An overview of orthodontic-surgical treatment in patients with dentofacial skeletal deformities that represents 18 to 24 months of treatment time, with most time spent in orthodontic management. The treatment involves 5 phases: 1) preorthodontic preparation to improve oral health, 2) presurgical orthodontics to reveal the skeletal deformity by removing dental compensations, 3) surgery, 4) postsurgical orthodontics, and 5) retention. The goal is to achieve both occlusal and aesthetic goals by coordinating the efforts of the orthodontist and surgeon.

1. Orthodontic Management
of Dentofacial Skeletal Deformities
dr Maher Fouda
Faculty of Dentistry
Mansoura Egypt
Professor of orthodontics

2. In correcting dentofacial skeletal deformities, the
roles of the orthodontist and the surgeon are
equally important. The responsibility of the orthodontist
is to diagnose and plan the treatment for
the case, decompensate the dentition, and provide
the surgeon with a stable intra-arch dental framework.

3. The surgeon must then place the skeletal
components into the most pleasing and functional
position possible to achieve the pretreatment goals
established for the patient.

4. Clear communication is
essential because the goals of presurgical orthodontic
treatment are generally opposite to that of the
routine orthodontic regimen used to camouflage
the skeletal discrepancies in patients who choose
not to pursue surgery.

5. Successful occlusal relationships
can be achieved with orthodontic treatment
alone in minor skeletal discrepancies and, at
times, even in more significant deficiencies; however,
it is frequently at the expense of a pleasing
facial appearance.

6. These same patients who have
had orthodontic treatment without consideration
for combined surgical-orthodontic management
may seek plastic surgical procedures later in life
to address this residual skeletal deformity .
Facial photographs: initial diagnosis, pretreatment I, after phase I,
pretreatment II, after phase II, and 2-year retention

7. is compromised and frequently requires the use
of prosthetic implants and soft tissue procedures
to camouflage the deformity, the results of which
are less than ideal.
Skeletal correction once the occlusion is achieved

8. When is the problem too severe for orthodontic
treatment alone? It depends on the severity and the
age of patient. In a growing child, orthodontic treatment
is likely to have a favorable influence and may
avoid the necessity for orthognathic surgery, with the
exception of the clefting and craniofacial conditions.
In an adult with the same degree of severity, surgery
may be the only option.

9. However, when the malocclusion
persists in the growing child despite orthodontic
treatment used to modify growth, surgical
consideration should be considered, either during
active growth or at the time of skeletal maturity.

10. A successful outcome occurs when the occlusal goals
and the aesthetic goals are achieved. In the opinion
of many orthodontists, the limits of orthodontic
treatment lie within an envelope of a positive overjet
of18 mm, a negative overjet of4 mm, and a transverse
width discrepancy of 3 mm .

11. Dental development plays an important role in
maxillary-mandibular alveolar development. It
consists of two aspects. One aspect is dental eruption
itself and the other is the ‘‘drifting’’ of the tooth
as a whole within the alveolar process.
Camouflage
treatment of skeletal
Class III

12. Orthodontic
movement of the tooth itself involves a tension/
pressure gradient, causing a bony remodeling of
the associated alveolus aided by the periodontal
ligament.
Compensatory Class
III malocclusion
treatment
associated with
mandibular canine
extractions

13. Compensatory Class
III malocclusion
treatment associated
with mandibular
canine extractions

14. While growth is present, the orthodontist
can guide the individual teeth into position, taking
advantage of the active phase of development with
braces.

15. In contrast, other orthodontic interventions,
such as headgear, face masks, and restraining chin
cups, can alter the vector of the displacements of
the maxilla and mandible, including the dental
unit as a whole, by affecting the sutures and sites
of regional growth.

16. These orthodontic maneuvers
can have a significant and stable impact on future
facial skeletal development only while growth is
active and can be modulated (orthodontic growth
modification)

17. Surgical intervention at an early age is often not
questioned in the child with a severe deformity as
a result of either a congenital or acquired condition.
However, the child with a moderate deformity and
a dental malocclusion is the one who poses the
problems in timing and sequencing of treatment.
postoperative photographs.Initial facial and intraoral photographs.
A female
patient
aged 14
years
Facial and
intraoral
photographs at
age 18 showing
again a skeletal
disharmony
caused by
postoperative
growth.

18. a poor result. Thus, timing of the ‘‘ortho/surgical’’ intervention
becomes the more critical question .
A
fundamentally correct treatment plan instituted at
the wrong time in the child’s development can yield
Facial and intraoral
photographs
showing a new
Class III skeletal
disharmony due to
continued
treatment.,
preoperative
photographs.
postoperative
photographs.
A male patient, 13 yea- at age 18

19. If the skeletal malalignment is minimal to moderate,
then it is possible to achieve correction by
influencing the pattern of jaw growth with interceptive
facial orthopedic treatment.

20. This interceptive
treatment must be initiated during the periods of
active growth in early to late childhood, but before
the completion of the adolescent growth spurt. By
the time the child has reached sexual maturity, it
is usually too late to attempt such treatment.
Eight-year-old patient with a
Class III malocclusion and a
deficient maxilla treated
with maxillary expansion and
protraction.

21. It makes sense in most circumstances of moderate
deformity to wait until skeletal maturity when planning
for orthognathic surgery, to avoid reoperation
because of recurrence of the deformity with continued
disproportionate growth.

22. The timing of skeletal
maturity varies with gender. Serial cephalometric
radiographs objectively indicate deceleration of
growth, and a hand-wrist film or cervical vertebrae
maturity can be used to determine skeletal age

23. In some circumstances, however, relying
solely on ensuring stability of correction to determine
the timing of surgery may be inappropriate.

24. Adolescents who have a poor self-image, are socially
introverted, or are victims of ridicule can greatly benefit
from early intervention. Similarly, functional indications
such as speech, airway difficulties, and
malocclusion may dictate earlier intervention.

25. An overview of orthodontic-surgical
management
Treatment planning begins by reviewing the various
orthodontic and surgical options available that
would address the problem list.

26. is significant enough to require surgical repositioning
or whether growth modification and orthodontic
alignment of the dentition alone achieve
a satisfactory result without significantly
compromising the facial aesthetics
The primary decision
that needs to be made is whether the deformity

27. If surgical intervention
is contemplated, the question arises as to whether
to intervene before completion of skeletal growth
or to await skeletal maturity, to eliminate the variability
of subsequent growth and the need for further
surgical intervention.

28. Once the decision is
made for combined dental-surgical correction, the
overall treatment must be carefully planned. Formulation
of a treatment plan thus requires the close
cooperation of the surgeon working with the orthodontist.
A: Sagittal osteotomy;
B: End of surgery.; C:
End of expansion. Front
view; D: End of
expansion. Palatal view.

29. Unlike many surgical procedures, the outcome
depends not only on the surgical procedure
itself but also on a multitude of factors that begin
long before the actual surgery and the control of
variables long after surgery .

30. The management
is divided into five phases:
1. Preorthodontic preparatory phase
2. Presurgical orthodontic treatment phase
3. Surgical phase
4. Postsurgical orthodontic phase
5. Retention Phase

31. An overview of
orthodontic-surgical
treatment in patients
with dentofacial
skeletal deformities
that
represents, in most
cases, 18 to 24
months of treatment
time. Most of that time
is under orthodontic
management,
with the surgical team
involved at the initial
treatment planning
stage and, typically, a
6- to 8-week
period at the time of
surgery.

32. An overview of
orthodontic-surgical
treatment in patients
with dentofacial skeletal
deformities that
represents, in most
cases, 18 to 24 months
of treatment time. Most
of that time is under
orthodontic
management,
with the surgical team
involved at the initial
treatment planning stage
and, typically, a 6- to 8-
week
period at the time of
surgery.

33. Preorthodontic preparatory phase
Before the initiation of the presurgical orthodontic
treatment, creation of good oral health and
elimination of caries must be managed . Patients
who have periodontal disease or gingivitis
have an increased risk with the long-term application
of orthodontic appliances, tooth movement,
and the postoperative surgical period.

34. Preorthodontic preparatory phase
A lack of sufficient attached gingiva must also be managed
before orthodontic tooth movement. Interim temporary
restorative or prosthetic restorations must
be used to stabilize a mutilated dentition before
the initiation of orthodontic and surgical treatment.

35. Presurgical orthodontic management
Once oral health is achieved, the presurgical orthodontic
treatment phase can begin . In skeletal
discrepancies, the teeth naturally compensate
to establish as functional an occlusion as possible
within the limitations of the deformity.

36. The goal of
presurgical orthodontic preparation is to remove
the dental compensations, to reveal the true extent
of the skeletal deformity.

37. Presurgical orthodontic management
The teeth are orthodontically
returned to their ideal position (axial inclination
and alignment) within their respective
maxillary and mandibular dental arches, which
may require the extraction of premolar teeth..
Class ll, division 1 patient. (a) The lower incisors are proclined and
mildy crowded, with no space for retraction. (b) Pre-molar
extractions have allowed lower incisor decompensation

38. The
occlusion and facial appearance is often made
worse until surgical correction occurs. Without
appropriate dental decompensation, the surgeon
is limited by the tooth position in fully correcting
the skeletal deformity

39. Presurgical orthodontic management
The decompensation must
be accomplished in all three dimensions: the
transverse plane (width), the sagittal plane (anterior-
posterior), and the coronal plane (vertical).

40. An overview of presurgical orthodontic management.

41. An overview of
orthodontic-surgical
treatment in patients
with dentofacial
skeletal deformities
that
represents, in most
cases, 18 to 24
months of treatment
time. Most of that
time is under
orthodontic
management,
with the surgical
team involved at the
initial treatment
planning stage and,
typically, a 6- to 8-
week
period at the time of
surgery.

42. In the transverse plane, the maxillary and mandibular
dental arches need to be coordinated with
the postsurgical occlusion. Because of the
relative transverse arch width discrepancy with
Class II and Class III malocclusions, the dentoalveolar
compensations need to be removed. As
with removing the sagittal compensations, the
arch width discrepancy is worsened.

43. Orthodontic management of transverse component of
dentofacial skeletal deformities.

44. Depending
on the discrepancy, the options are transpalatal
orthodontic expansion with or without surgical
assistance versus segmental maxillary osteotomies
at the time of the orthognathic surgical procedure.
.

45. Expansion may be accomplished orthodontically
alone with a palatal expansion device if the midpalatal
suture is open; otherwise, expansion may
require surgical assistance with an osteotomy.

46. When interdental osteotomies are needed, orthodontic
root divergence must be created. Minor
width discrepancies may be acceptable with some
degree of orthodontic compensation and can be
corrected postsurgically
Mandibular incisor root
divergence.
Midsymphyseal distraction osteogenesis: A new
alternative for the treatment of dental crowding
MSDO surgery: A, bone separation;
B, periosteum suture.
Occlusal x-rays of symphysis area: A, after
activation; B, after consolidation period.

47. The anterior-posterior decompensation involves
the correction of the maxillary and mandibular incisors
In an adaptive Class II malocclusion,
the maxillary incisors are often retroclined and the
mandibular incisors proclined to allow a functional
bite as a natural compensation for the skeletal deformity

48. Thus, the decompensation involves orthodontically
uprighting the proclined mandibular
incisors and advancing the maxillary incisors into
the proper position to create adequate lip support.

49. (A) Orthodontic
management of the
sagittal (anterior-
posterior)
component of
dentofacial skeletal
deformities.
(B) Class II
decompensation
followed by
mandibular
advancement. Class
III decompensation
to allow
maxillary
advancement and
mandibular setback.

50. To develop a Class I dental occlusion with proper
tooth-to-tooth contact often requires the removal
of the maxillary second premolars and the mandibular
first premolars to relieve the compensations
and dental crowding

51. Decompensations of Class III malocclusion occurs
in the reverse pattern, with advancement of
the lower incisors and retraction of the maxillary
anterior teeth..

52. The extraction sequence is often represented
by the removal of the maxillary first premolars
and the mandibular second premolars,
thereby attaining a functioning Class I posterior
presurgical occlusion

53. In the vertical plane, dental decompensation of
the anterior dentition depends on three factors:
the amount of dental display of the maxillary incisors
to the upper lip, the interlabial gap, and the
lower anterior facial height.

54. maxillary teeth that compensate the open bite can
be intruded orthodontically only to a limited extent
in an effort to develop a level occlusal plane that
permits a single-piece maxillary Le Fort impaction
surgical procedure.
When dental
display and gingival show are excessive in skeletal
anterior open-bite deformities, the extruded

55. Orthodontic correction OF OPEN BITE alone
will be unstable. Frequently, the posterior teeth
may be in a significantly different occlusal plane
than the anterior dentition.
Non-Surgical Correction of a Skeletal Class II Anterior

57. Orthodontic management of the vertical component of
dentofacial skeletal deformities.

58. In such cases OF OPEN BITE , if
segmental maxillary repositioning is needed, the
presurgical orthodontic treatment correspondingly
involves segmental leveling in two or more different
planes . In such cases, root diversion is needed
to allow for interdental osteotomies for multisegmented
Le Fort I procedures.

59. In patients who have a deep anterior incisor
overbite, the decision as to whether to level the occlusal
plane orthodontically depends on the lower
facial height..

60. When the lower facial height is normal,
the deep bite is corrected by intruding the
incisors and extruding the first molars and
premolars
Prior to retreatment
Treatment Pre surgery

61. In contrast, when the lower facial height is reduced,
as in deep Class II skeletal conditions, the
arches are not leveled until the mandible has
been advanced..

62. By maintaining the curve of
Spee, the mandibular advancement results in a ‘‘tripod’’
occlusion, the incisors anteriorly and the molars
and premolars posteriorly on either side,
which allows a natural increase in the lower facial height

63. The resulting lateral open bite is then
closed by extruding the mandibular first molars
and premolars and leveling the curve of Spee. If
the occlusal plane is instead leveled presurgically,
a more anterior than vertical projection of B point
is produced.

64. When a mandibular osteotomy such as a sagittal
split is contemplated, it is generally wise to have the
mandibular third molars extracted well in advance,
typically 8 to 12 months, to allow for new bone formation.
This extraction minimizes the risk of unfavorable
fractures and allows for successful internal
fixation .
sagittal
split
Preoperative panoramic
radiography.
rigid
fixation of the segments and complete
removal of impacted teeth.
Rigid fixation of split
segments of the
mandible.

65. During this phase, the dentition is
coordinated,
the curve of Spee may or may not be leveled,
and the anterior dentition is decompensated

66. The resultant malocclusion is frequently
made worse and the patient must be made aware
of this before the initiation of treatment. The
maxillary
and mandibular dentition is coordinated.
.
.

67. Hand-held dental casts are obtained throughout
the orthodontic treatment, and when they can be
manually coordinated or tripoded, planning for surgery
can begin .

68. If segmental osteotomies are
planned, the dentition must be prepared accordingly.
Anterior decompensation using segmental osteotomy (ADSO) with the patient under local anesthesia. A,B,
Pretreatment photographs.
C,D, Photographs of surgical procedure with the patient under local anesthesia. E,F, Photographs at the end of
preoperative orthodontic
treatment. Comparisons between G, pretreatment and H, postdecompensation using 3-dimensional computed
tomography data. A coordinated
dental basal arch form was achieved.

69. Presurgical orthodontics necessary to accomplish proper skeletal repositioning. (A, B) Illustrate
orthodontic
decompensation, alignment and leveling of the dental arches. Hand articulating the dental models will
assess
how well the maxillary and mandibular dental arches are coordinated for surgery.

70. (C, D) Illustrate advancement
using dental without presurgical orthodontic preparation showing instability and the need for
orthodontic
preparation.

71. (E, F) Illustrate advancement using models after presurgical orthodontic preparation showing
stability
and readiness for surgery.

72. (G, H) Illustrate mandibular advancement without leveling the curve of Spee to
increase lower facial height in Class II deep bite. There is ‘tripod’ skeletal stability. The lateral open bite is
closed
after surgical advancement.

73. closed at the time of surgery or by orthodontics following
surgery.
If osteotomies are not approached through
planned extraction sites, interdental space must be
orthodontically prepared, with the roots widely divergent
to prevent injury and the space favorably

74. Periapical or cone beam computerized
tomography (CBCT) films should be used to
evaluate the space for osteotomies. Segmental dental
casts then confirm the readiness for surgery
Schematic drawing of Le Fort I osteotomy and posterior
segmental osteotomy. a Le Fort I down fracture and vertical
osteotomy line of posterior segmental osteotomy. b Preoperative
state of palatal side showing osteotomy line. c Postoperative state of
palatal side that corrected intermolar width

75. At the time of surgery, the orthodontic arch wires
should be fully engaged in the bracket slots, the arch
wires should be completely passive, and surgical
hooks should be soldered or crimped in place to facilitate
intermaxillary elastic traction for the surgeon.

76. If segmental osteotomies are planned, the
arch wires can be segmented before surgery.
A to C, Photographs before
anterior decompensation
using segmental osteotomy
(ADSO). D to F,
Photographs 2 weeks after
ADSO.G toI, Photographs at
the end of preoperative
orthodontic treatment.
Comparisons between J,
pretreatment and K,
postdecompensation
using 3-dimensional
computed tomography
data.

77. The length of this presurgical phase typically varies between
12 and 18 months, depending on what needs
to be accomplished to maximize the final surgical
stability.
A to C, Photographs before anterior decompensation using segmental osteotomy (ADSO). D to F,
Photographs 3 weeks after
ADSO. G,H, Superimposition using 3-dimensional computed tomography data.

78. The postsurgical orthodontic phase typically begins
6 weeks after the surgery. The patient is then returned
to the orthodontist for finishing dental alignment
with the relative position of the skeletal bases
in their final position.
Postsurgical orthodontic phase
Combined
multisegmental
surgical-orthodontic
treatment of
bialveolar protrusion
and chin
retrusion with severe
facial asymmetry
Pretreatment facial and intraoral photographs.
Leveling and alignment.

79. Preoperative facial and intraoral photographs. Postoperative orthodontic treatment in progress.
Combined multisegmental surgical-orthodontic
treatment of bialveolar protrusion and chin
retrusion with severe facial asymmetry

80. Any remaining interdental
spaces are closed and the dentition is brought into
maximal intercuspal relationship.
A. Preoperatory aspect. Orthodontic appliance was used to open space for the right maxillary canine traction. B.
Oclusion in 30 days postoperative control. Tooth 14 substitutes the lost canine, with closure of the space, in the
horizontal
immobilization stage, prior to orthodontic alignment. C. Clinical control of 10 years and 10 months postoperatively.
Orthodontic appliances were removed for 10 years and 3 months. Patient’s occlusion maintains excellent functional
and
esthetic result

81. Postsurgical orthodontic phase
This phase typically
lasts for about 8 to 12 months and ends with
the removal of the orthodontic appliances and instructions
to the patient about the use of a retainer
to maintain long-term stability..

82. Photographs, radiographic
studies, and dental models are obtained on
debanding and at 1 year after completion of
treatment.

83. Ideally, when possible, the patient should be
followed annually for an extended period of time
to assess long-term results

84. Management of orthognathic surgical patients following
combined orthognathic surgery usually
presents similar problems to those posed by the traditional
orthodontic patient: failing to cooperate in
wearing the retainers, breaking the retainers, or losing
the retainers.
Retention phase

85. .
The unique problem presented by
the Class III patient is the potential for residual
mandibular growth, and this fact must be carefully
outlined to the family and the patient.

86. a small amount of residual growth occurs following
active care
It would not
be uncommon to have some orthodontic posttreatment
regimen necessary to address the minor mandibular
positional changes occasionally seen when

87. Management of specific dentofacial
deformities
Mandibular deficiency
Patients who have mandibular deficiency clinically
present with a convex facial profile . The aesthetic
soft tissue analysis of the upper and middle
thirds of the face is within an acceptable norm,
and the lower third of the face is retruded.
A skeletal
Class II
requiring
mandibular
advancement.

88. The
lower lip is everted with a deep labial mental crease,
and lip incompetence and mentalis cause muscle
strain with lip closure. The neck length may be
short, with an obtuse cervical mental angle, and redundancy
of the soft tissue may be present.

89. Dental
examination shows a Class II angle malocclusion
that is further subdivided into angle division 1 or
angle division 2, based on the incisor
relationship.

90. In angle Class II division 1, the maxillary incisor angulation
is within an acceptable range and overjet is
significant, but the lower facial height is usuallynormal.

91. In angle Class II division 2, the maxillary incisors
are retroclined, giving the appearance of less
overjet, and, in addition, an associated deep bite
and an overaccentuated curve of Spee result in a
decreased lower facial height.

92. Because the location of the incisors often dictates
the degree of surgical movement, the orthodontist
positions the maxillary and mandibular incisors in
the ‘‘ideal’’ position in the anterior-posterior and
vertical planes

93. Failure to decompensate adequately
limits the surgical correction and aesthetic outcome.
When the mandibular dental arch is crowded, it is
frequently necessary to extract the lower first premolars
and retract the anterior dentition, which allows
for maximal mandibular advancement..
(a) These check models, taken for a class II patient during pre-surgical orthodontics, revealed that
the buccal segment occlusion would be class II, due to incomplete incisor decompensation. (b)
Inter-maxillary traction with class III elastics, aimed at retroclining the lower incisors and proclining
the uppers enabled class I buccal segments to be achieved in the final result (c)

94. In comparison,
maxillary crowding in many circumstances can
be managed by transpalatal expansion, or, when severe,
by extraction of the upper second premolars to
minimize retraction of the maxillary incisors and allow
for maximum mandibular advancement
extraction of
lower rst premolars.

95. Routine
leveling of the occlusal plane to obtain arch
compatibility needs to be individualized, depending
on the severity of the curve of Spee. Orthodontically
leveling the curve of Spee before surgery is accomplished
by intrusion of the mandibular incisors
and further adversely decreases the lower facial
height in Class II division 2 patients.

96. It is instead
preferable to advance the mandible skeletally to incisor
Class I before leveling, to increase the lower facial
height maximally. The resultant lateral open bite
is then closed orthodontically in the postsurgical
phase by extrusion of the first molars and premolars.
With only three-point contact (anterior and the two
posterior molar regions), a surgical splint is needed to
ensure stability .

97. The greater the lower facial
height, the more likely the leveling should be done
by incisor intrusion before surgery. With the exception
of the patient who has severe curve of Spee
and the decreased lower facial height discussed earlier,
establishing maximal arch compatibility and occlusal
interdigitation before surgery is important to
ensure immediate postoperative stability.

98. Skeletal advancement is achieved by the bilateral
sagittal split osteotomy (BSSO) of the mandible . Postsurgical
management includes using ‘‘light’’ Class II
elastics to override proprioception and to guide the
new occlusion in the immediate postoperative period.

99. Orthodontic management then finalizes the
coordination of the dental arches by the definitive
leveling of the curve of Spee, closure of any spaces,
and correction of any minor occlusal interferences.
Following mandibular
advancement the resulting
lateral open bites can (a) be
closed in the postoperative
orthodontic phase (b) or
may even close
spontaneously (c) and (d).

100. Mandibular excess (prognathism)
Patients who have mandibular excess (prognathism)
present with a concave facial profile where
the deformity is primarily isolated to the lower
third . However, most patients will also
show midfacial skeletal deficiency to some
extent, and each patient should be made aware of this.
Midface deficiency
contributing to the Class
III skeletal relationship

101. A number of patients will also have overclosure
of the mandible, further accentuating the
prognathism and midfacial deficiency. Dental
examination will show a Class III malocclusion
with lingually inclined mandibular incisors and often
procumbent maxillary anterior teeth.

102. Presurgical orthodontic preparation includes decompensating
the maxillary and mandibular incisors
to an ‘‘ideal’’ position that, in many patients,
presents some clinical challenges because often
these types of patients present with a thin alveolar
process in the symphyseal region, accompanied by
thinly attached gingiva.

103. Any transverse maxillary
width discrepancy needs to be addressed by either
orthodontic expansion of the maxillary dentition
or, if needed, surgically assisted, rapid palatal expansion,
before formally correcting the Class III
sagittal discrepancy.

104. The surgeon’s options to correct the Class III skeletal
relationship are the intraoral vertical ramus osteotomy
(IVO) or the BSSO of the ramus.
BSSO of the ramus

105. For
minimal setbacks, it is frequently preferable to correct
the Class III malocclusion with a maxillary
advancement because the skeletal expansion allows
filling of the soft tissue envelope and is more favorable
over time with aging of the face.

106. For large setbacks,
similarly combining midfacial skeletal
advancement limits the amount of mandibular setback
required, and a BSSO instead of an IVO can be
accomplished.
Photographs of a patient who underwent maxillary
advancement: (a) pre-treatment, (b) post-treatment. Photographs of a patient who underwent mandibular
setback: (a) pre-treatment, (b) post-treatment.

107. Similarly, with mandibular setback,
the surgeon must be cognizant of the tongue being
confined to a smaller intraoral volume and the potential
for sleep apnea.
A, For mandibular
prognathism, the
sagittal split is
completed in a
similar fashion as
for mandibular
advancements. B,
Bone from the
proximal segment
must be removed
from the anterior
and superior
aspects. C, The
segments can be
interdigitated and
rigid fixation used
to stabilize the
segments.
A 18 years old man with prognathism.
Preoperative and postoperative views.
A 21-year-old woman with
mandibular prognathism.
Preoperative and postoperative views.
BSSO was used to retract the mandible,

108. Sagittal maxillary deficiency
Because of the similarity in clinical presentation,
maxillary anterior-posterior sagittal deficiency has
often been diagnosed solely as mandibular excess
(prognathism) and a mandibular setback procedure
is planned .

109. (A–D) Class III
maxillary
deficiency with
canine
transposition
and open bite.
Completed
case in
preparation
for prosthetic
reconstruction
in the anterior
dentition.

110. However, in many circumstances,
the deformity also includes the
midface, and instead of a mandibular setback
alone, the patient is better served with a midfacial
skeletal advancement, either solely or in combination
with mandibular surgery. Both present with
a Class III skeletal pattern.
Maxillary advancement surgery was performed with the help of LeFort I osteotomy and mandibular setback with
bilateral split sagittal osteotomy with rigid internal fixation (RIF) followed by the placement of intermaxillary
elastics intraoperatively

111. Sagittal maxillary deficiency
Clinically, the patient
presents with a concave facial profile, deficiency of
the maxilla that may extend to involve the zygoma,
paranasal deficiency with a narrow alar base, an
acute nasolabial angle, short upper lip length, and
a retrusive upper lip with a thin vermilion, and, in
many circumstances, an accompanying lack of
dental display (vertical deficiency).

112. Dental characteristics
include a Class III molar and canine relationship,
maxillary dental crowding with canines
blocked out of the dental arches, and, in many circumstances,
deficient transverse palatal arch width
(posterior lingual crossbite), proclined maxillary
incisors, and mandibular incisors either normal or
retroclined.

113. The orthodontist eliminates the dental compensations,
establishes an ideal incisor position, and coordinates
the maxillary and mandibular dental arches.
Orthodontic
presurgical
decompensation
of class II
malocclusion.
Orthodontic
presurgical
decompensation
of class III.
Class III Pre-surgical orthodontic decompensation. In this Class III patient,
the lower incisors were retroclined and the upper incisors proclined initially. Pre-
surgical
orthodontics has corrected the incisor inclinations, resulting in an increased
reverse overjet.
This in turn facilitates maximum skeletal correction.

114. The roots of the central incisors (or the adjacent
teeth, wherever the osteotomy is to be
performed) must be tipped away from
each other to make room for the interdental
osteotomy.
Mandibular symphysis distraction
osteogenesis. A, Often the incisor roots are very
close together. B, Space must be created between
the roots of teeth adjacent to the intended vertical
osteotomy. C, Placing brackets on only the central
incisors with the mesial aspect of the brackets
higher
than the distal aspect on each tooth and placing
a short straight wire segment, will tip the roots
distally
away from each other, creating space to perform
the vertical interdental osteotomy.

115. This can be accomplished
by placing the mesial aspect of the bracket
higher than the distal aspect on each of the
central incisors. Placing a short segment
straight arch wire will then tip the roots
distally, creating space to safely perform
the vertical interdental osteotomy
Predistraction orthodontic movement can be done to diverge the mandibular anterior teeth to allow for an
osteotomy site.
The panoramic and occlusal X-rays show adequate space has been created to minimize the risk of trauma to the
incisors during the osteotomy.

116. as a two-segment Le Fort I osteotomy with simultaneous
correction of the sagittal discrepancy.
An absolute transverse width discrepancy may require
increasing the transverse palatal dimension
Segmental Le Fort I osteotomy in an adult patient
with skeletal Class III malocclusion. Maintenance of
the expanded maxillary width using a surgical wafer.
Le Fort I osteotomy

117. The
roots of the central incisors then need to be deviated
for safe performance of the interdental osteotomy.

118. In many circumstances, it is preferable to stage the
orthognathic surgery by first correcting the transverse
width discrepancy with orthodontic expansion
that may require surgically assisted rapid palatal expander
(SARPE), and then subsequently correcting
the sagittal discrepancy as a single-piece Le Fort I osteotomy
to postoperative skeletal stability.

119. With
maxillary crowding and the need for incisor retraction,
the decision to extract the first or second premolars
is based on the extent of crowding and the
degree of incisor decompensation needed

120. When the advancement of the mandibular incisors is
limited by a lack of attached gingiva or minimal alveolar
bony support, mandibular second premolar
extraction may be necessary to provide the necessary
space.

121. Under most circumstances, the maxillary first
premolars are extracted or, where needed, combined
with extraction of the mandibular second premolars
as a common extraction pattern.
Classic pattern extraction of 14, 24, 35 and
45 in order to increase the negative overjet
and presurgically decompensate for the
malocclusion. Correct planning of the
orthodontic tooth positioning before surgery
will enhance the surgical potential and,
hence, the esthetic result
Extraction of 14 and 24 is often
sufficient and molar Class II
acceptable

122. Vertical maxillary excess
Patients who have vertical maxillary excess (VME)
or long-face syndrome present with an increase in
the lower facial height with clockwise rotation of
the mandible a convex facial profile. The chin
may be vertically increased and retrusive .

123. Lip incompetence (increased interlabial gap) is
present and mentalis strain occurs with attempted
lip closure. The dental display is excessive on repose
and the smile is ‘‘gummy.’’

124. (A–D) Pretreatment digital diagnostic casts, presurgical dental arches
prepared for surgery, and posttreatment
digital dental casts. Cephalometric pretreatment, posttreatment, and
superimposition tracings. Pretreatment
and posttreatment extra- and intraoral photographs.

125. (A–D) Pretreatment digital diagnostic casts, presurgical dental
arches prepared for surgery, and posttreatment
digital dental casts. Cephalometric pretreatment, posttreatment,
and superimposition tracings. Pretreatment
and posttreatment extra- and intraoral photographs.

126. (A–D) Pretreatment digital diagnostic casts, presurgical dental arches
prepared for surgery, and posttreatment
digital dental casts. Cephalometric pretreatment, posttreatment, and
superimposition tracings. Pretreatment
and posttreatment extra- and intraoral photographs.

127. (A–D) Pretreatment digital diagnostic casts, presurgical dental arches
prepared for surgery, and posttreatment
digital dental casts. Cephalometric pretreatment, posttreatment, and
superimposition tracings. Pretreatment
and posttreatment extra- and intraoral photographs.

128. The alar base is frequently
narrow in width, the paranasal regions
are deficient, and malar projection is lacking in
many patients..

129. Intraoral examination reveals an anterior
open bite deformity in most patients, a high
arched palate with a V-shaped transversely narrow
maxilla, and dentition in the palatal crossbite. The
occlusal relationship is Class II in most cases; however,
Class I and Class III VME can occur

130. Downward and posterior rotation of the mandible
(clockwise rotation of the mandibular plane) as
a result of excessive vertical maxillary growth makes
the associated mandibular deficiency appear worse
and mandibular excess not as severe.
Management of Skeletal Class III Malocclusion due to
Mandibular
Prognathism Coexisting with Vertical Maxillary Excess

131. Although anterior
open bite is the usual presentation, patients
who have a deep bite can exhibit VME.

132. The orthodontic management involves eliminating
dental compensations and minor leveling of the
mandibular arch..
Extraction of
first premolars

133. In cases where the open bite is
severe and the maxillary arch has an excessive reverse
curve of Spee, it is preferable to level the
arch in segments, with appropriate root divergence,
to allow interdental osteotomies and surgical leveling
with a three-piece Le Fort I osteotomy
3 segments (1 anterior and 2 lateral)
three-piece Le Fort I osteotomy

134. When the vertical discrepancies are minimal, the
arch can be leveled in a single plane and the open
bite corrected by differential posterior-anterior impaction,
single-piece Le Fort I osteotomy.

135. To minimize
dental relapse, the open bite should not be
closed orthodontically. Relief of dental crowding
and transverse palatal expansion (surgically assisted)
should be addressed before definitive orthognathic
surgery.

136. In many circumstances, correction of significant
VME requires double jaw surgery: differential Le
Fort I impaction of the maxilla either as a single
segment or a multi-segment with mandibular
BSSO advancement.
(a) Le Fort I maxillary
osteotomy, (b) rigid
fixation with bone plates
and intermediate occlusal
splint, and (c) BSSO with
mandibular
setback and final occlusal
splint.
Mandibular ramus sagittal split
osteotomy is the most common
technique used for mandibular
advancement.
, For mandibular
prognathism,

137. Occasionally, however, Le
Fort I impaction, with or without a genioplasty,
with reliance on autorotation of the mandible, results
in a stable occlusion and a satisfactory aesthetic
outcome. Prediction cephalometric tracing
is beneficial to assess the need for concomitant
mandibular surgery.

138. Orthodontic Management
of Dentofacial Skeletal
Deformities
John Grubb, DDS, MSD, Carla Evans,
DDS, DMS
Reference