3. Introduction
Indications
Psychological implications
Collection of records
Treatment plan
Different surgeries
- maxilla
- mandible
References
4. ORTHOGNATHIC SURGERY is the art and
science of diagnosis treatment planning and
execution of treatment by combining
orthodontics and oral and maxillofacial surgery
to correct musculoskeletal, dento osseous and
soft tissue deformity of the jaws and associated
structures .
5. It is indicated in patients who have skeletal problems, dento
alveolar problems that are too severe to be corrected by
orthodontics alone, in whom growth is completed and growth
modifications cannot be done.
6. When a jaw discrepancy accompanies a severe
malocclusion, there are three broad possibilities for
correction:
(1) growth modification,
(2) camouflage (orthodontic positioning of the teeth to
compensate for the jaw discrepancy),
or
(3) orthognathic surgery in conjunction with
orthodontics to reposition the jaws and/or dentoalveolar
segments.
7. Proffit and Ackerman introduced the concept of the
envelope of discrepancy to graphically illustrate how
much change can be produced by various types of
treatment.
The inner circle, or envelope, represents the limitations
of camouflage treatment involving only orthodontics;
the middle envelope illustrates the limits of combined
orthodontic treatment and growth modification;
and the outer envelope shows the limits of surgical
correction.
10. Growth modification, generally referred to as
dentofacial orthopedics, is the most desirable
approach to a severe skeletal problem when the potential
for further growth exists.
Although the pattern of growth can be favorably
modified for some patients, the capacity for major
increments in growth is rather limited.
The variation in response of individual
patients, however, suggests growth modification should
be attempted in preadolescent patients.
11. When a moderate skeletal discrepancy exists and there
is no potential for further growth (or if more change is
required than can be accomplished through growth
modification alone), orthodontic camouflage should be
considered.
The teeth are repositioned to establish normal overjet
and overbite in an effort to compensate for the jaw
discrepancy .
12. The final treatment option for a severe skeletal
discrepancy is orthognathic surgery. Once growth has
ceased, surgery becomes the only means of correcting a
severe jaw discrepancy. Although surgery may allow
greater changes, there are still limitations to the surgical
options, depending on the type of problem and direction
of desired jaw movement, and certain problems are
more receptive to surgical correction than others.
13. The term reverse orthodontics is often used in reference
to the deliberate movement of teeth in a direction that
appears to make the worse initially when preparing the
dentition for orthognathic surgery.. When dental
compensations exist, they limit the distance the jaws can
be repositioned to achieve a desirable esthetic result.
14. First mandibular osteotomy : HULLIHEN (1849) done
to correct a protrusive malposition of a mandibular
alveolar segment.
In 1927, WASSMUND introduced total maxillary
osteotomy and inverted “L” ramal osteotomy, by
external approach.
In 1959, TRAUNER and OBWEGESER introduced
sagittal split osteotomy as the beginning of a new era of
orthognathic surgery.
The beginning of the early orthognathic surgery was in
St.Louis where the orthodontist Edward Angle and the
surgeon Vilray Blair worked together
HISTORY
15. Epker, Bell and Wolford developed Lefort-1 maxillary
downward fracture ,so that we can keep the maxilla
stable in all 3 planes of spaces.
By 1980 progress has reached to such an extent
that, it is possible to reposition either or both the jaws
and to move the chin in all 3 planes of spaces & Rigid
internal fixation made it possible for comfort and better
immobilization after surgery.
AJODO. 2007 Feb;131(2):263-7
16. CASE(1921): To correct malocclusions to normal
function and esthetic relationship and to beautify facial
outline.
ACKERMAN AND PROFFIT(1970): To establish
optimal proximal and occlusal contact of the teeth
within the framework of acceptable facial
esthetics, normal function and stability.
LINDQUIST(1985): To improve facial esthetics, to
align the teeth evenly; to create good occlusal
relationships; static and functional; to obtain
psychological benefits; to maintain healthy supporting
structures and stable dentition.
ROTH(1992): To serve the patient‘s needs in the five
categories of facial esthetics, dental esthetics, functional
occlusion, periodontal health and stability.
17. ETIOLOGIC FACTORS
Dentofacial deformity Developmental problem.
ETIOLOGY
KNOWN SPECIFIC
CAUSE
HEREDITARY
FACTORS
ENVIRONMENTAL
INFLUENCES
Occasionally the deformity is due to a single specific cause,
much more frequently they result from a complex interaction among
multiple factors that influence growth and development.
18. FACIAL SYNDROMES ,
CONGENITAL DEFECTS,
WHOSE ETIOLOGY IS PRE-NATAL
POST NATAL GROWTH
DISTURBANCES, INCLUDING THE
EFFECT OF TRAUMA
1.SPECIFIC CAUSES
FAS AND RELATED PROBLEMS
ABORMALITIES OF NEURAL CREST CELL
ORIGIN AND MIGRATION :
Hemifacial microsomia
Mandibulofacial dysostosis
ACHONDROPLASIA
PREMATURE FUSION OF CRANIAL AND
FACIAL SUTURES:
Crouzon’s syndrome
Apert’s syndrome
TRAUMA:
Maxillary trauma
Mandibular trauma(functional
ankylosis)
MUSCLE DISTURBENCES
Torticollis
CONDYLAR HYPERPLASIA
FACIAL CLEFTING SYNDROME
19. 2.HEREDITARY FACTORS
Malocclusion is much more common now than it was in
primitive human populations. It seems logical that, the effect of
increased Consangineous marriage among previously isolated
population subgroups would be an increase in number of
individuals requiring orthodontic –surgical treatment.
The influence of inherited tendencies seems to be particularly strong
for mandibular prognathism.
Craniofacial anomalies often have a genetic background
.Recent advances in molecular genetics have revealed a genetic
explanation for conditions that do not even appear to be genetic in
origin .
20. 3.ENVIRONMENTAL INFLUENCES
Environmental influences on dento facial development includes external
influences such as trauma ,but more importantly , this category includes
the group of etiologic factors related to functions of jaws.
Form Function
The form function interaction includes both the effects of active
movement and the long lasting effect of the soft tissue pressure on the
developing skeletal and dental structures.
Soft tissue pressure on development of dentofacial skeleton
21. Respiratory influence
Mouth breathing has been blamed for altered dentofacial development
Harvold et al, showed that total blocking the nares
led to Various moderate to severe malocclusions,
Because the lower jaw was positioned forward , the
deformity always included a component of mandibular
prognathism along with various displacements of teeth
Total nasal obstruction
Downward backward rotation
Long face deformity
(AJODO, vol 79. 1981).
22. 1.When orthodontic treatment alone cannot
correct a problem.
2.To improve jaw function.
3.To enhance the long term orthodontic result
(stability).
4.Reduction in overall treatment time.
5.Change in facial appearance.
6.Improved breathing.
7.Improved speech.
8.Improvement in jaw pain.
23. One answer to the question of "When is a problem too
severe for orthodontic treatment only?" is "When the
combination of tooth movement and growth modification does
not have the potential to bring the patient to normal occlusion."
24. Some uncommon dentofacial deformities requiring
orthognathic surgery includes, cleft lip and
palate, Pierre robin syndrome, treacher- Collins, aperts
syndrome.
Facial asymmetry is seen in parry- romberg
syndrome, goldenhar syndrome, hemifacial hypertrophy
and unilateral ankylosis treated at early age .
Mid face deficiency is seen in syndromes like
craniosynostoses, apert`s, crouzon`s, pfeiffer, binders
syndrome, achondroplasia dwarf and cleidocranial
dysplasia.
Mandibular deficiency is seen in pierre robin, treacher-
collins, and goldenhar (hemi facial microsomia)
syndrome. Mandibular prognathism is seen in gorlin –
goltz syndrome, achondroplasia, klinefelter syndrome.
25.
26. Facial deformity is
defined as ― a
physiognomic form that
is sufficiently negatively
marked, so as to set the
individual apart from the
general population‖.
A dentofacial
anomaly may have an
adverse effect on an
individuals self esteem
and self confidence as
well as evoke an
undesirable social
response .
27. FACE IS THE INDEX OF MIND
The area of the body which maximally determines
physical attractiveness is the face. It is a primary means of
identification , expression and non-verbal communication.
There is a high value of cosmetic characteristics in the
current society and severe cranio-facial deformity may
cause significant psychosocial problems.
28. Concept of “Body image” ( Schilder and Schonfeld )
2 components of body image are
1. Body sense
2. Body concept
Body sense
The actual appearance the person sees when viewing himself in a
mirror or photograph.
Body concept
The internal process of how the patient feels about his
appearance.
Generally those patients with a good body image in
spite of having a deformity are better candidates for
surgery
29. EXTERNAL & INTERNAL PRESSURE
Edgerton & knorr pointed out the importance of external versus
internal motivation.
Internal pressure’ would be that originating within the patient and
usually involves depression and a sense of inadequacy.
‘External pressure’ would include the need to please others and a
desire to overcome career or social problems through a change in
appearance.
30. Selection of patients for orthognathic treatment involves
various factors that may ultimately influence levels of
patient satisfaction.
These include: physiological; medical; interpersonal
and psychological.
The majority of studies investigating the psychological
aspects of patients undergoing orthognathic
treatment, have shown that patients seeking orthognathic
treatment are psychologically well adjusted prior to
surgery, and appear to have fewer deficits in their
personality dimensions than those patients seeking other
‗cosmetic-type‘ procedures.
31. 31
Body Dysmorphic Disorder – (BD)
Body Dysmorphic Disorder formerly referred to as
Dysmorphophobia, tends to occur in young adults equally in
either gender.
These patient are characterized by certain key and associated features, because of
which they becomes specifically pre-occupied with a non-existent or minimal
cosmetic defect of a particular body part that the person considers unattractive,
(nose, cleft lip and palate, deficient chin, gummy smile ) and persistently seeks
medical attention to fix it surgically. Some clinicians feel it is a variant of
obsessive-compulsive disorder
Body Dysmorphic Disorder Psycotic patients
Many do well with surgery No improvement
Associated Features:
Depressed mood
somatic dysfunction
Guilt or Obsession
Anxious or Fearful or dependent personolity
(Plast.
Reconstr. Surg.
118: 167e, 2006.)
Body Dysmorphic Disorder Psycotic patients
Many do well with surgery
Body Dysmorphic Disorder Psycotic patients
No improvementMany do well with surgery
Body Dysmorphic Disorder Psycotic patients
Associated Features:
Depressed mood
somatic dysfunction
Guilt or Obsession
Anxious or Fearful or dependent personolity
No improvementMany do well with surgery
Body Dysmorphic Disorder Psycotic patients
(Plast.
Reconstr. Surg.
118: 167e, 2006.)
Associated Features:
Depressed mood
somatic dysfunction
Guilt or Obsession
Anxious or Fearful or dependent personolity
No improvementMany do well with surgery
Body Dysmorphic Disorder Psycotic patientsBody Dysmorphic Disorder Psycotic patientsBody Dysmorphic Disorder
No improvement
Psycotic patientsBody Dysmorphic Disorder
Many do well with surgery No improvement
Psycotic patientsBody Dysmorphic Disorder
Associated Features:
Depressed mood
somatic dysfunction
Guilt or Obsession
Anxious or Fearful or dependent personolity
Many do well with surgery No improvement
Psycotic patientsBody Dysmorphic Disorder
(Plast.
Reconstr. Surg.
118: 167e, 2006.)
Associated Features:
Depressed mood
somatic dysfunction
Guilt or Obsession
Anxious or Fearful or dependent personolity
Many do well with surgery No improvement
Psycotic patientsBody Dysmorphic Disorder Psycotic patientsBody Dysmorphic Disorder
32. An orthodontist must determine at an early stage why
the patient is seeking treatment and what the patient
hopes to achieve .
The surgeon must then decide whether this demand can
be met surgically.
33. Lavell et al, emphasized that satisfaction begins
with selection of appropriate patients.
The selection can be represented by the
acronym .....
‘SAFE’
S- Self-assessment of attractiveness
A-Anxiety
F- Fear
E- Expectations
Journal of Orthodontics, Vol. 33, 2006, 107–115
34. High satisfaction with most of orthognathic patients
treated can be related to:-
Realistic expectations with regard to outcome.
Patients with a realistic expectation of post-operative
discomfort and recovery.
Effective pre-operative preparation of the patient.
Good psychological adjustment both pre- and post-
operatively.
35.
36. Data base
(case history, patient
examination, Radiographic
and model analysis)
Problem list in priority order –
Diagnosis
Possible solution to the problem – Tentative treatment plan.
Discussed with the patient & modified
Optimal treatment plan
Execution of treatment
37. Patient History
Clinical
Examination
Analysis of
Diagnostic Records
Classification Problem List
= Diagnosis
Treat pathology
(caries, gingivitis etc.)
Problems
in
priority
order
A
B
C
D
Possible
solution to
individual
problems
Optimal
Treatment
Plan
Data
Base
A
B
C
D
38. Phase I Includes assembling the database, synthesizing the problem
list, diagnosis and team conference
Phase ii Includes developing interdisciplinary problem list with
dentofacial problems in order of priority, and possible
solutions, which forms the tentative treatment plan. A patient
parent doctor team conference is arranged to discuss the tentative
treatment plan with the patient and the family and definitive plan is
arrived .
Phase iii Includes the preparatory phase
(Restorative, endodontic, periodontic), the definitive
orthodontic-surgical treatment and continuous team
monitoring, re-evaluation, interaction, and modification of the
therapy.
Phase iv is the maintenance phase.
39. The patient-parent conference should include the
following three components:
(1) A description of the problem list by the orthodontist. The patient
should have input on the prioritization of the problem list,
(2) A review of the risk/ benefit considerations must be presented.
The merits of each treatment alternative should be given, including
the consideration of no treatment as an option because most
orthodontic treatment is elective, and
(3) Consideration of the patient's expectations and values is of
paramount importance .
Informed consent requires not only obtaining the
patient's permission to treat after having explained
the risks, but also a dialogue between the clinician
and patient in deciding on the final treatment plan.
41. A. General patient evaluation.
1.Medical history
2.Dental evaluation.
a.Dental history.
b.Dental health.
B. Social-psychological evalution
C. Esthetic facial evaluation.
1.Front face analysis
2. Profile analysis
D.Cephalometric evaluation.
1.soft tissue.
2.Skeletal relation
3.dental relation.
42. E. Panoramic or full-mouth peri apical evaluation.
F. Occlusal evaluation.
1.Functional
2.Static.
G. Masticatory muscle & TMJ evaluation
1.Masticatory muscle.
2.Mandibular movements.
3.TMJ symptoms.
4.TMJ signs
43. A. Comprehensive psychologic evaluation.
B. Additional photographs.
1.symmetric view
2.submental view
3.superior view.
4.three quarter face view.
C. Computed assited analysis
1.video manipulation
2.Three dimentional CT scan reconstruction.
44. D. Additional Radiographs
1. Lateral cephalometric radiograph in Rest position.
2. P-A view.
E. Diagnostic Occlusal splints.
F. velvopharyngeal evalutions
1.speech evaluation.
2,Nasoendoscopy.
G.Tongue Evalution
1 speech evaluation
2.Radographic evaluation of tongue posture.
3.clinical evaluation of tongue posture
45. Demographic data Consists of basic chart information of
name, address (home, work or school), age, sex, marital
status and type of employment or school attended.
Chief complaint
The first goal of the interview is to establish the patient’s
major reason for seeking treatment, which is the chief
complaint.
Collection of Data base:
46. Psychological makeup of the patient is important
because, despite on objectively favorable treatment
result, certain patients will express dissatisfaction with
their results due to unrealistic patient expectations
regarding the result of the treatment .
47. Unrealistic expectations are most likely to occur in
two types of patients,
patients with acquired deformities and
Those with external motivations.
Treatment of such patients must be entered into only after
careful consideration and psychologic consultation.
Frequently it is best not to treat the patients since they are
generally unhappy with the results achieved. These kind
of patients can be distinguished by a deliberate social
psychologic evaluation.
48. Classification of patients
Highly positive reactive / group I
Patients who respond positively to all questions and are good
candidates for surgery
Neutral reactors / group II
Patients who had given positive responses with 2 or 3 negative
or slightly negative responses belong to this group. In
general these patients require more than the usual amounts
of attention and counseling during the preoperative phase to
prevent difficulty later.
Negative reactors / group III
Patients who gives negative responses to most of the questions
are unlikely to be satisfied by the results of surgery.
49. Patient‘s medical information must aim to obtain
information regarding medical conditions like history of
medication, allergies to drug, bleeding disorder or other
congenital abnormalities .
Respiratory problem, cardiac
problem, asthma, diabetics, anemia, rheumatic fever etc
that may complicate correction of a skeletal
deformities.
Patients with medical problems can have surgical
orthodontic treatment but only if the medical
problems are of great concern.
50. Family history
Includes information regarding the marriage of the
parents consanguineous/ non consanguineous
marriage, about the siblings, sibling’s general and
dental conditions, history of familial disease if any
and Parent’s concern for treatment.
Dental history.
Knowledge about previous orthodontic therapy, or existing
active orthodontic treatment carries important. Any
previous records if available or narrative description
about treatment from the previous orthodontist
regarding the nature of treatment and evaluation of
results should be reviewed
51. Dental history
The patient‘s interpretation of past orthodontic,
periodontic and prosthetic experiences will give some
insight regarding his willingness to co-operate and
personal motivation level.
A previous history of periodontal disease should alert
the surgeon to potential problems in hygiene and patient
compliance.
The incidence of TM dysfunction and possibility of
aggravating any problems makes pre operative
documentation essential.
Many maneuvers involved in orthodontic therapy can
complicate diagnosis If overlooked may result in
unusual post surgical results.
52. - Study models.
- Panoramic and lateral cephalometric radiographs
- PA cephalogram in patients with significant
asymmetry
- Photographs: A minimum set of five intra oral
photographs.
- Photographs: A minimum set of four extra oral
photographs
53. Facial proportions and esthetics.
A precise and detailed soft tissue evaluation is always essential to
derive proper diagnosis and accurate treatment plan which
maximizes the patient‘s benefit.
The most important point in proper analysis of facial esthetics is
the use of a clinical format.
Examination should not be based on static laboratory x-ray film
and photographic representation of the patient alone.
54. Three important parameters which are to be checked before
proceeding with clinical examination are:-
Natural head position
Centric relation
Relaxed lip posture
Once after these 3 things are established one can go ahead with
facial examination.
58. Outline form & symmetry.
General outline form & symmetry of face are noted.
The widest dimension of the face is the zygomatic
width.
According to the normal values established by Farkas
with Anthropometric studies the bigonial width is
approximately 30% less than the bizygomatic
dimension.
59.
60. Facial level
To examine facial levels a reliable horizontal
landmark is necessary. With the patient in natural head posture,
the pupils are assessed for level with the horizon. If pupils are
level, they are used as the horizontal reference line and adjacent
structures are measured relative to this line. Structures
compared with the pupil line are:-
Upper canine level
Lower canine level
Chin & jaw level
61. Midlines are assessed with
posteriosuperior most condyle
position and first tooth contact.
If occlusal slides alter joint
position, no reliable midline
assessment can be made.
The relative positions of soft tissue
landmarks (nasal bridge, nasal
tip, philtrum, and chin point)
and dental midline landmarks
(upper incisor midline, lower
incisor midline) are assessed for
midline alignment..
Philtrum is usually a reliable midline structure and can be used as the
basis for midline assessment most often.
63. Symmetry.
Right and left comparison.
Absence of obvious asymmetry
is necessary for good
esthetics.
Balance.
Well balance between thirds.
Morphology.
Determined by dividing the
width of each facial third
by the total facial hight.
Upper 3rd-bitemporal.
Middle third-bizygomatic
Lower 3rd-bigonial.
65. Eyes and Orbits.
Mesurements of intercanthal and interpupilary
distances.
Telecanthus-
Hypertelorisam.
Occulo orbital symmetry
By true horizontal line between inner and outer
canthus of eye
Lateral canthal dystonia.
Occular muscle imbalance,sclera discolration,sclera
between lower eye lid and pupil --SKELETAL
DEFICIENCY IN MIFACIAL AREA
67. 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
Outer fifth
From the pinna
RULE OF FIFTHS
68. This area of facial analysis is
extremely important in surgical
orthodontic diagnosis and treatment
planning. The importance of relaxed
lip position for these measurements
should be overemphasized.
69. The lips are measured
independently in a
relaxed position. The
normal length from
subnasale to upper lip
inferior is 19 to 22mm.
The lower lip is measured
from lower lip superior to
soft tissue menton and
normally measure in a
range of 38 to 44mm.
70. Increased or decreased anatomic upper lip length
Increased or decreased maxillary skeletal length
Thick upper lip expose less incisor than thin upper lips,all
other factors being equal. The angle of view changes
the amount of incisor visible to the viewer.
The distance from upper lip inferior to maxillary incisal edge is measured.
The normal range is 1 to 5 mm. Women show more within this range.
Surgical and orthodontic vertical changes are based primarily on this
measurement .
71. With the lips relaxed, a
space of 1 to 5mm
between upper lip
inferior and lower lip
superior is present.
Females show a larger gap
within the normal range.
This measurement is also
dependent on lip lengths
and vertical dento-
skeletal height.
72. Increase in inter labial gap
are seen with anatomic
short upper lip, vertical
maxillary excess, and
mandibular protrusion
with open bite secondary
to cuspal interferences.
Decreased interlabial gap is
found with vertical
maxillary
deficiency, anatomically
long upper lip (natural
change with ageing, esp.
in males) and mandibular
retrusion with deep bite.
73. The closed lip position also
reveals disharmony between
skeletal and soft tissue lengths.
Increased mentalis contraction, lip
strain, and alar base narrowing
are observed in vertical skeletal
excess, anatomic short upper lip
and in some cases of mandibular protrusion
with open bite.
74. Ideal exposure with smile
is three-quarters of the
crown height to 2mm of
gingiva. Females show
more gingival exposure
than males.
Reveals 75% to 100% of the maxillary
anterior teeth and the interproximal
gingiva
75. Excess gingival exposure
may be caused by a short
upper lip,.
vertical maxillary excess, .
short clinical crown,. and
large lip elevation
Because of etiological variability surgical shortening of the maxilla is indicated
only when excess gingival exposure is found in combination with increased
interlabial gap, increased incisor exposure, increased lower facial height.
76. 1. Soft tissue profile angle
2. Naso labial angle
3. Maxillary sulcus contour
4. Mandibular sulcus
contour
5. Orbital rim
6. Cheekbone contour
7. Nasal base-lip contour
8. Nasal projection
9. Throat length and
contour
10. Sub nasale-pogonion
line ( sn-pg‘)
Profile facial analysis
77. This angle is formed by
connecting soft tissue
glabella, subnasale, and
soft tissue pogonion.
General harmony of
forehead , midface ,and
lower face is appraised
with this angle
78. Defined as anterior or
posterior inclination of
the lower face in
relation to forehead.
Purely influenced by
ethnic or racial
background.
Anterior
, straight, posterior
divergence.
80. UPPER 3RD.
Forehead is sloped antero –inferiorly,with
projected supraorbital margins.normally they
are 5 to 10mm beyond the most anterior
projection of globe.
Distinction should be made
Frontal bossing,
Supra orbital hypoplasia.
Globular angle -G-nasion –pronasale.
132+/-150
excessive- frontal bossing or
depressed dorsum
81. Relationship of the forehead is considered to the
bizygomatic width. It can be described as Narrow
or wide.
The lateral forehead contour or the slope of the
forehead could be Flat, protruding, steep. The
dental bases are more prognathic than incases with
a flat forehead.
82. .Nose 5 to 8mm ant to the globes.
Dorsum.- normal, concave ,converse,.
Nasal tip projection, turned up or
down.
Horizontal plane nasal tip-sub nasale
,,subnasale to alar base is 2:1.
1;1 suggest lack nasoskeletal support
for alar base ,or maxillary or
middle third face defficency.
MIDDLE THIRD
83. The vertical nasal length measures 1/3rd of the total
facial ht. (dist. From hairline to gnathion)
The relationship b/w vertical & horizontal length of the
nose is 2:1.
Microhinic type: The root of the nose is high, short
nasal bridge & an elevated tip.
84. This angle is formed by the
intersection of the
upper lip anterior and
columella at subnasale.
This angle can change
noticeably with
orthodontic and surgical
procedures that alter the
antero-posterior position
or inclination of the
maxillary anterior teeth.
Desirable range of 90 to
110 degrees
85. Evaluation of nose
Bell described three type of nose
Leptorrhine-long, high and narrow nostrils.
Mesorrhine-lack of dorsal height and
columellar support.
Platirrhine-flat broad nose and wide nostrils
Alar base width is equal to the intercanthal width of eye
of which is influenced by inherited ethnic characters.
Lefort 1 osteotomies affect the alar base width, superior
repositioning is associated with widening of alar base.
simultaneous rhinoplasty is indicated if siginificant
change in alar base width is expected during surgery.
86. The nasal projection measured
horizontally from subnasale to nasal tip is
normally 16 to20mm ,
. Nasal projection is an indicator of
maxillary antero posterior position.
This length becomes particularly
important when planning for anterior
movement of maxilla.
Nasal projection
87. The orbital rim is an antero-
posterior indicator of
maxillary position.
Deficient orbital rims may
correlate positionally with a
retruded maxillary position
because the osseous structures
are often deficient as groups
,rather than in isolation.
The Eye globe normally is
positioned 2-4mm anterior to
the orbital rim.
88. The surgical maxillary versus mandibular decision is
influenced by the orbital rim position.
Deficient orbital rims dictates the need for maxillary
advancement with all other parameters being normal..
89. Cheekbone contour
Cheekbone assessment requires frontal and profile examination
simultaneously. Cheekbone contour(CC) correlates with maxillary
antero-posterior position, frequently the cheek bone contour is
deficient in combination with maxillary retrusion.
.
90. Continuation of the cheek
bone contour line. This area
is an indicator of maxillary
and mandibular skeletal
anteroposterior position.
Normal position is indicated
by the maxilla point (Mxp).
Mxp is continuum of the
cheekbone nasal lip contour
and is indication of
maxillary anteroposterior
position.
91. Maxillary retrusion is indicated by a straight or concave at
Mxp, when this anatomic area is concave are flat , maxillary
advancement is necessary.
92. Mandibular protrusion interupts the nasal base –lip in
the length of the upper lip.
When this line is interrupted within the height of the
upper lip mandibular set back may be indicated.
93. Normally this sulcus is
gently curved and gives
information regarding
upper lip tension
Maxilla should not be retracted significantly when a deeply curved
thick lip is present since this produces poor lip support.
If possible maxilla should be moved forward towards the curved lip
to improve lip support.
95. Angle between lower lip ,chin ,R-
point,
Should be approximately 900.
Increased in-
Chin deficiency
Lower lip procumbency.
Excessive sub mental fat.
Low hyoid bone position.
Lip-chin throat
angle
97. The relationship of lips to the
sn-pg’ line is an important aid in
orthodontic soft tissue analysis and
treatment.
Tooth movement changes the
relationship of the lips to the sn-pg’
line and therefore the esthetic result.
SUBNASALE - POGONION LINE ( SN-PG’)
98. Burrstone reported that the upper lip is in front of the sn-
pg‘ line by 3.5mm 1.4mm, and lower lip in front of the
line by 2.2mm 1.6mm.
All tooth movements should be assessed in regard to the
anticipated lip change to the sn-pg‘ line.
100. Developed by Charles Burstone et al
Presented first in Journal of Oral Surgery. 1978 April.
Followed by Soft tissue Cephalometric Analysis for Orthognathic
surgery in Journal of Oral Surgery. 1980 .
Data derived from samples obtained from Child Research Centre,
Univ. of Colorado school of medicine.
Sample type: Northern european descent
Sample Size = 27
16 females
11 males
101. A constructed plane called Horizontal Plane which
is surrogate Frankfort Horizontal plane
constructed by drawing a line 70 from SN plane
Most measurements will be made from projections
either parallel or perpendicular to the Horizontal
Plane
102. Chosen landmarks and measurements can be altered by
various surgical procedures.
The appraisal includes all facial bones and a cranial base
reference.
Rectilinear measurements can be readily transferred to a
study cast for mock surgery.
Critical facial components can be examined.
Standards and statistics are available for variations in
age and sex from 5 to 20
Consists of a series of measurements that can be
computerised.
103.
104. GLABELLA NASION
ANS PNS
POINT A POINT B
SELLA PORION
BASION POGONION
GNATHION
MENTON
GONION
ORBITALE
CEPHALOMETRIC
LANDMARKS
122. By William Arnett and Robert Bergman
AJODO 1999
Sequale to Facial keys to orthodontic diagnosis and
treatment planning. Part I and II
AJODO 1993
123. “We only treat what we are educated to
see. The more we see, the better the treatment
we render our patients”
-Arnett.
125. It is a Vertical line passing through
the Subnasale with natural head
posture.
It may be used to quantify
favorable or unfavourable change in
the profile after overjet reduction
and has a potential role in post
treatment analysis and research
126. Data base: Based on 46 white models
Males = 20
Females = 26
All models had natural class I occlusion and
reasonably well balanced facially
127. Metallic Markers are placed on right side of
face to mark key midface structures. i.e
1. Orbital rim marker
2. The alar base marker
3. The subpupil marker
128. Composed of five components
1. Dentoskeletal factors
2. Soft tissue structures
3. Facial length
4. Projections to TVL
5. Harmony values
129. Have a large influence on the facial profile.
When in normal range individually produce a
balanced and harmonious nasal base, lip, soft tissue A’
and B’, and chin relationship.
132. Soft tissue thickness in combination with
dentoskeletal factors largely control lower facial
esthetic balance.
Nasolabial angle and upper lip angle are important
in assessing the upper lip and may be used by the
orthodontist as part of the extraction decision.
135. The presence and location of vertical abnormalities is
indicated by assessing maxillary height, mandibular
height, upper incisor exposure and overbite.
138. They are antero-posterior measurements of soft
tissue and represent the sum of the dentoskeletal
position plus the soft tissue thickness overlying
that hard tissue landmark.
The horizontal distance for each individual
landmark, measured perpendicular to the TVL, is
termed the landmark’s absolute value.
142. Created to measure facial structure balance
and harmony.
It is the position of each landmark relative to
other landmarks that determines the facial
balance.
The harmony values represent the horizontal
distance between two landmarks measured
perpendicular to the true vertical
150. Landmark values are dependent on TVL placement.
HOWEVER
Harmony values are independent of the position of the TVL
thus making it very reliable
151. Model surgery is the dental cast version of
cephalometric prediction of surgical results.
Typically model surgery is done just prior to the actual
surgery, after orthodontic preparation has been
completed, so there is no need to reposition teeth on
casts, but a simulation of the final occlusion can be
seen prior to any treatment if a diagnostic setup has
been done. Mandibular advancement can be
simulated, for instance, by sliding the lower cast
forward relative to the upper cast.
152. It is easier to study the possible tooth relationships if the
casts are mounted temporarily on an arbitrary articulator
so that they are held in the desired position. The better the
occlusion without any tooth movement, the easier it is to
articulate the casts by hand and vice versa.
If the maxilla will be repositioned vertically, it is important
to use a face-bow transfer to mount the casts on a semi-
adjustable articulator so that the condyle-tooth
relationships are recorded and mandibular rotation is
correctly accounted for Doing the cephalometric
prediction and articulating the casts by hand to check for
arch compatibility nearly always is sufficient prior to the
treatment, but articulator mounting is necessary during
the final surgical planning so that the surgical splints will
be accurate.
153. Purpose of model surgery.
1) To verify that the planned movements are
possible
2) To relate the mandibular and maxillary dentitions
in the position where the surgical splint will be
made.
157. Fit the teeth accurately.
Minimum thickness – not
more than 2 mm.
Excess acrylic should be
trimmed off the buccal
aspect, to allow for
proper visual
verification during
surgery and oral
hygiene maintenance.
159. The goal of the treatment plan is develop the plan that
will maximise the patient benefit. It is completely
based upon diagnostic truth.
Surgical treatment possibilities
Logical sequence in planning surgical orthodontic
treatment
Treatment plan techniques of cephalometric
prediction and cast prediction
160. The surgical treatment of deformities of the mandible must
be considered in all 3 dimensions. The defects that affect
the various parts of the mandible may be symmetrical or
asymmetrical. Preoperative assessment will identify the
site involved.
Classification
MANDIBLE
Ramus osteotomies
Oblique subcondylar osteotomy
The vertical subsigmoid osteotomy
The sagittal split and its modifications
The inverted ‘L’ and ‘C’ osteotomies of the ramus
161. Condylectomy
Osteotomies of the body of the mandible
Segmental procedures
Genioplasties
• MAXILLA
1. Lefort I
2.lefort II
3. lefort III
4. Segmental osteotomy
162. BELL & PROFITT
VAGHESE MANI
PETERSON PRINCIPLES OF ORAL SURGERY
PETER WARD BOOTH
DIMITROULIS
REYENEKE
