Surgical orthodontics /certified fixed orthodontic courses by Indian dental academy


Published on

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 ,or call

  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. Surgical Orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Dentofacial Deformity:  Refers to deviations from normal facial proportions that are severe enough to be handicapping 1. Affects individuals in two ways: Jaw function is compromised 2. Leads to discrimination in social interactions 
  3. 3.  Handicapping malocclusion↔ Dentofacial deformity “Who is a candidate for surgery in addition to orthodontics?” Severe skeletal or very severe dentoalveolar problem “What makes a problem too severe for orthodontics alone?”
  4. 4. Three possible treatment options for a jaw discrepancy: 1. Growth modification 2. Camouflage 3. Surgical repositioning
  5. 5.  Growth modification  Current consensus: 1. 2. Pattern of growth can be modified in a favourable way Extent of change is rather limited
  6. 6.   Treatment inevitably displaces teeth in the direction of the correcting occlusal relationship- dental compensation for skeletal discrepancy Unless very favourable growth occurs, the dental occlusion is corrected better than the chin deficiency
  7. 7.   - Camouflage: In a patient too mature to grow much more Surgery: Only way to correct a jaw discrepancy “Reverse orthodontics”
  8. 8. “Envelope of Discrepancy”
  9. 9.  Transverse Envelope of Discrepancy
  10. 10. “What makes a problem too severe for orthodontics alone?” - In a child In an older individual
  11. 11. Development of SurgicalOrthodontic Treatment    Before the 1960’s- exclusively reserved for mandibular prognathism Body ostectomy was used to set the mandible back Surgical treatment was done independent of orthodontics
  12. 12.  Unwillingness of the surgeon or orthodontist to use the orthodontic appliance for stabilization
  13. 13.   With steel orthodontic appliances better control than with the heavier but les precise arch bars Orthodontics could be done before and after surgery
  14. 14. Evaluation of Facial Soft Tissues:  - - The Soft Tissue Paradigm: Angle Paradigm: To produce perfect occlusion of teeth and facial beauty would naturally follow Modern Model: Soft tissues largely determine the limitations of orthodontic and orthognathic treatment
  15. 15.  1. 2. Clinicians must establish treatment plans for the dentition and facial skeleton by “reverse engineering” It is revolutionary Diagnosis and treatment planning must be approached differently. Places greater emphasis on clinical examination
  16. 16. Growth and Maturation of Soft Tissues:  - Lips: Lip separation at rest is common in children. Merely a reflection of incomplete soft tissue growth.
  17. 17. - - Vertical growth of upper lip is achieved in females by 14 and lower lip by age 16 In males growth of both lips continues into the late teens
  18. 18. -  - Lip thickness Girls have greater lip thickness than boys at all ages Nose: Grows more vertically than AP
  19. 19.  - - Spurt of adolescent growth occurs in boys Dorsal hump develops in Class II malocclusion Soft tissue chin: In preadolescent girls, soft tissue chin is greater than boys Increased chin projection occurs in males during growth
  20. 20. Soft tissue changes in Younger Adults:      Lips become thinner Interlabial line descends Philtral columns become less prominent Commisures drop in relation to midphiltrum Nasolabial folds become more prominent
  21. 21. Gender Differences:   - In Males: Profile straightens Soft tissue thickness at pogonion increases In Females: Profile does not become straighter Soft tissue chin thickness decreases Trend to show less upper and more lower incisor
  22. 22. Changes at Older Ages:  -   - Nasal Projection: Increase in nasal projection and “droop” of the nasal tip Lip Thickness: Less prominent and change in lip drape Nasolabial Changes: Clockwise rotation of the nasolabial complex
  23. 23. Current Concepts of Smile Evaluation: It is important to consider the soft tissues during facial animation, not just at rest Methods for Smile Evaluation:  The dynamic display zone  Ackerman and Proffit proposed video clips of anterior tooth display 
  24. 24.   Ackerman et al suggested differentiating between posed and spontaneous smiles Spontaneous smile↔ Duchenne smile
  25. 25.  Ackerman et al used a “smile mesh” to analyze photographs of posed smiles
  26. 26. Smile Related to the Natural Dentition:  - - The amount of incisor and gingival display: Elevation of the lip should stop at or near the gingival margin of the maxillary incisors Males show less upper and more lower incisors
  27. 27.  - Transverse Dimension of the Smile: “Buccal corridors” or “negative space” Heavily influenced by the anteroposterior position of the maxilla
  28. 28.  - The Smile Arc: Relationship of the curvature of the upper anterior teeth to the curvature of the lower lip on smile
  29. 29. - Consonant or nonconsonant smile arc Orthodontic treatment, by flattening the smile arc, can make patients look older
  30. 30. Smile Arc Flattening During Orthodontic Treatment:   Bracket placement based on tooth measurements Bracket placement that leads to superior repositioning of the maxillary incisors relative to the posterior segments
  31. 31.   Bracket placement that elongates lower incisors Maxillary incisor intrusion to decrease gingival display
  32. 32. Other Factors:  Habits  Attrition
  33. 33. Assessment of Facial Soft Tissues: Frontal View  - Vertical Facial Proportions: Facial thirds
  34. 34. - - Commisure height no more than 2-3mm more than philtrum height Base of the nose has a “gull in flight” contour
  35. 35.  Excess lower face height has two major components: vertical maxillary excess and excess chin height
  36. 36. - Tooth-lip relationships: In adolescents, 3-4mm of incisor display at rest is normal  Excessive incisor display:  - Judged better at rest May be a result of both hard and soft tissue factors: 1. Short philtrum height -
  37. 37. 2. Vertical maxillary excess 3. Excessive crown height 4. Lingually tipped maxillary incisors Inadequate Incisor Display: 1. 2. 3. 4. Excessive philtrum height Vertical maxillary deficiency Inadequate crown height Flared maxillary incisors
  38. 38. Transverse Facial Proportions:  “Rule of fifths”
  39. 39. The Central Fifth: - Delineated by the inner canthus of the eyes - Inner canthal distance= alar base of nose The Medial Fifth: - Width of mouth= interpupillary distance - Line from the outer canthus should coincide with the gonial angles
  40. 40. The Outer Fifth: - Measured from the outer canthus to the ear helix
  41. 41. Soft Tissue Proportions: Profile View
  42. 42. Soft Tissue Proportions: Profile View  - -  - Projection of the Forehead: Glabella should be coincident with the base of the nose Should slope posteriorly at a 5° angle Nasal and Paranasal Relationships: Bigger the nose, more the prominence of the lips and chin needed
  43. 43. - Prominence of the paranasal areas
  44. 44.  - - Lip projection: Normal lip projection is seen when lips are slightly everted with several mm of vermilion displayed Dental protrusion
  45. 45. - Relationship of the lips to the nose and chin: In a chin deficient patient, lower lip may appear full or procumbent
  46. 46.  -  - Mentolabial sulcus: Affected by the degree of lip support from the incisors and by face height Throat Form: Lip-chin-throat angle: Angle between the lower lip, chin and R point
  47. 47.  - An obtuse angle reflects: Chin deficiency Retropositioned mandible Lower lip procumbency Excessive submental fat Low hyoid bone position
  48. 48.  - Chin-throat length: Distance from the soft tissue pogonion to the R point
  49. 49.  - Chin-neck angle: Also termed cervicomental angle Varies between 105-120º
  50. 50. Diagnosis: Gathering and Organizing the Appropriate Information
  51. 51.    Diagnosis requires two things: collecting an adequate database and distilling from it a problem list The goal of diagnosis is to discover the truth about the patient The objective of treatment planning is wisdom
  52. 52.
  53. 53. Interview:  1. 2. 3. Diagnostic data from the interview is of three types: The patient’s Chief Complaint Patient’s socio-psychological status Medical-dental history
  54. 54. Chief Complaint: - - 1. Patient’s major reason for seeking treatment Necessary to ask a series of leading questions Patient’s fall into two broad groups: Age range from teens to early fortiesgenerally concerned about appearance and function
  55. 55. 2.  Age range from 35-55: concerned about specific health related problem Chief complaint gives insight into what is most important for the individual
  56. 56. Social-Psychological Status: 1. 2. - i. Why are you seeking treatment and why now? What do you expect as a result of treatment? Motivation: Can be internal or external Important to explore motivation for two reasons: Cooperation with treatment and tolerance of treatment procedures
  57. 57. ii. Patient satisfaction with treatment Expectation: - The clinician needs to understand how realistic the expectations are - Is it realistic to expect that TM joint pain will disappear? - Is it realistic to expect a great improvement in interaction with others?
  58. 58. Physical Status: Health History 1. 2. - - What is the patients present condition? What, if anything, may change in the near future that would affect the course of treatment? Seek to evaluate not only the physical health but also the developmental status For dentofacial patients, chronic conditions are of greater concern
  59. 59. Clinical Examination: 1. 2. 3. Health of the hard and soft tissues Oral function, including TM joint evaluation Facial proportions/ esthetics Health of Hard and Soft Tissues: Dental Evaluation: Midline periapical radiographs may be needed
  60. 60.  - - Periodontal Health: Periodontal breakdown and pocketing must be evaluated Adequacy of attached gingiva must be ascertained- gingival grafts may be needed
  61. 61.  - - Oral Function: Mastication Speech: degree of adaptation in this regard is remarkable Neuromuscular adaptation TM joint problems: Dentofacial patients are remarkably similar to patients with normal facial proportions in the prevalence of TM Joint problems
  62. 62. - - General guideline: Range of motion and pain should be evaluated In case of TM joint problems, a splint to overcome muscle spasticity should be prepared.
  63. 63. Diagnostic Records: - - - Dental casts Panoramic and lateral cephalometric radiographs PA cephalogram in patients with significant asymmetry Photographs: A minimum set of four photographs-
  64. 64. 1. 2. 3. 4. Frontal, with lips relaxed Frontal smile 45 degree (three quarter), lips relaxed Profile, in natural head position
  65. 65. - - In cases of lip incompetence, image reflecting lip strain Submental view: mandibular/ midface asymmetry; nasal tip form
  66. 66. - Special problem areas such as loss of attached gingiva TM Joint Imaging: - Panoramic view gives a good picture of condyles - Transcranial, tomographs, CT, arthrography, MRI
  67. 67.  1. 2. 3. Dental Casts: Articulator Mounting? Not required in patients with no TM joint symptoms with no anterior or lateral shifts Desirable in patients with TM joint problems In planning surgical treatment to reposition the maxilla Semiadjustable articulator is satisfactory
  68. 68. Data from Diagnostic Records:   Cephalometric Analysis Analysis of PA Cephalometric Films:
  69. 69.  - - - Analysis of Hand-Wrist Radiographs: Question for dentofacial patients is whether they have reached the adult levels of growth Accuracy declines towards the adult end of the scale. For example: Patients with mandibular prognathism The most accurate measure is obtained from superimposing tracings from lateral cephalometric films
  70. 70. Deriving a Problem List from the Database  -   - First step is to separate the pathologic problems from the developmental problems Periodontal disease, psychological disorders, degenerative TM joint changes Alignment and symmetry of the dental arches Effect of dentition on facial esthetics: Lip separation at rest
  71. 71.  - - Transverse Dental and Skeletal Relationships: Focus is on posterior crossbite and anterior midlines Distinction between skeletal and dental crossbites
  72. 72. Treatment Planning: Optimizing Benefit to the Patient
  73. 73. Treatment Planning: Optimizing Benefit to the Patient  1. 2. 3. Treatment possibilities for Dentofacial Deformity: Growth modification Camouflage Surgery
  74. 74. Camouflage: - - Camouflage means correcting the obvious aspects of the deformity Problem: Being able to predict whether it would be satisfactory
  75. 75.  Class II camouflage: 1. Retraction of protruding maxillary incisors: - Teeth should not be retracted to compromise upper lip Reduction rhinoplasty 2. Displacement of teeth of both arches: - - Puts the incisors in an unstable position Tends to accentuate chin deficiency
  76. 76. - Giving the dentition a “Class II elastics” trip is almost never satisfactory Addition of genioplasty 3. Repositioning the chin and/or nose: - - - To improve balance between lower incisors and chin Makes retraction of upper incisors more acceptable
  77. 77.
  78. 78.  - - - Class III camouflage: Retracting the mandibular incisors into a premolar extraction site usually is not a good idea Extraction of one lower incisor; potential tooth size discrepancy is compensated Onlay grafts and reduction genioplasty
  79. 79. Bottom Line: In dentofacial deformity, orthodontic camouflage is much more likely to be successful in Class II problems than in Class III problems
  80. 80.  - - Camouflage of Asymmetry: Nose is likely to tilt in the same direction; dental midlines closer together Emphasis on correcting the maxillary midline Nasal asymmetry must be addressed
  81. 81. - Moving the chin laterally can conceal the underlying jaw asymmetry
  82. 82. Surgical Camouflage:  1. 2. - Chin Surgery: Addition of some extraneous material Inferior border osteotomy Allows repositioning in all the three planes
  83. 83. - - When moved laterally, may be necessary to add material Advantage of inferior border osteotomy:Ratio of hard to soft tissue change is quite predictable
  84. 84. - - When advanced: soft tissue moves by 60% Reduction genioplasty: 50% soft tissue reduction Vertically: soft tissue moves same amount
  85. 85. Augmentation of Deficient Facial Surfaces:  - Midface and Paranasal deficiency: Lower eyelid tends to droop High LeFort I osteotomy, augmentation
  86. 86. Soft Tissue Procedures:  Esthetic Lip Surgery: - Reduction cheiloplasty for hypermobile lip  Lengthening of the Short Philtrum: - V-Y cheiloplasty as an isolated procedure or in combination with LeFort I osteotomy, rhinoplasty
  87. 87. Orthognathic Surgery:  Changes in Width: Maxilla - Technically it is possible both to widen and narrow the maxilla
  88. 88. - - 1. 2. 10mm of change is maximum Major constraints are palatal soft tissues and soft tissues laterally With a segmental osteotomy, there is more opening posteriorly Considerable relapse tendency Skeletal relapse: Permitted by orthodontic tooth movement Dental relapse
  89. 89. - - 40% decrease in intermolar width achieved at surgery Similar to RPA First attempts: Midpalatal incision Osteotomy in the lateral buttress region
  90. 90. Mandible - Possible to narrow anteriorly but impossible to widen posteriorly
  91. 91.  Anteroposterior and Vertical Changes: Maxilla - - Can be moved forward and upward Forward movement: 10mm and upward 10mm or more Major limitation to forward movement is upper lip
  92. 92.
  93. 93. - Velopharyngeal incompetence: Unrecognized submucous cleft: Phonation cephalometric radiograph
  94. 94. Superior repositioning of maxilla: - - Great concern that neuromuscular adaptation would not occur Fears heightened by denture wearers Mandibular posture does respond to vertical changes in the maxilla
  95. 95. - Pressure receptors in the PDL of maxillary posterior teeth
  96. 96.   Posterior movement of maxilla: Moving the maxilla down is difficult from the point of stability
  97. 97. Mandible:
  98. 98. - 1. 2. 3. Moving the mandible forward or back nearly always causes vertical changes Three possibilities: Down anteriorly and up posteriorly Along the mandibular plane Up anteriorly and down posteriorly
  99. 99.  1. 2. Two important guidelines: Lengthening the ramus should be avoided Planning surgery to elevate the posterior maxilla
  100. 100. - Dentoalveolar Surgery: Can be repositioned in all three planes - Key is maintaining an adequate blood supply 
  101. 101.  1. 2. Guidelines: Nature of tooth movement Size of dentoalveolar segments
  102. 102.   - Timing of Surgical Treatment: Orthognathic surgical procedures have little impact on subsequent growth Deformity caused by excess growth Deformity caused by deficient growth Surgery can be done sooner in deficiency than in excess growth problems
  103. 103. Logical Sequence of Treatment Planning: Pathologic Vs Developmental Problems  Can be divided into three major groups: 1. Chronic systemic disease states 2. Local conditions 3. Psychologic or emotional problems
  104. 104.  Chronic Systemic Diseases: Arthritis - - - Principle in planning treatment: Manipulation of the TM Joint should be as little as possible In children with JRA, functional appliances are not advocated Surgical advancement should be avoided Superior repositioning of the maxilla with genioplasty
  105. 105. Diabetes Has two major implications: 1. Healing is decreased 2. Rapid and severe periodontal bone loss can occur
  106. 106.  Local Conditions:  Trauma 1. - 2. Teeth that have been traumatized are more likely to undergo pulpal and periodontal changes Severe root resorption may occur in traumatized teeth Evaluation of growth and growth potential
  107. 107.  Dental Disease:  Restorative Problems: - - Caries control calls for temporary restorations: composite resins and amalgam are satisfactory Use of sodium fluoride rinse Patients with fixed bridges- sectioning the bridge so that abutments can be repositioned
  108. 108.  Brackets can be bonded on a replacement tooth
  109. 109. - - As a general rule, it is better to retain an existing crown Poor crown margins and exaggerated contour make repositioning impossible
  110. 110.  -  - Periodontal Problems: Definitive periodontal procedures to be deferred Regular recall at 2-3 month intervals Quantity and quality of attached gingiva: Gingival attachment is stressed by orthodontic procedures that expand the arch and by vestibular incisions
  111. 111. - Gingival grafts should not be delayed
  112. 112.  -  - - Psychologic Problems: Considerable caution in proceeding with elective treatment Prioritizing the Developmental Problem List: The first step is to place the problems in priority order Maximize benefit to the patient
  113. 113. - - Patient’s chief complaint must be considered carefully Patient’s must agree with the prioritization of the problem list
  114. 114. Interaction, Compromise and Cost-Benefit Ratio:  -  -  Interaction: Solutions which interact positively by solving multiple problems should be preferred Compromise: May be necessary because not all problems can be solved optimally Cost-Benefit Ratio
  115. 115. Prediction as a Treatment Planning Tool:  Manual Cephalometric Prediction:  Tracing Overlay Method - Simulates the effect of mandibular surgery Limited to surgery that does not affect the maxilla
  116. 116.
  117. 117.
  118. 118. 1. 2. 3. It helps to have dental casts when the prediction is carried out. Trace the incisal and cusp outlines of all the teeth. Major orthodontic tooth movement should be simulated on a diagnostic set up Estimates are based on changes in lip position at rest
  119. 119. Template Method  When maxilla will be repositioned, major tooth movements, chin repositioning
  120. 120.
  121. 121. - - - Templates are made for the entire maxilla with a one-piece or two-piece osteotomy Importance of locating the condyle as accurately as possible Possibility of repositioning the chintemplate prepared by tracing the anterior and inferior outlines of the chin
  122. 122. Computer Prediction: 1. 2. A digital model of the ceph tracing is entered into the computer program A lateral image of the patients profile closely matching the cephalogram must be captured
  123. 123. 3. The digital tracing is “sized” to fit the facial 4. 5. image A “treatment screen” provides the clinician with “handles” to move the hard tissues The computer program applies the embedded soft tissue algorithms
  124. 124. The software “warps” the profile image to match the prediction line drawing 7. A quantitive table records the exact movements in millimeters Accuracy of computerized predictions? - Far from perfect but good enough to be useful clinically - Chin and upper lip are good, lower lip area is problematic 6.
  125. 125.
  126. 126.
  127. 127. Advantages: - Ease of multiple predictions - Better communication Disadvantages: - Cost - Limitations of the existing programs
  128. 128. Cast Prediction(Model Surgery) - - - Dental cast version of cephalometric prediction In its simplest form requires articulating the casts by hand Generally is not required at this stage
  129. 129. Combining Surgery and Orthodontics: Who Does What, When?
  130. 130. Presurgical Orthodontics:   - - It is neither necessary nor desirable to set things up perfectly presurgically Goals: Align the teeth Establish anteroposterior and vertical position of incisors Arch compatibility
  131. 131. Selection of the Appliance: - Should allow rigid stabilization - Should include:  Headgear tubes on upper molars  Auxiliary tubes on upper and lower molars  Lingual cleats or hooks on molars - The less visible the appliance, the less impact it has on social adjustment 
  132. 132.     Lingual appliance is ill suited because: Impossible to use it to stabilize the jaws Difficulty in manipulation post-surgically Plastic and ceramic brackets Routine stainless steel twin or single brackets with wings Both 18 and 22 slot bracket systems can be used
  133. 133.  Bracket positioning is no different- tip the brackets on teeth adjacent to the osteotomy sites
  134. 134.  1. 2. 3. Alignment: The First Step in Treatment Achieved by tipping the crowns of the teeth Initial wires should be: Round rather than rectangular Undersized Highly resilient
  135. 135.  - - Vertical Position of the Teeth: Leveling the Arches When the mandible is moved forward or back surgically, the vertical position of the lower incisors will determine the face height The difference between leveling by extrusion and leveling by intrusion is largely a difference between continuous and segmented arch wires
  136. 136.
  137. 137.  Leveling within the segments
  138. 138.  - - Anteroposterior Incisor Position Will determine how much one jaw can be moved relative to the other jaw Eliminate dental compensation Modest overtreatment of incisor position is desirable
  139. 139.  - - - Arch Compatibility: Expansion of constricted arch forms Heavy labial auxiliary to accentuate the effect of main arch wire Orthodontic expansion should be limited to 23mm per side Not more than half-cusp crossbite correction should be left for post-surgical orthodontics
  140. 140.  - - Judging arch compatibility can be difficult In mandibular advancement, arch compatibility can be judged clinically In maxillary advancement or mandibular setback, compatibility can only be judged with study casts
  141. 141.
  142. 142. Final Surgical Planning and Preparation:  - - Presurgery Records Include panoramic and lateral cephalometric radiographs, dental casts, photographs, PA ceph in significant asymmetry An ideal time is about 2 weeks before surgery
  143. 143.  - -  Cephalometric/ Computer Image Predictions and Model Surgery: Cephalometric prediction must be done before the model surgery When is it necessary to use a facebow transfer to mount the casts on an articulator? If the condyles will be separated from the dentition, there is no advantage in maintaining this relationship during model surgery
  144. 144. 1. 2. Model surgery serves two purposes: Verification of planned movements Fabrication of occlusal wafer splints The best orthodontics and the most skillful surgery can be negated by poor presurgical planning
  145. 145. Model Surgery- Single Jaw Surgery
  146. 146. Model Surgery - Double Jaw Surgery Impressions Wax bite to record Pre surgical occlusion Face-bow record
  147. 147. Casts mounted on semi-adjustable articulator
  148. 148. Mounting of maxillary cast with spacer
  149. 149. Blue plaster used for initial mounting
  150. 150. Jig positioned in articulator
  151. 151. Maxillary cast stabilized with putty
  152. 152. Initial mounting plaster removed
  153. 153. Maxillary impaction
  154. 154. Measurement of amount of impaction
  155. 155. Simulation of mandibular autorotation
  156. 156. Intermediate splint
  157. 157. Mandible advanced to desired position
  158. 158. Final splint fabricated
  159. 159. Final Splint
  160. 160. If the jig is not available, markings can be made on the cast
  161. 161.  1. Common Problems at this Stage Interferences from the second molar teeth: arise from the absence of bands on lower second molars or from the presence of bands on the upper second molars
  162. 162. 2. Incompatible canine widths: rarely a problem in Class II patients; Class III patients cannot simulate the postsurgical position
  163. 163. 3.  -  Lack of space for interdental osteotomy cuts: 4-5 mm of root separation is required Stabilizing Arch Wires and Splints Full dimension rectangular wire; at least 21x25 in a 22- slot appliance and 17x25 in a 18- slot appliance Attachments for maxillomandibular fixation Soldered brass spurs are preferred
  164. 164.  1. 2. Crimp-on hooks are a tempting but dangerous option: May become loose Act of crimping can distort the wire
  165. 165. Postsurgical Orthodontics - - - When healing has reached the point of satisfactory clinical stability First step is to remove the splint and stabilizing arch wires.Price of removing the splint alone is a centric relation- centric occlusion discrepancy Insertion of working wires: 17x25 TMA, 19x25 TMA or 21x25 NiTi; 16 or 18 round steel
  166. 166. Placement of light vertical elastics; should be worn full time - Elastics serve two purposes:  Bring the teeth into solid occlusion  Override the proprioceptive drive - Transverse control is maintained by using a heavy labial auxiliary wire placed in the headgear tubes -
  167. 167. - - -  - Second appointment: elastics can be omitted while eating; Class II or Class III vector Third appointment: elastics only at night Observe patient for 4-6 weeks without elastics before debonding Appliance removal: 4 months after returning from the surgeon Retention: Care to prevent transverse relapse
  168. 168. Surgical Treatment
  169. 169. Principles of Surgical Management:  Advantages and Disadvantages of Rigid Internal Fixation: Advantages 1. Improved comfort and convenience: Improved nutrition, speech, oral hygiene 2. Increased safety in the immediate postoperative period: When excessive haemorrhage or vomiting occurs, easy access to the mouth and pharynx
  170. 170. More rapid bony healing 4. Ability to stabilize multiple bony segments: 3. Cases in which bony contact is insufficient for direct wiring Increased stability 6. Faster reduction of postoperative edema 7. Rehabilitation of muscles and TM joint 5.
  171. 171. Disadvantages 1. 2. 3. Technical Difficulties: Plates must be contoured so as to adapt passively. Postsurgical adjustment of the segments is difficult Increased Costs Possible Need for Plate Removal: Presence of a palpable plate or screw, persistent wound infection, metal sensitivity
  172. 172. Neurosensory Disturbances 5. Postoperative TM Joint Symptoms: Torquing, 4. distraction or rotation of the condylar segments
  173. 173. Maxillary Surgery
  174. 174. Maxillary Surgery:  - - - Historical Development: Originated by Cheever in 1864 to gain access to the nasopharynx In 1921, Herman Wassmund employed maxillary osteotomy to correct dentofacial deformity In 1934, Auxhausen related his experiences with mobilization of the maxilla
  175. 175. - - - In 1952, Converse reported on maxillary osteotomy Stoker and Epker offered encouraging results Wilmar, Obwegeser and Bell led American surgeons to adopt totally maxillary osteotomy procedures Allows the maxilla to be moved in all three planes of space
  176. 176. LeFort I Osteotomy: Surgical Techinque  External reference mark is established at the frontonasal area by inserting a Kirschner wire or Steinmann pin
  177. 177.
  178. 178.
  179. 179.
  180. 180.
  181. 181.
  182. 182.
  183. 183. Maxillary Segmentation:   To facilitate expansion or contraction, leveling of the occlusal plane or space closure Paramidline sagittal osteotomy minimizes the defect in the palate
  184. 184.  - Stabilization and Fixation: With rigid fixation, maxillomandibular fixation should always be removed and the occlusion checked
  185. 185.   - Nasal Airway Considerations: Adverse effect on nasal breathing because space in the nasal cavity is reduced? Nasal resistance usually decreases When maxilla is moved up, alar base widens
  186. 186. - Nasal septum is repositioned without buckling Excessive flaring: suturing of transverse nasalis muscle/ alar base cinch suture
  187. 187. Segmental Surgical Techniques: Maxilla  Historical Development: Kole, Murphey and Walker, Mohnac Maxillary Subapical Osteotomy Wassmund and Wunderer
  188. 188.   - By 1980’s greater flexibility of LeFort I osteotomy relegated maxillary subapical osteotomy Indications for isolated posterior maxillary subapical osteotomy: Reposition posterior dentoalveolar segments Isolated unilateral posterior crossbite
  189. 189. Surgical Techniques:  - - - - Anterior Subapical Osteotomy Performed either in isolation or in conjunction with mandibular anterior subapical osteotomy Most easily moved in a posterior and inferior direction With difficulty, can be moved in a superior direction Anterior movement is almost impossible
  190. 190.   Accomplished by using modifications of the Wassmund or Wunderer techniques Wassmund Technique:
  191. 191.
  192. 192.
  193. 193. • Palatal soft tissue pedicle should be inspected to make sure that it is not folded on itself
  194. 194.  Wunderer Technique:
  195. 195. - - With the Wunderer technique, a premolar can be removed on one side and a molar on the other If necessary, the segment can be divided in the midline for expansion
  196. 196.  - Posterior Maxillary Subapical Osteotomy: For isolated unilateral posterior crossbite or excessive eruption of posterior maxillary teeth
  197. 197.
  198. 198. • When sufficient bone exists distal to the terminal molar, vertical cuts made in this area
  199. 199.
  200. 200. Mandibular Surgery
  201. 201. Historical Development:     Prior to the 1950’s, body ostectomy for shortening the mandible Ease of access and prevalence of missing teeth Caldwell and Letterman’s paper on vertical subcondylar osteotomy in 1954 Surgical procedures to lengthen the mandible: intraoral surgery popularized by Trauner and Obwegeser
  202. 202. -  - • 1. 2. Intraoral approach to vertical subcondylar osteotomy Sagittal-Split Osteotomy: Surgical Technique Originally described to American surgeons by Obwegeser Advantages: Great flexibility Broad bony overlap
  203. 203. Minimal alteration in position of muscles and TMJ Technique: 3.
  204. 204.
  205. 205.
  206. 206.
  207. 207.  - - - Transoral Vertical Ramus Osteotomy: Option for correction of mandibular prognathism Used alone or in combination with sagittalsplit osteotomy on the opposite side Intraoral approach minimizes the disadvantages of the extraoral approach
  208. 208. Difficulties exist when large posterior repositioning or asymmetry is present - RIF techniques are difficult to apply Technique - Initial incision similar - Periosteum reflected from the sigmoid notch to inferior border -
  209. 209. - Few mm of periosteum reflected on the medial aspect
  210. 210. - Stabilization and Fixation:
  211. 211.  - - Patients are left in MMF for 4-6 weeks Extraoral Vertical Ramus Osteotomy: Most common procedure for setback Scars from skin incisions and damage to the facial nerve Modifications have made advancement possible
  212. 212.  - - - Technique: Skin incision made below the angle and posterior body of the mandible Facial nerve identified and protected Osteotomy: 5mm in front of posterior border and behind the neurovascular bundle No fixation, direct wiring, screws or bone plates
  213. 213.  - Combined Vertical Ramus and Sagittal Osteotomies: When large advancements are needed Skin incision extended as far forward as the mental foramen
  214. 214.
  215. 215.  - - Body Ostectomy: First procedure performed in orthognathic surgery Special indications today: narrow the dental arch; when deformity is primarily an elongation of the body
  216. 216.  Inferior alveolar neurovascular bundle decompression
  217. 217.
  218. 218.  Inferior Border Osteotomy: - To reposition the chin in all three planes - Decompression usually not necessary
  219. 219.
  220. 220.
  221. 221.
  222. 222.
  223. 223.  - - Anterior Subapical Osteotomy: To close anterior open bite, to depress elevated anterior dentoalveolar segment, to advance or retrude Combined with anterior maxillary subapical osteotomy
  224. 224.  Technique:
  225. 225. - Neurovascular decompression may or may not be required
  226. 226.
  227. 227.  - - Total Subapical Osteotomy: Major technical problem centers on management of neurovascular bundle Indicated when deformity is confined to the dentoalveolar aspect
  228. 228. - Tangential cut extends from alveolar crest into residual mandibular canal
  229. 229. Mandibular Deficiency
  230. 230.  - Diagnostic Characteristics: Chin and lower lip deficiency Everted lower lip Increased overjet Anterior deep bite Excessive Curve of Spee More severe maxillary than mandibular incisor crowding
  231. 231.  In short face individualsdeficiency at the lower lip more than at the chin
  232. 232. - Interaction between the vertical and AP positions of the lower incisors and the chin
  233. 233.  1. 2. Anterior deep bite causes two functional problems: Irritation of gingival tissues Tendency of TM joint clicking The deep bite may predispose to TM joint problems but is unlikely to be their sole cause
  234. 234.  - - - Surgical Approach: In patients with short face height, the chin needs to be moved down Difficult to move the chin down nonsurgically by rotating the mandible at the condyles Half or more of the rotation created is lost in retention
  235. 235.  Subapical Osteotomy vs Ramus Osteotomy:
  236. 236.  Indication for subapical osteotomy:  Prominent chin relative to the dentition; face height only slightly reduced Presurgical Orthodontics:  Goals: 1. 2. 3. Align irregular teeth Establish AP and vertical incisor position Establish compatible arch forms
  237. 237.  - - Orthodontic Approach Need to properly position the incisors in both the vertical and AP planes of space Extraction decision Tendency towards posterior crossbite when mandible is advanced more than a few mm
  238. 238.
  239. 239.  - - - Levelling: Done by post surgical extrusion Arch wires are flat in the upper arch and with an accentuated curve in the lower arch If intrusion is required- segmented arches Extraction spaces should be completely closed Culmination with placement of full dimension rectangular wires
  240. 240.  - - Final Presurgical Planning: Presurgical records to be taken When ramus surgery alone is planned, no need to mount No further tooth movement should occur
  241. 241.  1. 2. 3. 4. Guidelines for Positioning Casts for Splint Fabrication: Keep things symmetrical in the transverse plane Bring incisors in an ideal relationship, not overcorrecting Keep skeletal midlines correct If wire osteosynthesis/MMF, bring incisors in an edge-to-edge relation
  242. 242.  Surgery: - BSSO   - Remove 3rd molars: erupted or impacted Teeth are in the surgical site Best site for lag or position screws BSSO may be combined with inferior border osteotomy
  243. 243. - - -   Lengthening the inferior border is a predictable procedure AP chin reduction is not esthetically predictable With large advancements, extraoral ramus procedure may be indicated Maxillary surgery: To widen the maxilla To bring the maxilla down
  244. 244.  - - - Postsurgical Orthodontics: Splint should not be removed till the patient is ready for orthodontics Mandibular advancement patients to be levelled postsurgically make a “three-point landing” occlusally Orthodontic treatment can resume 3-4 weeks with RIF and 6 weeks with wire osteosynthesis/ MMF
  245. 245. Long Face Problems
  246. 246.  - - - Diagnostic Characteristics: Excessive lower facial height: It is impossible for a long face patient not to have a problem in the AP plane of space Lip incompetence: Unfortunately, lip incompetence by itself is misleading A tendency towards an anterior open bite: 1/3rd may have normal or even deep bite
  247. 247. - - - A tendency towards mandibular deficiency and Class II malocclusion A tendency towards more crowding of the lower than the upper incisors A tendency toward a narrow maxilla and posterior crossbite
  248. 248.  - Cephalometrically, long face patients have the following: Rotation of the palatal plane down posteriorly
  249. 249. - - Excessive eruption of maxillary posterior teeth Rotation of the mandible down and back Excessive eruption of the mandibular and maxillary incisors
  250. 250.   - - Treatment Planning Adolescents with Questionable Growth Potential: Most long face patients have a receding chin and a Class II malocclusion A camouflage treatment plan is ineffective Incisors elongate, nasolabial angle will increase, effects of Class II elastics
  251. 251. - - If extraction for camouflage is to be avoided, is there any orthodontic alternative for the long face adolescent? Growth modification after the adolescent growth spurt is more a theoretical than actual possibility
  252. 252. - - - Anterior open bite in adolescents(or adults) often can be corrected with orthodontic treatment Open bite correction almost totally occurs by elongation of the incisors Elongation of the lower incisors is both more stable and more esthetic than elongation of the upper incisors
  253. 253.
  254. 254.
  255. 255.   Lower border osteotomy in borderline cases Relaxing the lower lip also improves the stability of the lower incisors
  256. 256.   Adults with Little or No Growth Potential A patient who has a genuine long face problem and who refuses surgical correction is better left untreated Surgical Approach: Three options 1. Superior repositioning of the maxilla or at least the posterior part
  257. 257. Mandibular surgery to bring the lower jaw forward and upward 3. Inferior border osteotomy Guideline: 2. In patients whose face height should be reduced, maxillary surgery is the primary procedure
  258. 258.  1. 2.   Maxilla is the focus of treatment for 2 reasons: It nearly always has excess vertical development Moving the maxilla up produces a stable correction Class I rotated to Class II Class III rotated to Class I
  259. 259.   - If mandible is small, ramus osteotomy is indicated Dentoalveolar segments can be created: Two segments for widening of the maxilla Three segments for moving the posterior segment up
  260. 260.  1. 2. Presurgical Orthodontics Incisions tend to stress the gingival attachments; place grafts at least 2-3 months before surgery Patients with anterior open bite and vertical steps in the arch
  261. 261. It is a mistake to level the upper arch presurgically because this produces a relapse tendency
  262. 262. 3. Orthodontic or surgical expansion  Final Presurgical Planning Two critical elements: 1. How far the maxilla is moved up 2. If there would be residual overjet with straight vertical movement
  263. 263. 1. How far the maxilla is moved up: - Moving the maxilla too far up is harmful - It is better to leave 4 mm of lip separation - Associated soft tissue changes accentuate this effect 2. Residual overjet with vertical movement: - Moving the maxilla back is bad for esthetics
  264. 264.
  265. 265.  Patients who posture the mandible forward are a problem
  266. 266.
  267. 267.
  268. 268.
  269. 269.
  270. 270.  - - Postsurgical Orthodontics Maintaining transverse maxillary expansion achieved at surgery Patients who had maxillary expansion should wear their retainer diligently
  271. 271. Class III Problems
  272. 272. Surgical Options:  - - - Maxillary versus Mandibular Surgery: Setting the chin back was the original orthognathic surgical procedure Although maxillary osteotomies were introduced in the 1960’s mandibular setback remained till the 1980’s Why did this change occur?
  273. 273. - - When the mandible is set back, the volume of the oral cavity is reduced Undesirable changes in throat form accompany mandibular setback
  274. 274.
  275. 275. - When maxillary deficiency is part of the Class III problem
  276. 276. -  In severely affected individuals, maxillary deficiency is three dimensional Treatment of transverse and vertical deficiency can be problematic
  277. 277.  LeFort I osteotomy plus lower border osteotomy
  278. 278.  - - Timing of Orthognathic Surgery in Class III Patients: Can be done early to control social handicaps but late growth can lead to relapse If Class III problem is due to maxillary deficiency, surgery can be done earlier
  279. 279.
  280. 280.  Serial cephalometric radiographs at yearly intervals
  281. 281.  - 1. - 2. Orthodontic Preparation for Surgery: Class III patients have two types of dental compensations Extraction of maxillary first premolars is often required Should the orthodontist totally close the extraction spaces prior to surgery? Moving the lower incisors forward provides better tooth-lip balance
  282. 282. - 3. - 4. - Extraction of mandibular second premolars If there is not a posterior crossbite before surgery, there will be afterward Check for arch compatibility Should surgically assisted RPA be done for transverse maxillary deficiency? Reserved for the patient who needs large expansion (10mm or more)
  283. 283. 5. - Should model surgery and splint fabrication build in overcorrection for postsurgical relapse? Under no circumstances should the dental casts be placed with more than 2-3mm of excess overjet
  284. 284.  - - Special Considerations at Surgery: Stabilization after a segmental osteotomy must be carefully managed Downward movement of the maxilla is also a stabilization problem
  285. 285. - Controlling the inclination of the ramus during mandibular setback
  286. 286.  - - Postsurgical Orthodontics: Labial wire to maintain transverse expansion Elastics in a triangular pattern with a Class III component Retention: If mild continuing relapse towards Class III, light Class III elastics at night
  287. 287. Special Considerations in Cleft Palate Patients: - - - Most cleft palate patients have a tendency towards Class III malocclusion Almost never in a cleft palate patient is it a good idea to attempt Class III camouflage Retrusive upper incisors are not an argument for compensatory extraction in the lower arch
  288. 288.  1. 2. Posterior crossbite in cleft patients: Surgical intervention has produced tight palatal tissue No equivalent of a mid palatal suture
  289. 289. Orthognathic Surgery in Cleft Patients: - - 1. 2. Almost always involves moving the maxilla forward Two limiting factors in surgery for cleft patients: Residual scarring from previous surgeries Risk of producing velopharyngeal incompetence
  290. 290. -  - Both scarring and speech effects limit the amount of maxillary advancement possible Surgical Orthodontic Coordination: Timing of orthognathic surgery is critical Difference in orthodontic preparation Moderate overcorrection of anterior crossbite is desirable
  291. 291. Dentofacial Asymmetry
  292. 292.   Perfect facial symmetry is exceedingly rare All normal faces have a degree of asymmetryuse of composite photographs
  293. 293.
  294. 294.  - Special Considerations in Diagnosis and Treatment Planning: Careful history taking Obtaining a PA cephalogram Care while taking lateral cephalograms
  295. 295.  Use of stereolithographic models for planning surgery
  296. 296. 2. Timing of Treatment: Progressive deformity vs stable deformity Common conditions causing asymmetry: Hemifacial microsomia Condylar fractures 3. Hemimandibular hypertrophy   1.
  297. 297.    In preadolescent children, hemifacial microsomia and condylar fractures cause severe asymmetry Both primarily affect the mandible, maxilla is affected secondarily Basic difference, in hemifacial microsomia both hard and soft tissue elements are missing
  298. 298.   Early treatment: use of hybrid functional appliances Should be continued only as long as it is effective
  299. 299. Hemifacial Microsomia: - Grade I: Soft tissues and mandible are deficient on the affected side - Grade II: Condyle, ramus and glenoid fossa may be present or absent - Grade III: Complete absence of condyle and ramus
  300. 300.
  301. 301. - Children with grade I and mild grade II may respond favorably to functional appliance therapy
  302. 302.
  303. 303. - Surgical Correction: Three stages of surgical intervention: Converse; Vagervik, Hoffman and Kaban  Surgical phase I: tissue augmentation.  - - Replace missing skeletal elements and augment severely deficient areas If a patient has a ramus and condyle, it is better to accept this articulation
  304. 304. 1. 2. Two approaches to augmentation: Inverted L osteotomy Distraction osteogenesis
  305. 305. -  - - Functional appliance in the immediate postsurgical period to control eruption of teeth and improve the cant of maxilla Surgical phase 2: jaw relationships After the adolescent growth spurt, should address orthognathic concerns Inferior border osteotomy; onlay bone grafts Less likelihood of maxillary surgery
  306. 306.  - - Surgical phase 3: contour modification To enhance the contour of the skeleton and soft tissues Soft tissue augmentation with fat Ear reconstruction
  307. 307.  - - - Condylar Fractures: Management of Post- Traumatic Asymmetry More growth on the normal than the affected side Old condylar fracture or mild hemifacial microsomia? Response to a functional appliance should be evaluated
  308. 308.
  309. 309.
  310. 310.    1. 2. - Purpose of surgery is not to correct the asymmetry Remove TM Joint restrictions Surgical reconstruction: Use local tissue Costochondral graft In children costochondral graft does not work well
  311. 311.  -  - Hemimandibular Hypertrophy: Formerly called condylar hyperplasia Usually becomes apparent after the adolescent growth spurt Tends to be self limiting Clinical Management: If asymmetric stops, delay the surgery If severe enough, remove the growth site
  312. 312. 1. Two modes of presentation: Head remains normal in size, neck increases
  313. 313. 2. Condylar head enlarges
  314. 314.  Technetium bone scan
  315. 315.  1. 2. Surgical options: Excision of bone at the head of the condyle Removing the condyle and condylar process
  316. 316. - - Sagittal split osteotomy on the unaffected side Maxillary surgery if maxilla is canted
  317. 317.
  318. 318.
  319. 319. Asymmetry in Adults:  - - Treatment Planning Considerations: Extent to which surgery will be used to correct the deformity at its point of origin Nose may deviate in the same direction as the chin: moving the jaw magnifies the deviation of the nose
  320. 320.
  321. 321. - - 1. 2. - Goal of presurgical orthodontics is to remove dental compensations Two approaches to transverse decompensation: Asymmetric extraction Asymmetric elastics Correction of canted maxilla by LeFort I osteotomy
  322. 322. - - Asymmetric elastics in patients who have undergone surgery Box elastics with Class II component on one side and Class III component on the other
  323. 323. References: Contemporary Treatment of Dentofacial Deformity - William R. Proffit, Raymond P. White Jr., David M. Sarver  Contemporary Orthodontics - William R. Proffit, Henry W. Fields Jr.  Orthodontics: Current Principles and Techniques - Thomas M. Graber, Robert L. Vanarsdall Jr. 
  324. 324. Thank you For more details please visit