLA.     Lower arch well aligned and in proper anteroposterior position. Recessive chin can be corrected with augmentation genioplasty.
  104. 104.     Must be emphasized that this orthodontic surgical approach does not produce the same result as would be achieved by similar isolated orthodontic orthodontically, treatment, only the upper because teeth are retracted, with surgery the bone and teeth both are retracted.
  105. 105. Pre surgical orthodontic goal:    Decision of extraction is to be taken and alignment of teeth. If the crowding is severe then the premolars are extracted.     While in case of severe anterior crowding they are extracted prior to the treatment begins so that the teeth can be aligned without moving them farther anteriorly.   The upper arch is treated segmentally without using a continuous arch wire before surgery.
  106. 106. After the final wires have become passive, impressions are made and feasibility surgery done on models. Note: It is imperative, particularly for the patient with deep bite, that adequate space exists between the teeth for the surgeon to complete the interdental osteotomies without damage to the adjacent teeth.
  107. 107. Anterior maxillary osteotomy is done in two pieces if there is large midline diastema or when there is a transverse discrepancy of the canine teeth. It is often preferable to correct a transverse' discrepancy in the canine area surgically because by doing so; we Can prevent the risk of periodontal dehiscence over the canine tooth root.
  108. 108. Factors affecting the orthodontic treatment:  stability of the     Adequate preparation of segments: Proper torque.    Proper tooth-to-tooth relationship to allow them to fit precisely over the lower arch. The angulation of the tooth adjacent to the ostectomy site should be erect so that adequate surgical access and bone removal is possible to allow proper positioning of the segments at surgery
  109. 109. Maintaining Surgery: Space Closure Effected at When ostectomy is done interdentally and the teeth surgically moved together, it is imperative that the orthodontist closes any remaining spaces immediately on release of fixation by ligating the teeth together and keeping the space closed from that time until retention.    Elimination of tooth mass discrepancy.    Lower incisor position should be optimally within acceptable limits relative to the A-PO line to promote a stable result.
  110. 110. AGE RELATED FACTORS: Age of patient has no effect on the stability of the anterior maxillary osteotomy, and this procedure can be done successfully. For any patient when the maxillary teeth are fully erupted.
  111. 111. CLASS II DIVISION 1 DEFORMITY WITH DEEP BITE: Usual approach is mandibular advancement. routinely again the outline of our treatment will be  1.Place the appliance  2.Level and align  3.Coordinate arches  4.Class III elastics as necessary
  112. 112. Determine feasibility of surgery Methods of deep bite correction are; 1) Leveling the arches to the molar incisor occlusal plane and opening the bite surgically by clockwise rotation of the distal segment during advancement of the mandible. 2) Leveling the arches by intrusion of the incisors with subsequent advancement of the mandible. straight forward
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  114. 114. NOTE:  When the face is symmetric at the beginning of the treatment, it is important that the magnitude of the class II occlusion is equal on both sides and the dental midline are coincident with the midline of the face to avoid the production of asymmetric chin when the mandible is advanced
  115. 115. LEVELING TO THE MOLAR INCISOR OCCLUSAL PLANE:    Here there is little concern for how leveling is done.   With this method of treatment the biggest problem encountered is tendency for lower incisor to flare (due to small round flexible wires used for aligning). Therefore almost without exception, the patient needs to wear class III elastics. Excessive flaring must be avoided because it diminishes the amount of advancement possible.
  116. 116. LEVELING TO THE FUNCTIONAL OCCLUSAL PLANE: In class II division 1 deformity the deep bite is carried by an increased curve of spee in the lower arch while upper arch curve of spee is within normal limits.Thus lower arch will take a longer time and thus is begun first. Appliance is first placed on the lower posterior teeth (second molar through first premolar) and these segments are leveled to define the functional occlusal plane.
  117. 117. Appliance is then placed on the lower incisors and a 16 x 22 utility arch is placed to begin incisor intrusion. This utility arch must have a labial root torque across the incisor section to keep the incisor roots away from the lingual cortical plate during intrusion and have tip back bends sufficient to produce 50-100 gm of intrusive force across the incisor section.
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  119. 119. After the lower incisor are leveled with the posterior segments, a continuous 16 x 22" arch wire is placed. This wire steps down at the canine teeth but otherwise ideal in shape.
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  121. 121. Once the canine is at the desired level the upper and lower arches are coordinated class III elastics are worn until the desired antero-posterior relationship is achieved. Class III elastics are avoided till this phase of treatment because they will elevate the functional plane by decreasing the anterior intrusion if used before this time.
  122. 122. FACTORS AFFECTING TREATMENT:  STABILITY OF 4 factors as discussed earlier.  Note: Relapse is not common in deep bite cases. Note that the decision as to precisely how to level the curve of spee is best predicted on the esthetic objectives, that is, whether the optimal movement of the mandible is to achieve maximal projection of the chin or conversely minimal chin projection with maximally increased lower face height.
  123. 123. A DOUBLE PROTRUSION CAN BE EASILY PRODUCED: In a patient with deep bite, when the. Mandibular advancement surgery involves clockwise rotation of the distal segment of the mandible, in this the teeth are advanced more than A-pogonion line. As such, it is easy to produce a BIMAXILLARY protrusion that may adversely affect both the facial esthetics and maintenance of lower incisor alignment following the removal of retention appliance. This can be avoided by retraction of the upper and lower incisors or the addition of an augmentation genioplasty.
  124. 124. MANDIBULAR ADVANCEMENT WITH ANTERIOR MANDIBULAR SUBAPICAL OSTECTOMY 1.When lower curve of spee is extreme.  2.Maximum desired.  advancement of bony chin is 3.Increase in face height is avoided.  Most useful when either the orthodontic mechanics to level the excessive curve of spee are problematic or significant reduction in the treatment time will result from leveling the curve of spee surgically
  125. 125. Disadvantages However note that this procedure negates the possibility of simultaneous horizontal osteotomy for augmentation genioplasty .  It also increases the risk of periodontal problems. Thus it is not a substitute for the routine orthodontic leveling of the curve of spee.
  126. 126. DETAILS OF THE TREATMENT: The upper arch is dealt with as previously discussed if extraction or surgical orthodontic maxillary expansions are to be done. But lower arch is dealt in a totally different manner. The anatomy of the lower curve of spee is important. There are two general types:
  127. 127. 1) The dual plane curve, in which the molars and the premolars are essentially on one plane while canines and incisor are elevated.  2) The rainbow curve - curve is continuous from molars through central incisors which are the highest points on the curve. When the rainbow curve exists; it must be first converted into a dual plane curve by orthodontic treatment before surgically leveling is possible. This is so because the teeth within the segment are not properly related to one
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  130. 130. FACTORS AFFECTING STABILITY 1) Adequate surgery room to perform the indicated 2) Improper positioning 3) Injury to adjacent roots 4) Teeth properly related within the subapical segment i.e., dual plane curve of spee must be created. 5) Proper arch shape.
  131. 131. 6) Immediate post-fixation orthodontic control. It is important to tie the teeth together on either side of an ostectomy (close any space that may remain open after surgery as rapidly as possible to minimize the reopening during retention). 7)Age related factors as discussed earlier
  132. 132. MANDIBULAR ADVANCEMENT WITH REDUCTION GENIOPLASTY: 1) Patients having class II dentofacial deformity there exists adequate (normal) projection of the chin while mandibular dento-alveolus is retruded. 2) In this case mandibular advancement will result in excessive protrusion of chin. 3) However, the most important factor in making this decision is the actual magnitude of the discrepancy between the lower incisors and pogonion positions. 4) When the antero-posterior discrepancy is less than 5mm, good esthetics can generally be achieved with routine mandibular advancement and properly done reduction genioplasty.
  133. 133. Presurgical orthodontic treatment: 1)    These patients generally have mandibular retrusion. 3)    Surgical posterior repositioning of pogonion line makes it possible for the lower incisors to be placed in their optimal position without excessive advancement. 4)    Prediction tracing must be done to determine the specific orthodontic mechanics and need for extraction. 5)    Frequently this patient may have a class II division 2 malocclusion.
  134. 134. TOTAL MANDIBULAR SUBAPICAL ADVANCEMENT:  Difference approaching 10 mm, poorer esthetics results are achieved with reduction genioplasty because when major posterior movement are done by this approach, the labiomental fold is eliminated and a permanent increased fullness is created in the submental area. This is large discrepancy existing between the lower incisor and pogonion position, the total subapical mandibular advancement becomes the treatment of choice. When there is need for aligning by anterior subapical procedure and a reduction genioplasty but as we know this sound very unpractical, therefore total mandibular subapical advancement is to be considered.
  135. 135. PRESURGICAL ORTHODONTICS: 1) Done without augmentation mandibular dentoalveolus. 2) Rest all is the same. 3) Create a dual plane curve of spee. of the
  136. 136.
  137. 137. CLASS II DIVISION 2 DEFORMITY: OUTLINE OF TREATMENT: PRESURGICAL ORTHODONTIC TREATMENT: 1. Non -extraction. 2. Place upper appliances. a. Maxillary expansion if necessary b. Torque and intrude upper central incisor 3. Place lower appliances align and level upper and lower arches. 4. Co-ordinate arches while using class III elastics as necessary. 5. Impression for feasibility model surgery.
  138. 138. PRESURGLCAL ORTHODONTIC TREATMENT: 1) Aim at producing a class II division 1 malocclusion so that the mandible can be advanced i.e.. create a. positive overjet by intruding, advancing and torquing of upper central incisors. 2) But this has very little effect on the upper lip drape and esthetics because initially there is a void between the lip and central incisors, which are supported by the lateral incisors. 3)Expansion may or may not be accommodate the advanced mandible). 4) Align and level lower arch. 5) Preferred method for leveling arches. required (to
  139. 139. A) If increase LFH is desired: Pogonion is prominent, lower level face is short. Then, minimally intrude anterior and instead, extrude posterior i.e., leveling to molar incisor occlusal plane. Therefore on surgery increase lower face height but minimally increase chin Appliance only in upper arch. prominence.
  140. 140. If increase LFH is not desired then  1) Sectional arch wires from 2nd molars to 1 st premolar and 16 x 22 utility arch is placed with labial root torque and 80-100 Gms of intrusive force for incisors. 2) Once the incisors are leveled with the posterior teeth, a continuous stabilizing arch wire is placed with the wire stepping down at the canine and elastic thread used to intrude the canine to the level desired. 3) An ideal, continuous lower arch wire is placed.
  141. 141.
  142. 142. CLASS II DIVISION 2 WITH INFERIOR REPOSITIONING OF THE MAXILLA WITH MANDIBULAR ADVANCEMENT:  BASIC CONDITIONS:      Upper incisors are buried superiorly beneath the upper lip and are perhaps not even visible upon smiling.     Extreme reverse curve of spee exists in the maxillary occlusal plane.    A very short lower third face height.     Patient requires an improvement in facial balance and in upper tooth to lip esthetics.
  143. 143. PRESURGICAL ORTHODONTIC TREATMENT:  Just level and align and coordinate the arches, as surgery will place the maxilla correctly in both vertical and antero-posterior position and occlusion is corrected by advancing the mandible. In transverse discrepancy maxilla can be expanded or constricted at time of surgery. Thus while doing this treatment our main concern is:     Tooth mass discrepancy.      Torque of upper incisor.      A-P position of the lower incisor.
  144. 144. MECHANICS: 1)    Appliances placed on the upper arch. 2)    Sectionals arch wires placed from molar to 1 st premolar (or 1 anteriorly to where reverse curve begins). 3)     A Utility arch is placed on the anterior teeth usually canine to canine, to torque and advance them into proper antero-posteriorposition. This utility arch will need to have extrusive force on canine area to offset the intrusive effect produced by the overly upright central incisors.
  145. 145.
  146. 146. TPA may be given for better control. Advancing utility may also be given. Molar and premolars at that time are tied together to prevent the spaces from opening up. Once room is made for lower incisor bracket the lower appliance is placed and leveling is begun. When lower curve of spee is biplanar or very extreme, it may be leveled segmentally and these segments leveled surgically by a lower subapical procedure or body osteotomies when increased LFH desired.
  147. 147. FACTORS AFFECTING STABILITY: When segmental surgery is done, several unique situations occur and hence must be understood. 1) Interdental surgical osteotomies and ostectomies. 2) Proper relation of the teeth within these segments. 3) Immediate post surgical orthodontic control of these areas.
  148. 148. AS DISCUSSED EARLIER; 1) Enough room to do the proposed surgery. 2) Relation of the teeth- within the segments: Surgically moved segments must fit well during surgery. 3) Immediate post surgical orthodontic control following release of fixation.  The teeth adjacent to the osteotomy to be tightly ligated together to prevent the formation of fibrous tissue in this area thus preventing the spaces from opening up later on.
  149. 149. VERTICAL MAXILLARY EXCESS WITHOUT OPEN BITE:  Lefort I superior repositioning of the maxilla with augmentation genioplasty.  PRESURGICAL ORTHODONTIC TREATMENT: 1.Place the appliances, align and level. 2.Coordinate arch forms. 3.Elastics as necessary to place lower incisors in the proper antero-posterior position.
  150. 150. Details of treatment:    Presurgical orthodontics required.    Can have orthodontic appliances placed and can immediately go for surgery. Either single piece or a segmentalized procedure. With or without extraction of upper 1st premolar. Lower arch may need to be set up presurgically
  151. 151. The A-P and transverse positions of the lower teeth at the time of surgery are critical because they determine the upper tooth to lip relationship both antero-posteriorly and symmetry. Extraction decision in lower arch depends on the prediction tracing. Non-extraction - Both the arches are aligned and leveled independently. Class III elastic may be used if necessary. Extractions - Mechanics is same, for maximal retraction of anterior.
  152. 152. TAKE CARE    Lower midline must coincide with the facial midline.     Lower canines must be equal in their anteroposterior position (otherwise may lead to asymmetry).     Hence it is very important to correct the mandibular asymmetry - (consider unilateral extraction or elastic therapy) .
  153. 153. Arch coordination and need for segmentalization.     Usually for people with vertical maxillary excess - V- shaped maxillary arch and Ushaped mandibular arch.     Maxillary arch shape is best changed with surgery and segmental mechanics are used.
  154. 154. FACTORS AFFECTING STABILITY OF TREATMENT:  INAPPROPRIATE VERTICAL MECHANICS : Extrusion of anterior and intrusion of posterior teeth" must be avoided. Presurgical orthodontic expansion of maxilla is contraindicated
  155. 155. SUPERIOR REPOSITIONING OF THE MAXILLA WITH MANDIBULAR ADVANCEMENT: IN MOST CLASSII  Vertical maxillary excess dentofacial deformities maxillary superior repositioning is not sufficient to correct class II occlusion by solely autorotation of the mandible. it may be necessary to reposition the maxilla both superiorly and posteriorly. But when esthetics does not permit posterior positioning of maxilla (an obtuse NLA, recessive paranasal areas ) in this case superior or supero-anterior repositioning of maxilla and simultaneous mandibular advancement may be indicated.
  156. 156. PRESURGICAL ORTHODONTIC TREATMENT: 1)     Primary emphasis on lower arch, because if mandibular teeth are properly related to the mandible, and maxilla positioned in relation to them then the esthetic result will be good. 2)     The general treatment sequence is same as described earlier. Note: No pre-surgical orthodontic maxillary expansion is indicated best produced during surgery.
  157. 157. FACTORS TO SUMMARIZE:  1. Avoid inappropriate mechanics.  use of vertical 2. Maxillary expansion for adults is done surgically.  3. Make occlusion more class II before surgery.  4. Properly managed tooth mass discrepancies before surgery. 5. Adequately level both upper and lower arches or segments.
  158. 158. CLASS II DEFORMITY WITH OPEN BITE: Segmental total subapical superior maxillary repositioning augmentation genioplasty.  OUTLINE OF TREATMENT: 1.Extract lower first premolars 2. Place lower appliance. 3. Retract lower canines
  159. 159. 4. Begin lower incisor retraction, extract upper 1 st premolar 5. Place upper appliance; align and level segmentally. 6. Ideal lower arch and ideal upper sectional arches 7. Impressions for feasibility model surgery.
  160. 160. BASIC GOALS: Symmetrically place the lower dentition in the proper antero- posterior and transverse position with respect to the mandible such that when maxilla is surgically repositioned all the teeth will be in proper antero-posterior, vertical and transverse relations. Symmetry of lower arch is important because it will dictate the symmetry of upper arch. Any orthodontic procedures that tend to open the bite need to be done presurgically like molar uprighting, rotations.
  161. 161.
  162. 162. Teeth are aligned so that no cross bites will need to be corrected following surgery.  .Any mechanics that are expressly intended to close the bite are avoided during the presurgical orthodontic treatment. Vertical elastics, high pull headgear with facebow, vertical pull headgear to a chin cup or any other device used in an attempt to close the w bite is
  163. 163. Actual treatment:    Begin 1 at in lower arch.     superior repositioning of maxilla with augmentation genioplasty.    Mostly extraction of upper and lower 1st premolar is indicated.   Appliance placed in lower arch.
  164. 164. NOTE : Lower brackets are bonded 1 mm lower than usual so that brackets do not interfere with production of the desired overbite at time of surgery 1) Lower arch - Maximal anchorage case usually lingual arch is placed. 2) Stabilize utility arch with retraction sectional arches to the lower canines are used.
  165. 165. When canines are excessively labial - it is often helpful to have, the elastic thread tied to the lingual arch to supply a lingual vector during retraction and help the canines move out of the labial cortical plate and minimize strain on anchorage.     In critical anchorage cases banding of upper arch is done earlier so it would be useful to use of class III elastics to back up the lower anchorage.
  166. 166.
  167. 167.      Once lower canines retracted, 16x22 sectional arch wire are placed to upright the canines and lower retraction is begun. Lingually tipping of incisors as said earlier is done with a boot hook utility arch made from 0.018 round wire and intra-arch elastics traction.     Upper arch extraction. Appliance is placed and segmental arch wires are placed in the upper arch.
  168. 168.      TPA for rotating and torquing the upper molars. Also helps stabilizing surgically produced expansion.    Sectional mechanics are used in the upper arch to maintain the dual occlusal plane usually found in class II open bite dentofacial deformity.
  169. 169.
  170. 170. NOTE: When upper canines are excessively constricted relative to the lower canines and premolars then it is desirable to split the anterior segment into 2 segments and produce the desired canine expansion surgically, widening both the teeth and bone (rather than risk periodontal problems). A potential problem faced is the insufficient space through which to do the surgical ostectomies. Orthodontist therefore must intentionally tip canine root mesially and premolar root distally
  171. 171.
  172. 172. CLASSIII DEFORMITIES Mandibular prognathism The usual orthodontic approach that we have is:  Mandibular setback or with simultaneous adjunctive surgical procedures.  1) Reduction genioplasty: A) Vertical reduction genioplasty: When the chin is vertically Long, (i.e.., when the distance from the lower lip to menton is excessive). Note : In excessively long chin the reduction genioplasty helps as much as the mandibular setback.
  173. 173. B) A-P, reduction genioplasty: When there is excessive projection of pogonion (i.e.., increased distance between point Band Pog). C) Both vertical and A-P reduction genioplasty.
  174. 174. AUGMENTATION GENIOPLASTY: Class III malocclusion and normal A-P chin position and a normal neck chin angle and length. Correction of malocclusion by a mandibular setback will often compromise the facial esthetics by producing an unaesthetic chin, one that is retrusive and lacks good neck chin definition.
  175. 175.
  176. 176. PARANASAL AUGMENTATIONS: A) Class III malocclusion with narrow alar base and some paranasal deficiency exists in profile. B) Not indicated in major class III dentofacial deformity (I.e., greater than 10-12 mm which true maxillary deficiency and prognathism exist). mandibular
  177. 177.
  178. 178. Midsymphisis osteotomy or ostectomy: In the class III prognathic dentofacial deformity it is not unusual that occlusal discrepancy exists (i.e. posterior Crossbite) when teeth are positioned into the proper class I relation. The actual magnitude of this discrepancy is best determined before beginning orthodontic treatment so that a deliberate decision can be made regarding the optimal method by which to correct it.
  179. 179. Options in the adult patients are ??  Orthodontically moving the upper posterior teeth buccally and lower posterior teeth lingually(less than5mm discrepancy) . Combined orthodontic - surgical expansion of the maxilla when the transverse discrepancy is greater than 5mm. Surgical narrowing of the mandibular simultaneously with mandibular setback. arch
  180. 180. When there exists both a significant anterior tooth mass discrepancy (4mm or more) and a minor transverse discrepancy (5mm or less), the treatment of choice may be bilateral ramus osteotomies to set the mandible back and a lower midline body ostectomy with extraction of a lower incisor to narrow the mandible an hold, simultaneously correct the anterior tooth mass discrepancy. Helpful when transverse discrepancy is in canine area. . Eliminates the time consuming orthodontic closure of the lower incisor extraction space while increasing stability of the result.
  181. 181. MANDIBULAR BODY OSTECTOMIES: Mandibular prognathism with an acceptable class III posterior occlusion or one that can be made acceptable by routine orthodontic treatment. This most basically is a class III molar occlusion without a cross bite.
  182. 182.
  183. 183. There are two specific situations that may be best treated by body ostectomies:  When posterior edentulous spaces exists then body ostectomies may be done to. Close the spaces or shorter the Span of the needed prosthetic replacement. Considerable linguoversion of the lower anterior teeth and yet no crowding is present. In this situation the dental compensations may be eliminated by orthodontically opening spaces, usually between the first premolars and the canines
  184. 184. Orthodontic treatment objectives: Proclination of lower incisors. Retraction of upper incisors. May be expansion of upper arches. Few vertical consideration because upper and lower arches are in level.
  185. 185. Extractions may be considered from a prediction tracing usually 14, 24, 35, 45. Usually a non-extraction approach is considered. Expansion Transverse discrepancy more than 5 mm and age 18 years above - surgical orthodontic expansion is considered.
  186. 186. Proclination of lower incisors ??? How to get the desired A-P positions ??? Minor problem encountered ???
  187. 187.
  188. 188. Maxillary deficiency: Usual surgical approach is maxillary advancements . Other option is 1) Inferior repositioning of the maxilla: Class III dentofacial deformity with short lower third face with maxillary incisors being vertically located several mm above the upper lip line vertical maxillary deficiency.
  189. 189. Overclosed appearance - short upper lip, acute NLA and prominent chin. However in position of rest of mandible - Upper lip normal in length, NLA normal and chin is normal. Increased free way space of 5-15 mm. May usually appear a dentofacial deformity. Treatment is similar. secondary cleft
  190. 190. True midface dentofacial deformity: Those individuals who exhibit retrusion or hypoplasia of the midface without clinically significant cranial vault deformities. . Maxillary molar retrusion or deficiency. .Maxillary nasal retrusion or deficiency. .Maxillary molar - Nasal retrusion or deficiency
  191. 191.
  192. 192. Cephalometry is an excellent tool for quantifying, classifying and communicating patient data. It is useful as a treatment-planning tool through the construction of prediction tracings to study profile changes and to allow the planning of extractions and orthodontic mechanics to meet the treatment objectives.
  193. 193. The shape of the face depends mostly on the basic skeletal analysis is architecture. mandatory for Thus skeletal identifying and classifying any deformity. Innumerable analysis has been proposed to study the skeletal relations. Among them some are; Burstone's analysis( cogs for both hard and soft tissue) Dipaolo's (quadrilateral analysis) Grummons analysis
  194. 194. Cephalometrics for orthognathic surgery . Charles J Burstone, DDS, MS; Randal B. James, DDS; H. Legan, DDS; G. A. Murphy, DDS; and Louis A. Norton, DMD,Farmington, Conn
  195. 195. Successful treatment of the orthognathic surgical patient is dependent on careful diagnosis. Cephalometric analysis can be an aid in the diagnosis of skeletal and dental problems and a tool for simulating surgery and orthodontics by the use of acetate overlays. Cephalometric analysis also allows the clinician to evaluate changes after surgery. The first step in the diagnosis of the orthognathic surgical patient is to determine the nature of the dental and skeletal defects
  196. 196. Patients who require orthognathic surgery usually have facial bones as well as tooth positions that must be modified by a combined orthodontic and surgical treatment. For this reason, a specialized cephalometric appraisal system, called Cephalometrics for Orthognathic Surgery (COGS), was developed at the University of Connecticut. This appraisal is based on a system of cephalometric analysis that was developed at Indiana University, with the addition of clinically significant new measurements.
  197. 197. The COGS system describes the horizontal and vertical position of facial bones by use of a constant coordinate system; the sizes of bones are represented by linear dimensions and their shapes, by angular measurements. The standards are based on a sample obtained from the Child Research Council of university of Colorado School of Medicine. Although the sample of 16 females and 14 males is small, the mean measurement values closely correspond with those of other northern European populations. This longitudinal sample was selected to ensure consistent standards by age and rate of growth.
  198. 198. Cephalometric Analysis Sella (S), the center of the pituitary fossa. Nasion (N), the most anterior point of the nasofrontal suture in the midsagittal plane Articulare (Ar), the intersection of basisphenoid and the posterior border of the condyle mandibularis. Pterygomaxillary fissure (PTM), the most posterior point on the anterior contour of the maxillary tuberosity Subspinale (A), the deepest point in the midsagittal plane between the anterior nasal spine and prosthion, usually around the level of and ante-rior to the apex of the maxillary central incisors.-Pogonion (Pg), the most anterior point in the midsagittal plane of the contour of the chin
  199. 199. Supramentale (B), the deepest point in the midsagittal plane between infradentale and Pg, usually anterior to and slightly below the apices of the mandibular incisors. Anterior nasal spine (ANS), the most anterior point of the nasal floor; the tip of the premaxilla in the midsagittal plane. -Menton (Me), the lowest point of the contour of the mandibular symphysis Gnathion (Gn), the midpoint between Pg and Me, located by bisecting the facial line N-Pg and the mandibular plane (lower border). Posterior nasal spine (PNS), the most posterior point on the contour of the palate. Mandibular plane (MP), a plane constructed from Me to the angle of the mandible (Go). Nasal floor (NF), a plane constructed from PNS to ANS. -Gonion (Go), located by bisecting the posterior ramal plane and the mandibular plane angle.
  200. 200. The baseline for comparison of most of the data in this analysis is a constructed plane called the horizontal plane (HP), which is a surrogate Frankfort plane, constructed by drawing a line 7° from the line S to N. Most measurements will be made from projections either parallel to HP (11 HP) or perpendicular to HP ( 1 HP).
  201. 201. CRANIAL BASE First, it is necessary to establish the length of the cranial base, which is a measurement parallel to HP from Ar to N. This measurement should not be considered an absolute value but a skeletal baseline to be correlated to other measurements, such as maxillary and mandibular length, to obtain a diagnosis of proportional dysplasia.
  202. 202. Ar-pterygomaxillary fissure (Ar-PTM) is measured parallel to HP to determine the horizontal distance between the posterior aspects of the mandible and maxilla. The greater the distance between Ar-PTM, the more the mandible will lie posterior to the maxilla, assuming that all other facial dimensions are normal. Therefore, one causal factor for prognathism or retrognathism can be evaluated by this measurement of the cranial base.
  203. 203.
  204. 204. HORIZONTAL SKELETAL PROFILE A few simple measurements should be made on the skeletal profile to assess the amount of disharmony. We call this the horizontal skeletal profile analysis because all the measurements are made parallel to HP. This is very practical because most surgical corrections. primarily made in the anteroposterior direction. The first measurement quantitatively describes the degree of skeletal convexity in the patient. The angle of skeletal facial convexity is measured by the angle formed by the line N-A and a line A to Pg. The N-A-Pg (angle) gives an indication of the overall facial convexity, but not a specific diagnosis of which is at fault -the maxilla or mandible
  205. 205.
  206. 206. A perpendicular line from HP is dropped through N and the inferior anatomic point is horizontally measured in relation to the superior structures The horizontal position of A is measured to this perpendicular line (N-A). This measurement describes the apical base of the maxilla in relation to N and enables the clinician to determine if the anterior part of the maxilla is protrusive or retrusive. The measurement and related measurements are important in the planning of treatment of anterior maxillary horizontal advancement or reduction, and of total maxillary horizontal advancement or reduction. Point B and PG[ pogonion ] are measured in the same way.
  207. 207.
  208. 208. VERTICAL SKELETAL AND DENTAL A vertical skeletal discrepancy may reflect an anterior, posterior, or complex dysplasia of the face. Therefore, the vertical skeletal cephalometric measurements are divided into anterior and posterior components.
  209. 209. MAXILLA AND MANDIBLE The total effective length of the maxilla is the distance from PNS-ANS that is projected on a line parallel to the HP. The ANS-PNS distance, with the previous measurements N-ANS and PNS-N, give a quantitative description of the maxilla in the skull complex. Four measurements relate to the mandible Ar to Go Go-Pg Go angle [represents the relationship between the ramal plane and MP] B-Pg, [Distance from B point to a line perpendicular to MP through Pg.]
  210. 210.
  211. 211. DENTAL In the assessment of dental anomalies cephalometrically, one must attempt to relate the teeth to each other through a common plane, such as the occlusal plane (OP) or to a plane in each jaw, the MP, or the NF plane.
  212. 212. Table
  213. 213. Discussion: A cephalometric appraisal is only one step in diagnosis and planning of treatment. It gives the clinician insight into the quantitative nature of the skeletal-dental dysplasia. If surgery' is planned to produce cephalometric changes that make the face approach the normative standards, usually a more typical and desirable face is produced. It is a mistake, however, to treat to a standard that avoids other considerations. The soft tissues can and do mask the underlying bone and teeth; therefore one must compensate for this variations.
  214. 214. ADVANTAGES: A cephalometric analysis for patients who have orthognathic surgery It is based on the landmarks that can be altered by various surgical procedures. These rectilinear measurements examine critical facial components that can be readily transferred to acetate overlays and study casts for detailed planning of treatment and post surgical evaluation.
  215. 215. SOFT TISSUE CEPHALOMETRIC ANALYSIS FOR ORTHOGNATHIC SURGERY: Treatment planning for patients who require orthognathic surgery should include both a hard tissue and soft tissue cephalometric analysis. The hard tissue will show the nature of the existing skeletal discrepancy, it is incomplete in providing the information concerning the facial form and proportions of patient. The soft tissue covering the teeth and bone is highly variable in its thickness and this variation may be greater.
  216. 216. In planning surgery on patients with vertical discrepancies, lip length is an important factor. Sometime lips may be short,allowing the patient to close with great difficulty. Amount of incisor exposure will be more during speaking. Therefore, the diagnosis of vertical discrepancies will be depend upon both soft and hard tissues factor. Therefore, Charles J. Burstone in 1980 developed a soft tissue cephalometric analysis for orthognathic surgery.
  217. 217. Cephalometric landmarks: Soft tissue landmarks used are; Glabella (G) : The most prominent midsagittal plane of the forehead. point in the Columella point (Cm) : The most anterior point on the columella of nose. Subnasale (Sn) : The point at which the nasal septum merges with the upper cutaneous lip in the midsagittal plane. Labrale superiors (Ls) : A point mucocutaneous border of upper lip. indicating the
  218. 218. Stomion superius (Stms) : Lower most point on the vermilion of the lower lip.  Labrale inferius (stml) : The upper most point on the vermilion of the lower lip. Labrale inferius (Li): A point indicating the mucocutaneous border of lower lip. Mentolabial sulcus (Si) : The point of greatest concavity in the midline between the lower lip and chin. Soft tissue pogonion (Pg) : The most anterior point on soft tissue chin
  219. 219. soft tissue gnathion (Gn) : The constructed midpoint between soft tissue pogonion and soft tissue menton. Soft tissue menton (me) : Lowest point on the soft tissue chin, found by dropping a perpendicular from horizontal plane through menton. Cervical point (C): Innermost point between the submental area and neck located at the intersection of lines drawn tangent to neck and submental areas. Horizontal reference plane (HP): Constructed by drawing a line through nasion 7° up from sella - nasion line.
  220. 220.
  221. 221. Facial form To describe the soft tissue profile of patient angle of facial convexity, or facial contour angle, G - Sn - Pg is evaluated. G-Sn - Pg : 12°+/- 4° A line perpendicular to horizontal plane (HP) is dropped from glabella and the relationship of the maxilla and mandible is related to it to determine if the problem is maxillary or mandibular.
  222. 222.
  223. 223. G-Sn (Hp): The distance from subnasal (Sn) to vertical line parallel to the horizontal plane is measured maxillary which describes protrusion or the amount retrusion of in anteroposterior dimension. Negative number is maxillary retrusion, large positive number,is maxillary procumbency. G - Sn - (HP): 0 +/- 3 mm
  224. 224. G- Pg (HP) : The position of pogonion is measured parallel to HP from the Perpendicular line dropped from glabella. This measurement gives an indication of maxillary prognathism or retrognathism.  G - Pg : 0 +/- 4 mm
  225. 225. Vertical height ratio - G - Sn / Sn - Me (HP): In vertical dimension, anterior facial proportionality is assessed by taking the ratio of middle third facial height to lower third facial height measured perpendicular to HP. The ratio less than 1 to 1 connote a disproportionality large lower third of face . Normal: 1 mm
  226. 226. Lower face - throat angle (Sn - Gn - C): It is formed by intersection of the lines Sn - Gn and Gn - C. an obtuse lower face neck angle warns the clinician not to use procedures that reduce the prominence of chin.
  227. 227. Nasolabial angle (Cm - Sn - Ls) : 4 +/- 2mm It is important in assessing antero-posterior maxillary dysplasia. An acute nasolabial angle will often allow us to surgically retract the maxilla or retract the maxillary incisors. Obtuse nasolabial angle suggests a degree of maxillary hypoplasia. Cm - Sn - Ls: 102° +/- 8°
  228. 228. Upper lip protrusion Ls to (Sn - Pg) : 3 +-1 mm  Lower lip protrusion Li to (Sn - Pg) : 2+- 1 mm  It is evaluated by drawing a line from subnasal to soft tissue pogonion and amount of lip protrusion or retrusion is measured by perpendicular linear distance from this line to the most prominent point of both lips.  Labio-mental sulcus Si to (Li – Pg) 4 +/- 2 mm  It is measured from the depth of the sulcus perpendicular to Li- Pg line. Sulcus of about 4 mm is average in pleasing lower lip t0 chin contour.
  229. 229. Vertical lip chin ratio - Sn - Stms / Stms - Me: 0.5 mm: Lower third of face (Sn - Me) is divided into length of upper Sn - Stms. It should be approximately 1/ 3rd the total and distance Stms - Me is about 2/3rd. Sn - Stms/Stms - Me should be 1: 2 ratio becomes smaller than one half- vertical reduction genioplasty considered.  Distance of upper lip to the maxillary incisor (Stms - 1) is key factor in determining the vertical position of maxilla. Patient with vertical maxillary excess tend to show a large amount of upper incisors with the lip in response.
  230. 230. Interlabial gap - 3 mm: Vertical distance between the upper lip and lower lip with then lip in rest position is normally 3mm. If vertical maxillary excess tend to have large Interlabial gap, lip In competency.
  231. 231.
  232. 232.
  233. 233. ORTHODONTIC SURGICAL CEPHALOMETRIC PREDICTION TRACING (Epkar and Fish, 1994): one of the most Important planning tools in surgical cases is the cephalometric prediction tracing. Once the problem is recognized . The type of surgery provisionally decided, prediction tracing is done accordingly
  234. 234. Types of prediction tracings ; 1) Orthodontic surgical 2) Surgical Orthodontic surgical tracing is used for overall treatment planning and illustrates the effect of both orthodontic tooth movements and surgical skeletal changes. surgical tracing is done as a part of two patient concept.
  235. 235. The orthodontic surgical tracing is done for the fallowing reasons . To assess accurately the profile esthetic results of the proposed surgery and orthodontics.  Determine desirability the of procedures such as genioplasty. To help determine the orthodontics. adjunctive surgical sequencing of surgery and To help decide if extractions are necessary. To determine which teeth to extract if extraction treatment is required. To determine the anchorage requirements.
  236. 236. Esthetics directly depends on the soft tissue morphology and harmony. So, it is important to know the soft tissue change associated with the surgical procedure. Certain points to be kept in mind during prediction tracing are;     With the antero-posterior movement of the incisors, 60-70% change is seen in lips. With the vertical movement of incisors, associated with soft tissue changes are minimal but lip rotation is almost equal to the rotation of mandible.    In mandibular advancement, lip movement is 60-70%, but the soft tissue chin movement is almost as equal to the base movement.
  237. 237. In maxillary advancement, the nose tip is slightly elevated, but the change is usually temporary. In maxillary retro positioning, the movement of the base of the upper lip is only 20% of that of point A. The lower lip rotates along with the mandibular rotation. In surgery of chin, the soft tissue reacts about 6070%to forward advancement.
  238. 238. currently, there are three methods of prediction tracing. A) It involves repositioning acetate tracing. of the various bony and skeletal segments over the original tracing to duplicate the movement of potential treatment procedures. The post treatment soft tissue outline is established by considering the ratio of soft tissue to hard tissue change.
  239. 239. In Second technique appropriate landmarks from the cephalometric tracing are digitized and entered into a computer using commercial programs clinician can simulate surgical movements on screen and rapidly compare several possible options using computer is no more accurate than doing prediction by hand. The third method involves overlying the digitized image of the lateral cephalometric tracing on to a video image of patient. The surgical predictions produced from the digitized cephalometric tracing can be integrated with the video image so that the prediction includes not only a line drawing but also a corresponding facial image.
  240. 240. The available surgical prediction programs include Dentofacial planner plus Quick Ceph and Prescription Planner / Portrait, OTP, TOMAC, Dr. Ceph etc
  241. 241. Mandibular advancement:  First the bony and soft tissue landmarks are traced. Frankfort horizontal plane is drawn and then a line is passed from nasion through point A and extending inferiorly. Point A is frequently in its normal relation (90deg maxillary depth). Begin the prediction by tracing the distal portion of the mandible, the soft tissue chin, and the occlusal plane on clean acetate paper. A lightly dotted line is used for soft tissue chin and the corresponding part of mandible. It makes easier to add genioplasty whenever required.
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  243. 243. In deep bite cases, occlusal plane is made between functional plane and molar incisor occlusal planes. The choice must be made carefully as it affects the esthetics the amount and direction of advancement and the necessary orthodontic treatment. Functional occlusal plane Wolford L.M., Chemello B.D. and Hilliard F. (1994) quoted that deep bite frequently associated with excessive curve of spee in lower arch and a reverse curve of spee in the upper arch
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  245. 245. Molar incisor occlusal plane: The patient with deep bite has two divergent molar incisor occlusal planes. One from maxillary incisor to maxillary molar and another from mandibular molars to mandibular incisors. If mandible has to be advanced along these divergent planes, then rotate clockwise the distal of mandible, so that both planes get coincide. The teeth are advanced more than pogonion and lower face height is increased by the amount of excessive overbite.
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  248. 248. After tracing the fixed structures, draw A - Po line and the facial axis on the prediction. This line is used to place the teeth in their ideal position. Ideal position of lower incisor determined by Rickets, is with the incisal edge 1 mm ahead of the A - Po line and the long axis at 22° to A - Po line.
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  250. 250. The single most common problem encountered in doing a cephalometric Prediction tracing for mandibular advancement is the inability to produce the desired lower incisor tooth movements because the total arch length discrepancy is greater than the width of two premolars. Then start soft tissue profile prediction superimpose the prediction on the tracing. As the position of upper incisor was changed the upper lip vermilion will change in the same direction but about half as much. Draw appropriate lip in the new appropriate position and connect it to subnasale by a smooth curve .
  251. 251. Lower lip frequently not only supported by lower incisor but also everted by the upper incisors. Generally lower lip thickness is equal from point B superiorly and usually the same thickness in upper lip. The lay the prediction on tracing, touches upper lip, incisal edge of upper incisor and .labial surface of lower incisor on the prediction trace the vermilion portion of the lip. Finally, connect the lip to the soft tissue chin with a smooth curve to produce completed prediction tracing
  252. 252.
  253. 253. SUPERIOR REPOSITIONING OF THE MAXILLA AND ADVANCEMENT GENIOPLASTY: Routine tracing of pretreatment cephalogram with skeletal, dental and soft tissue landmarks done. Then to start with prediction - fresh tracing of the patients cephalogram without analysis line made. Construct subnasal perpendicular this tracing to allow assessment of changes in chin and lip position. For soft tissue chin and mandible use dotted lines, as it is easier to add genioplasty.
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  256. 256. Note : Accurate tracing of condyle is important as it serves as center of rotation for mandible, Functional occlusal plane ( molar-premolar) is used. Then the prediction is rotated counterclockwise around the condyle keeping the condyle in fossa, until the functional occlusal plane is 1-3mm below the upper lip on tracing .Where to place the occlusal plane is based on the amount of upper tooth exposed before treatment,
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  258. 258. Then hold the prediction and draw the fixed structures,observe the anteroposterior position of chin. The soft tissue chin optimally lies 2 - 6 mm behind the subnasale perpendicular on tracing. If chin is deficient at this time augmentation genioplasty done. There the bone to soft tissue ratio is 1 : 0.7.
  259. 259. For augmentation genioplasty, draw a horizontal line parallel to FH plane on symphysis. Then superimpose the tracing on prediction. Slide the prediction until the bony chin of the tracing projects anteriorly. Then hold the prediction and draw the new chin position, relative to both subnasale perpendicular and the forehead and nose. Then draw A - Po line should be coincident with A – Po line Place the teeth in their ideal position. Superimpose the Prediction on tracing and soft tissue can be compared.
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  268. 268. MODEL SURGERY : Model surgery simulates the actual surgery, in the dental arch model of the patient It gives a three dimensional uerstanding of the postoperative relationship of the jaws. Why Model surgery is performed ???
  269. 269. The basic reason to perform the model surgery is 1) To determine if the indicated surgical procedure will produce an occlusion that can be simply and safely perfected by subsequent orthodontic treatment. 2) To get a definite idea about the extent of bone / arch advancement or reduction required in the surgery. 3) To get a postoperative relationship of the jaws, dentition and occlusion. 4) To decide treatment. about the post surgical orthodontic 5) As a vehicle for fabrication of splints for stabilization after surgery
  270. 270. There are two basic types of feasibility model surgery.    Whole arch    Segmental Whole arch feasibility model surgery is done by hand articulating dental models into the best possible occlusion. Segmental feasibility model surgery is done by sawing the upper lower or both dental models into the dentoosseous segments to be produced at surgery and reassembling them into the best possible occlusion while using any simple hinge type articulator to help hold the model bases.
  271. 271. Technique: The models are duplicated, trimmed to simulate the anatomy and arbitrarily mounted on an articulator using a wax bite to ensure proper occlusion. The roots of the teeth adjacent to planned interdental osteotomies or osteoctomies are drawn on cast. The teeth and the alveolus are sectioned from the upper model base along a reference line made approximately 5 mm above the tooth root apices. Then the maxilla is sectioned into the appropriate segments taking care not to cut through the tooth roots.
  272. 272. The anterior segments are placed into its best occlusal relationship with the lower teeth and held in this position with soft Wax. The objective is to establish a class I canine occlusion with -normal overbite and overjet. Sometimes, it is necessary to section the anterior segment between the central incisors to increase or decrease inter-canine width, close the midline diastema etc.
  273. 273. In Lefort I osteotomy, models are articulated in an anatomical articulator with face bow transfer. An anatomical articulator is necessary because the repositioning of maxilla always result in some rotatory movement of mandible in Toto.
  274. 274. POST SURGICAL ORTHODONTICS AND RETENTION: Orthodontic objectives following surgery are generally similar to those considered in finishing a conventional orthodontic case. Final tooth alignment maximum interdigitation, finalizing torque and artistic positioning are all completed at this time. Establishment of correct root parallelism is important, particularly in segmental cases where the roots of the teeth adjacent to the osteotomy sites should have been kept divergent so as to provide additional lnteradental space for the surgical cuts.
  275. 275. The post surgical treatment time needed to reach such objective varies according to type of patient, minimum 34 months required for post surgical treatment Post-surgical orthodontic consideration (Bell and Jacobes, 1981; Epkar and Fish, 1994): 1)Immediate post surgical control: After the release of fixation, is the important time under the orthodontists control. During this time orthodontist can produce rapid and drastic changes that will profoundly affect the final result with regard to stability and function.
  276. 276. Appliance repair: All the arch wires are removed and the fixed appliance is checked for damage. Any bands or bonded attachment that have become loose, bent or other wise damaged are replaced. Arch wires: After surgery, arch wires that were removed are placed back in the mouth unless either they were damaged that they require replacement.
  277. 277. Appointment frequency: Patients are seen more frequently for the first month or 30 after release of fixation. Patient is seen on 3-4th day after surgery to check if he/she is having any problem. If all is well, second appointment in I week, then in 2nd week and then routing 4 week.
  278. 278. Finishing It is the most important part of post surgical orthodontics and is deliberate attempt to achieve. A. Compatibility between centric occlusion and centric relation b. Canine protection c. Incisal guidance d. Root parallelism e. Pleasing appearance
  279. 279. After completing finishing the patient is placed in passive arch wire and if good stability is demonstrated in absence of any mechanics, the appliance is removed. Retention: For retention. conventional retention appliances are given or the appliance is placed as it is for few months.
  280. 280. Class I dentofacial deformities: Today, clinicians tend to focus on the fact that the patient population has a class I occlusion and ignore the totality of the patient’s skeletal, functional and esthetic problems. Class deformities include; a. Vertical maxillary excess b. Vertical maxillary excess with open bite I
  281. 281. Factors affecting stability of treatment: .Orthodontic factors: Specific orthodontic factors that directly and most commonly contribute to relapse in the correction of patients with class I VME. a. in appropriate vertical mechanics: b. Expansion of maxilla
  282. 282. CLASS II DENTOFACIAL DEFORMITIES SECONDARY TO MANDIBULAR DEFICIENCY (Arnett, 1993; Epkar and Fish, 1994): Post-surgical orthodontic treatment: First appointment within 48 hour of patient release. Both the upper and lower arch wires are removed checked for damage and adjusted or replaced. Loose appliance re-cemented, occlusion is checked. The elastics are reviewed. In the next appointment, complications are noted
  283. 283. Mechanical principles used; 1.If equal movement is desired then either no arch wire is placed or same size arch wire is placed in both arches. 2.If more movement of teeth in one arch required, either no arch wire is placed in arch to be moved farthest or larger archwire is placed in the arch to be moved the least.
  284. 284. Factors affecting the stability of treatment: 1) Orthodontic factors: a. Removal of dental compensations b. Correction of tooth mass discrepancies c. Leveling of both arches d. Correction of transverse discrepancy e. Production of a double protrusion
  285. 285. 2. Surgical factors: a Soft tissue mobilization b. Distraction of the condyle from fossa c. Method of fixation
  286. 286. MANDIBULAR GENIOPLASTY ADVANCEMENT WITH REDUCTION Factors affecting stability of treatment Orthodontic factors: Very little effect on orthodontic stability, except to anteroposterior relationship to be normalized without excessive flaring of lower incisors. The factors are; 1.Making the occlusion more class II before surgery. 2.Properly managing tooth mass discrepancies before surgery. 3.Adequately leveling upper and lower arches before surgery. 4.Properly managing any transverse discrepancy before surgery. 5.Being aware that deep-bite relapse is not uncommon.
  287. 287. Surgical factor: Skeletal stability is excellent, if it is done as a free bone segment, The primary factor in obtaining the optimal soft tissue esthetic result is related to removing minimal soft tissue from the inferior (mobilized) segment. If the inferior chin segment is not degloved, the skeletal movement of the symphysis carries the soft tissue with 1: 1 ratio. Age related factors: The addition of reduction genioplasty will have no effect on subsequent growth.
  288. 288. MAXILLARY EXPANSION FOLLOWED BY MANDIBULAR ADVANCEMENT : Following surgery, the patient is informed about the appliance activation. Two-one quarter turns per days. The patient is seen 2-5 days following surgery to check his/her understanding about activation. The patient is seen at appropriate intervals until the desired expansion has been achieved. After expansion, the diastema occurs and bone has formed between them in 8-10 weeks after surgery.
  289. 289. FACTORS AFFECTING STABILITY OF TREATMENT: Orthodontic factors: 1.Appliance construction and cementation 2.Appliance activation 3.Maintenance of arch width
  290. 290. MANDIBULAR ADVANCEMENT WITH ANTERIOR MANDIBULAR SUBAPICAL OSTECTOMY The lower arch is usually 16 x 22 T' loop arch wire with loop being placed at the osteotomy sites. Use of light, flexible wires such us Nitinol is not recommended. If loops are avoided the stiff Segmental wires are maintained and light flexible wires are placed over them. Upper and lower arch wires should be coordinated.
  291. 291. FACTORS AFFECTING STABILITY: Orthodontic factors: 1.Adequate room to perform the surgery 2.Teeth properly related within the subapical segment Surgical factors: 1.Inadequate ostectomies 2.Excessive ostectomies
  292. 292. CLASS II DEFORMITIES SECONDARY TO VERTICAL MAXILLARY EXCESS: Post-surgical orthodontic treatment: The arch wire is usually 16 X 22 with 'T' loops at the site of any osteotomy, when there is no problem with bracket alignment on either side of an osteotomy; the 'T' loops are not necessary. Another option is to maintain the sectional archwires placed before surgery and place over these in piggyback fashion, a light flexible archwire.
  293. 293. Factors affecting stability: Orthodontic factors 1.Avoid inappropriate use of vertical mechanics. 2.Maxillary expansion for the adult is done surgically. 3.Make the occlusion more class II before surgery. 4.Properly manage tooth mass discrepancies before surgery
  294. 294. 5.Adequately level both upper and lower arches or segments. 6.Appropriately coordinate the lower arch and upper arch segment. Surgical factors: Two problems are encountered 1) The maxilla is expanded and poor bone contact exists posteriorly. 2.The posterior bone is thin and structurally does not produce a stable interface.
  295. 295. CLASS III DENTOFACIAL DEFORMITIES It is multifactorial in its developmental nature, large mandibles, small maxillae, and both midface deficiency and open-bite. Optimal esthetic results can only be achieved if the skeletal correction is done in the proper jaw. 1.Sagittal split ramus osteotomy setback and 2.Mandibular body ostectomies . with mandibular
  296. 296. Factors affecting stability of treatment: 1. Orthodontic factors: Room to do the proposed surgery Proper arch shape
  297. 297. CLASS III DENTOFACIAL DEFORMITIES SECONDARY TO MAXILLARY DEFICIENCY: 1.Anteroposterior, vertical and transverse maxillary deficiency: In the first post surgical visit, orthodontist removes splint. Check the appliance for damage. Damaged or loose appliance is replaced. When maxilla is surgically expanded, then Continuous upper arch wire is placed with careful coordination with lower wire. Since intentional anteroposterior over correction of 1-3 mm is usually done at the time of surgery, a small class II occlusal discrepancy present. will generally be
  298. 298. CLASS III DENTOFACIAL DEFORMITY WITH OPEN BITE: In such cases, post surgical orthodontic visit is optimally within 48 hours of removal of surgical splint. The arch wires are removed and appliance is checked for damage and necessary adjustments are made. When maxillary segmentalization is done, the teeth on either, side of the osteotomy (ostectomy) are tightly ligated together with a figure of 8 wire around orthodontic brackets and new upper archwire is placed.