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ORTHODONTIC CONSIDERATION IN SURGICAL ORTHODONTICS.pptx
This document discusses orthodontic considerations in surgical orthodontics. It covers the history and definitions of orthognathic surgery, indications and contraindications, advantages and disadvantages. It also discusses the roles of the orthodontist and surgeon in treatment planning, sequencing of treatment, and important orthodontic procedures like decompensation and presurgical orthodontics. Presurgical orthodontics aims to correct dental alignment, leveling, and removing natural compensation in order to allow for optimal surgical correction of jaw discrepancies. Close collaboration between the orthodontist and surgeon is important for achieving the best functional and aesthetic results.
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ORTHODONTIC CONSIDERATION IN SURGICAL ORTHODONTICS.pptx
- 1. ORTHODONTIC CONSIDERATION IN SURGICALORTHODONTICS Dr. GENOEY GEORGE
- 2. INTRODUCTION • Earliest orthognathicsurgery known as orthodontic surgery • Dentofacial deformities affect 20% of the population. However, the most common reason for patients seeking combined orthodontic and surgical treatment is dental and/or facial aesthetic problems
- 3. INTRODUCTION • Orthognathic surgeryis a team work. • This team must: Correctly diagnose existing deformities Establish an appropriate treatment plan Execute recommended treatment. • Basic therapeutic goals: Function Aesthetics Stability Minimizing the treatment time
- 4. INTRODUCTION Combined orthodontic andsurgical treatment usually requires about 18-24 months to complete. The treatment may be divided into four stages: • Treatment Planning • Presurgical Orthodontics • Surgical Treatment • Post-Surgical Orthodontics Orthodontic Preparation for Orthognathic Surgery Abdolreza Jamilian, Alireza Darnahal and Letizia Perillo, 2015
- 5. HISTORY Orthognathic surgery wasoriginally developed in the USA(Steinhauser) • The first mandibular osteotomy is considered to be Hullihen´s in 1849 to correct anterior open bite & mandibular dento alveolar protrusion with an intraoral osteotomy. • Osteotomy of the mandibular body for the correction of mandibular horizontal excess was performed by Vilray Blair in 1907
- 6. HISTORY • 1867 –David Cheever - Le fort I osteotomy(nasal obstruction) • 1921 – Cohn Stock – A M O • 1950 – Gillies & Harrison – Le fort III • 1959 – Schuchardt - post maxillary osteotomy • 1969 – Bell – Classical L I • 1970 – Kufner, Henderson & jackson - L II • 1990 – Keller & Sather, Quadrangular - L I
- 7. DEFINITION • Orthognathic surgeryis the surgical correction of abnormalities of the mandible, maxilla, or both. • The underlying abnormality may be present at birth or may become evident as the patient grows and develops or may be the result of traumatic injuries. • In majority of cases a combined surgical and orthodontic approach is required to achieve an optimum result.
- 8. ENVELOPE OF DISCREPANCY CURRENTCONCEPTS OF CHANGES PRODUCED BY VARIOUS TREATMENT MODALITIES Soft tissue limitations not reflected in the envelope of discrepancy often are a major factor in the decision - orthodontic or surgical–orthodontic treatment
- 9. PROTOCOL • Design softtissue to maintain adequate collateral blood supply to the ostetomised segment • Provide optimum exposure. • Minimum periosteal stripping. • Gentle soft tissue handling. • Avoid injury to neurovascular bundle. • Make osteotomy cuts under constant irrigation with normal saline.
- 10. SEQUENCE OF TREATMENT CHILD/ADULTDIAGNOSED WITH DENTAL DEFORMITY COMPREHENSIVE EVALUATION BY A SURGEON AND ORTHODONTIST COMPLETE RECORDS - LATERAL AND OPG RADIOGRAPHS, FACIAL AND OCCLUSAL RADIOGRAPHS, DENTALMODELS, AND CENTRIC BITE IMPRESSIONS SURGEON AND ORTHODONTIST THEN JOINTLY REVIEW AND ORGANIZE THE AVAILABLE INFORMATION INTO A RECOMMENDED TREATMENT PLAN PREOPERATIVE ORTHODONTICS ORTHOGNATHIC SURGERY AESTHETIC SURGERY POST OPERATIVE ORTHODONTIC TREATMENT POST ORTHODONTIC RETENTION Khechoyan DY. Orthognathic surgery: general considerations. InSeminars in plastic surgery 2013 Aug (Vol. 27, No. 03, pp. 133-136). Thieme Medical Publishers.
- 11. MAXILLARY OSTEOTOMIES TOTAL MAXILLARYOSTEOTOMIES SEGMENTAL MAXILLARY OSTEOTOMIES LEFORT I LEFORT II LEFORT III MID FACE CLASSIC QUADRANGULAR ANTERIOR PYRAMIDAL QUADRANGULAR ZYGOMATIC MALAR MAXILLARY SINGLE TOOTH ANTERIOR SEGMENT POSTERIOR SEGMENT HORSESHOE
- 12. MANDIBULAR OSTEOTOMIES RAMUS OSTEOTOMIES SUB APICAL OSTEOTOMIES BODY OSTEOTOMIES CHIN OSTEOTOMIES VERTICAL RAMUS OSTEOTOMY INVERTED “L”& “C” OSTEOTOMY SAGGITAL SPLIT OSTEOTOMY ANTERIOR SUB APLICAL OSTEOTOMY POSTERIOR SUB APLICAL OSTEOTOMY TOTAL SUB APLICAL OSTEOTOMY
- 13. THE ROLE OFORTHODONTIST • To achieve an occlusion which has good function, aesthetics and stability. • To enable the achievements of optimal facial aesthetic. • To provide the best means of intraoperative intermaxillary fixation. • To provide for the attachment of post-operative intermaxillary elastics.
- 14. INDICATIONS • Dentofacial problemstoo severe for orthodontics alone. • Non-growing adults. • Children with cranial-facial syndromes and severe dento facial abnormalities. • Cases where there are specific documented signs of dysfunction. • These may include conditions involving airway dysfunction such as sleep apnea, temporomandibular joint disorders, psychosocial disorders and or speech impairments.
- 15. INDICATIONS • Severe anteroposteriordiscrepancies (class II/ class III) • Vertical discrepancies (open bite/ deep overbite) • Transverse discrepancies • Skeletal asymmetry
- 16. CONTRAINDICATIONS • Growing patients •Mild malocclusion • Medical problems
- 17. ADVANTAGES • 75% -80% of patients seeks aesthetic improvement • Psychological • About 90% of patients who undergo orthognathic surgery report satisfaction with the outcome • And about 80% say they would recommend such treatment to others and would undergo it again • Able to speak and eat normally
- 18. DISADVANTAGES • Surgical risk •Relapse • Unsatisfied with results • Motivated patients • Availability of surgeons + orthodontist • Cost
- 19. CRITERIA FOR ORTHOGNATHICSURGERIES (AMERICAN ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONS, 2008) • Antero Posterior Discrepancies • Vertical discrepancies • Transverse Discrepancies • Asymmetries
- 20. ANTEROPOSTERIOR DISCREPANCIES • Maxillary/mandibularincisor relationship: overjet of 5mm or more, or a 0 to a negative value (norm 2mm). • Maxillary/mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm 0 to 1mm)
- 21. VERTICAL DISCREPANCIES • Openbite - No vertical overlap of anterior teeth. - Unilateral or bilateral posterior open bite greater than 2mm • Deep overbite - with impingement or irritation of buccal or lingual soft tissues of the opposing arch. - Supra eruption of a dent alveolar segment due to lack of occlusion.
- 22. TRANSVERSE DISCREPANCIES • Totalbilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, • unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth.
- 23. CONSIDERATIONS ACCORDING TO PROFFIT FORCLASS II: • OJ > 10mm • ANB > 9° • Pog posterior to N perpendicular > 18mm • Mandibular length > 70 mm • Anterior facial height > 125mm
- 24. CONSIDERATIONS ACCORDING TO KERR FORCLASS III: • ANB = - 4°. • Maxillary mandibular ratio = 0.84°. • lower incisor inclination (LI/MP = 83°).
- 25. SPECIAL CONSIDERATIONS • Orthognathicsurgery should be delayed until growth is completed in patients who have problems of excessive growth (mandibular prognathism). INDICATION OF SURGERY BEFORE PUBERTY: • A Progressive Deformity • Severe psychosocial problems caused by restriction of growth due to ankylosis of the mandible after a condylar injury or severe infection.
- 26. Other Considerations Special Pointsin Planning Orthognathic Surgery • If the attached gingiva is inadequate, gingival grafting should be completed before genioplasty to prevent recession of the gingiva in the lower incisors. • Remove the lower third molars at least 6 months before orthognathic procedure.
- 27. COMBINED DISCREPANCIES CLASS II SHORTFACE LONG FACE • DECREASED AFH INCREASED AFH MANDIBULAR RAMUS SURGERY DOWNWARD MOVEMENT OF POSTERIOR MAXILLA MANDIBLE FORCED TO ROTATE DOWNWARD AND BACK LE FORT I OSTEOTOMY TO ELEVATE POSTERIOR MAXILLA MANDIBULAR ADVANCEMENT,IF MANDIBLE FORCED TO ROTATE UP AN FORWARD
- 28. COMPENSATION • Severe jawimbalances, the teeth are inclined in such a way as to partially offset the discrepancies. • This, natures mechanism to compensate for the jaw imbalance by proclining or retroclining the teeth is known as compensaton of the jaws. • Presurgical orthodontics is aimed at removing this natural compensation termed as Decompensation.
- 29.
- 30. COMPENSATION FOR VARIATIONIN THE SAGITTAL JAW RELATIONSHIP • SKELETAL CLASS II To Compensate Larger Discrepancies Upper Incisors are retroclined and lower incisors are proclined to maintain normal overjet. • SKELETAL CLASS III Upper Incisors are proclined and the lower incissors are retroclined to maintain the normal overjet. Akiko Abe, Sachio Tamaoki, Masao Ozaki & Hiroyuki Ishikawa (2012) Analysis of dental compensation in cases using three-dimensional measurement of gnathostatics models, Orthodontic Waves, 71:1, 41,
- 32. COMPENSATION FOR VARIATIONIN THE VERTICAL JAW RELATIONSHIP • SKELETAL OPEN BITE Posterior dentoalveolar segment intrudes, The anterior dentoalveolar segment extrudes or both can happen, to maintain the normal overbite • SKELETAL DEEP BITE Posterior dento alveolar segment can extrude or the anteriors can intrude to maintain a normal overbite. Akiko Abe, Sachio Tamaoki, Masao Ozaki & Hiroyuki Ishikawa (2012) Analysis of dental compensation in cases using three-dimensional measurement of gnathostatics models, Orthodontic Waves, 71:1, 41,
- 33. COMPENSATION FOR VARIATIONIN THE TRANSVERSE JAW RELATIONSHIP • Discrepancy between narrow maxillary base and a wide mandibular base is Compensated by buccal tilting of upper teeth and lingual tilting of the lower teeth. • Discrepancy between wide maxillary base and a narrow mandibular base is Compensated by lingual tilting of upper teeth and buccal tilting of the lower teeth. Akiko Abe, Sachio Tamaoki, Masao Ozaki & Hiroyuki Ishikawa (2012) Analysis of dental compensation in cases using three-dimensional measurement of gnathostatics models, Orthodontic Waves, 71:1, 41,
- 34. PRESURGICAL ORTHODONTICS ALIGNMENT &LEVELING • Dental crowding, spacing, and rotations should be corrected before orthognathic surgery. • If segmental osteotomy is planned we should provide spaces between the roots, so we can tip the bracket. • Curve of spee should be flat (according to ideal occlusion). • A better result may be achieved by completing levelling post surgically.
- 35. PRESURGICAL ORTHODONTICS • ALIGNMENT& LEVELING • In short face , when an increase in face height is desired, lower incisors should not be depressed before surgery. Maintenance of curve of spee is needed. • In normal or excessive face height, levelling by intruding the incisors should be done before surgery.
- 36. DECOMPENSATION • Compensations canbe dental or skeletal, vertical, transverse and/or sagittal. • Presurgical orthodontic decompensation is essential to enable the surgeon to make a considerable amount of surgical correction. • Decompensation makes the maxillomandibular dental relation temporarily worse. Hence, it is sometimes called Reverse orthodontics
- 37.
- 38. DECOMPENSATION DECOMPENSATION IN CLASSII • Procline upper incisors. • Retrocline lower incisors. • Use class III elastic. Decompensation in class III • Retrocline upper incisors. • Procline lower incisors. • Use class II elastic.
- 39. DECOMPENSATION DECOMPENSATION IN DEEPBITE • Extrusion mechanics to molars. • Incisors also need to be extruded. • clockwise rotation of mandible occurs. • L.F.H increases & chin prominence reduces.
- 40. DECOMPENSATION DECOMPENSATION IN OPENBITE • Extrusion mechanics to molars. • Incisors need to be intruded • Dental extrusion of skeletal open bite will be unstable in the long run. • Reversed curve of spee should be levelled.
- 41. DECOMPENSATION DECOMPENSATION IN TRANSVERSEPLANE • Dental discrepancies are usually treated by means of buccal tipping of the posterior teeth while skeletal discrepancies are corrected by bodily movement of the posterior teeth. • The tipping should not exceed 4 to 6 mm total. • Bodily movement of the posterior teeth should be done by means of segmental osteotomy.
- 42. DECOMPENSATION DECOMPENSATION IN TRANSVERSEPLANE • Absolute skeletal transverse discrepancy requires planning for segmental osteotomy or surgically assisted rapid palatal expansion (SARPE). • SARPE technique is used in cases with a severe discrepancy or when the transverse defect of the maxillary bone is an isolated skeletal anomaly. • Segmental maxillary osteotomy is used for more (up to 7 mm).
- 43. CONCLUSION • Inadequate orthodonticpreparation can jeopardize the quality of the surgical result. • Therefore, A proper interaction between the orthodontic and surgical team is essential for the best result to achieve.
- 44. REFERNCES • Contemporary Orthodontic6th edition – William R. Proffit. • Khechoyan DY. Orthognathic surgery: general considerations. InSeminars in plastic surgery 2013 Aug (Vol. 27, No. 03, pp. 133- 136). Thieme Medical Publishers. • Posnick J. Craniofacial and Maxillofacial Surgery in Children and Young Adult. Saunders; 2000 • Akiko Abe, Sachio Tamaoki, Masao Ozaki & Hiroyuki Ishikawa (2012) Analysis of dental compensation in cases using three-dimensional measurement of gnathostatics models, Orthodontic Waves, 71:1, 41, • Principles Of Oral And Maxillofacial Surgery- Peterson • Orthodontic Preparation for Orthognathic Surgery Abdolreza Jamilian, Alireza Darnahal and Letizia Perillo, 2015