Surgical orthodontics

““Surgical Orthodontics”Surgical Orthodontics”
www.indiandentalacademy.com

Specialization in medical practice
emerged when the fund of knowledge in a
clinical area became great enough to
demand particular training to provide
efficient treatment.

Many medical clinical specialities are
dependent on an underlying basic
science(i.e)
Surgery - Anatomy
Urology - Renal physiology
Neurology - Brain Science ,etc.

Two of the distinct specialities in dentistry
are oral and Maxillofacial surgery and
Orthodontics. They have much in common
in that both are based on the underlying
basic science - Craniofacial growth &
development and anatomy

They are seperated from the other dental
specialities not just by distinctive technics,
but by different biological, psychological
and even cultural needs of the patients.

Traditionally an “Orthodontist” and
contemporarily“Dentofacial orthopedician”
has been
considered as the guardian of the growing
face since, he can alter the differential
growth of various craniofacial structures by
growth modulation procedures to achieve a
favourable result.

when an adult patient whose growth has
completed presents to us with severe
skeletal discrepancy, surgical repositioning
of the jaws is the only answer and this is
where as oral surgeon or aptly a Maxillo-
facial surgeon comes into the picture.

But in the past, each had been treating
cases with their own modalities without
acknowledging the importance or the
significance of the other, with less or no
concern at all for the poor patients. This
conflict and controversy still continues….

This incoordination between the oral
surgeon and the orthodontist can be perhaps
attributed to a lack of awareness of the need
of a combined effort for the optimal
correction of the orofacial discrepancies

Patients present to us with umpteen
number of problems.
Each patient is an entity by himself and to
treat such diverse entities one should have
the clinical acumen for the correct
diagnosis, or to find out the abnormal.
2

To find out the abnormal, one should know
what is normal. Further, a knowledge of the
feasible treatment modalities is also
essential.
A correct diagnosis and an ideal treatment
decision are the cornerstones of a
successful treatment. They form the proper
beginning.
2

Envelope Of Discrepancy
The “Envelope of discrepancy” graphically
illustrates the current concepts of how
much change can be produced by the
various treatment modalities.
1

7 12 15
2
5
15
2510
4
6
10
3 5 25
2
5
15
51012
4
6
10
2

Envelope Of Discrepancy
The inner circle indicate the limits to
orthodontic tooth movement ( Camouflage)
alone; the middle circle, tooth movement
combined with growth modification; and
the outer circle, surgical correction.
The precise dimensions of the envelope are
much less important than the concept.
2

It is obvious that greater change can be
produced in a growing child by a
combination of growth modification and
tooth movement than could be produced by
tooth movement alone.
Likewise, a greater change can be
produced in an adult by a combination of
surgery and tooth movement than by tooth
movement alone.
2

However, before we go ahead with the
discussion on the treatment modalities, it is
imperative that we understand the normal
growth and how these deformities develop.
1

Facial structures grow from beneath the
cranium in a downward and forward
direction.
2

Normal Growth
When the horizontal, vertical and
transverse growth components of maxilla
and mandible match that of each other,
normal growth results.
1

A Normal Face
1

Facial Discrepancies
The facial discrepancies present in the
sagittal, vertical and transverse dimensions.
1

Craniofacial Structures
1

First let us see how the discrepancies in
the sagittal direction as Class II and Class
III malocclusion develops..
1

Different Combinations of
Cl II Malocclusion
SAGITTAL DIRECTION
Normal Mandible, Prognathic Maxilla
2

Cl II Malocclusion
Normal maxilla, Retrognathic Mandible.
2

Cl II Malocclusion
Prognathic maxilla, Retrognathic
mandible.
2

Different Combinations of Class III
Malocclusion
Retrognathic maxilla, Prognathic mandible or a
combination of the two.
2

VERTICAL DIRECTION
Discrepancies in the vertical dimension
occurs in the form of a long face or a short
face syndrome.
2

The rotation of the mandible due to vertical
growth discrepancies also has to be
distinguished.
For eg., a class I skeletal case can be rotated
into class II skeletal conditions due to rapid
downward descent of the maxilla.
Forward and backward rotation of the
mandible occur in both class II and class III
skeletal conditions.
3

TRANSVERSE DIRECTION
Transverse discrepancies can be of two
types, laterognathy and laterocclusion.
2

Laterognathy
When the dental and skeletal midlines do
not coincide both at rest and in occlusion.
3

This condition could be due to basal
skeletal abnormalities such as a unilateral
condylar hyperplasia.
1

Laterognathy

Laterocclusion
When the midlines coincide at rest but the
mandible deviates during closure to the
right or the left side.
3

Laterocclusion develops when the
maxillary arch is severely constricted.
On closure, since the mandibular dentition
cannot be accommodated within the
maxillary arch, the mandible deviates in a
convenience bite to one side.
2

It is very critical to distinguish between
these two because the treatment varies
depending on the problem.
In the former situation, a predominantly
surgical approach is required.
In the latter however, an expansion of the
constricted maxilla will usually take care of
the mandibular deviation.
3

Every patient scheduled to undergo a
surgical approach should have a presurgical
orthodontic treatment to carry out
decompensation of the dentition.
1

What is compensation and decompensation ?
In cases of severe jaw imbalances, the teeth
are inclined in such a way as to partially
offset the discrepancies.
For eg., the lower anteriors may be upright
or retroclined in a case of mandibular
prognathism and proclined in mandibular
retrognathism.
3

This is nature’s mechanism to compensate
for the jaw imbalance by proclining or
retroclining the teeth i.e., as a compensation
for the jaw discrepancy.
1

Presurgical orthodontics is aimed at removing
this natural compensation i.e., decompensation.
In mandibular prognathism for eg., the
retroclined incisors should be brought into the
ideal axial inclination by proclining them. In
mandibular retrognathism, the proclined teeth
are brought back.
Often, teeth are extracted for decompensation.
3

Decompensation makes the
maxillomandibular dental relation
temporarily worse. Hence it is sometimes
called “Reverse Orthodontics”.
1

Once decompensation is over, surgery can
be carried out. Decompensation
compliments surgery.
One of the most common surgical
techniques for mandibular advancement or
setback is the sagittal split osteotomy.
2

Why is presurgical decompensation so
important ?
To position the teeth in an ideal axial
inclination with respect to the jaws.
To optimize the magnitude of the surgical
advancement or setback.
3

For better esthetics, stability and function.
If malpositioned anterior teeth are not
corrected they hinder the repositioning of
the jaws at the time of surgery.
2

Surgical Repositioning -
Cl II to Cl I
With Dental
Decompensation
Without Dental
Decompensation

Before surgery, the orthodontist must
establish not only the ideal anteroposterior
and transverse position but also the vertical
position of the teeth.
For instance, in patients who will have
only a mandibular ramus osteotomy, the
vertical position of the incisor teeth
determine the post surgical face height.
2

This in turn will determine whether
levelling an excessive curve of spee should
be done by intrusion of the incisors or
elongation of the posterior teeth.

The major steps involved in treating a case
with orthognathic surgery are:
Pre treatment records.
Multidisciplinary diagnosis and treatment
planning.
Pre surgical decompensation .
Pre surgical records.
5

Cephalometric/photographic prediction
tracing
Model surgery and construction of the
surgical splint
Surgery
Post surgical orthodontics
4

Computer-Aided Photographic Prediction

MODEL SURGERY &
CONSTRUCTION OF SPLINT
3

CASE REPORTS

POORNIMA KAMAT 18/F PRE - SURGICAL PHASE

POST SURGICAL PHASE

Pre treatmentPre treatment Post treatmentPost treatment

Mandibular surgery
Bsso advancement
Bsso setback
Genioplasty
Subpical osteotomy

SAGITTAL SPLIT OSTEOTOMY OF THE MANDIBLE

•MAXILLARY ADVANCEMENT
•MANDIBULAR SETBACK

ADVANCEMENT
GENIOPLASTY
REDUCTION
GENIOPLASTY

Maxillary surgery
Lefort I ostetomy
Lefort II ostetomy
Lefort III ostetomy

Conclusion
Inadequate orthodontic preparation can
jeopardize the quality of the surgical result.
A proper interaction between the
Orthodontic and Surgical team is essential
so that the best results are achieved.
2

We should make a sincere effort to lay an
enduring foundation for a robust and a
lasting co-operation between the
specialities for the sake of providing
excellent care for our patients

We should be open to criticisms and
update ourselves. We should be careful not
to get entangled in dogmatic philosophies
and treatment approaches.

A man who works with his hand is a
labour
A man who works with his hand & mind is
a artist
A man who works with his hand, mind &
heart is a orthodontist!!

I would like to leave you with an
inspirational saying
““Coming together is a beginningComing together is a beginning
Keeping together is progressKeeping together is progress
Growing together is success”.Growing together is success”.

Surgical orthodontics

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