Pre and post surgery final /certified fixed orthodontic courses by Indian dental academy

Pre and Post Surgical Orthodontics

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Contents
1.Pre Orthodontic Preparation – Control of
pathologic problems
2.Pre-surgical orthodontics
3.Final surgical preparations
4.Surgery and postoperative care
5.Post-surgical orthodontics
6.Retention

Before Orthodontics
• Adult Patients
a)Chronic systemic diseases
b)Pregnancy
c)Prolonged use of drugs
d)Dental problems


Before Orthodontics
a) Chronic systemic diseases
– Hypertension and diabetes
– Drugs and diet alteration

b) Pregnancy
– general anesthesia
– surgery must be delayed for 4-6 months after
delivery


Before Orthodontics
c) Prolonged use of
Drugs
– interactions with
general anesthetics
– Prostaglandins


Before Orthodontics
• Phenytoin
– gingival overgrowth
– seizures may be exacerbated by orthodontic
appliances

• Dryness of the mouth
– irritation due to the orthodontic appliance
– oral hygiene


Before Orthodontics
d) Dental Disease
• Caries control
– 0.05% NaF
mouthrinse

• Missing teeth
– Bridges – need
removal
– Riding pontic

Before Orthodontics
Periodontal problems
 oral hygiene
maintainance
 Hopelessly mobile
teeth

 Offer better
stabilization during
surgery than
removable partial
dentures.

Before Orthodontics
Implications of reduced periodontal support
• Lighter force
• Greater counter-moments are needed for
tooth movement


Before Orthodontics
Impacted and
unerupted teeth.
• Growing children –
unerupted teeth
may be encountered
during the
osteotomy cuts.

Before Orthodontics
• Adults –third molars can be removed at the
time of LeFort I osteotomy


Before Orthodontics
Mandibular 3rd molars
• Remove 6 months before a BSSO, so that the
socket is properly healed at the time of
surgery
• Complications – Bad split
– Chances of infection
– Difficult to use rigid internal fixation, due to the
space occupied by the tooth.
– Increased chances of fracture

Surgical and orthodontic treatment
BASIC OUTLINE
• Pre-surgical orthodontics
- removes dental
compensations, and
positions the teeth
properly in relationship
to the individual skeletal
bases.


• Heavy archwires are placed and the
appliance is used for stability and fixation
during surgery.


• Active orthodontics is reinitiated to
refine the occlusion.


Pre-Surgical Orthodontics
Goals –
1.Align and level teeth without concern for
dental occlusion.
2.Establish proper anterior-post. and vertical
position of the incisors.


General guideline If the patient is not properly prepared –
• Surgery cannot be carried out effectively,
• Quality of the result is diminished
• Post surgical orthodontic treatment time
increases


• Selection of the appliance
1.Stability
2.Esthetics
3.Slot Size
4.Bonding vs Banding


Stability
 PAE is recommened
 Begg appliance for surgical
patients
rectangular wire in the
ribbon mode.


Esthetics
Lingual appliances
• Post op – patients have difficulty in mouth
opening
• Hugo et al (J Adult Orthod &Orthognath Surg 2000)
– use of labial appliances just before the surgery
and thereafter until the end of the treatment.


• Width of the labial
brackets have been
reduced to increase
esthetics
• Extremely narrow
brackets have poor
rotational and tip
control.

Tooth colored brackets
• Plastic brackets
– Fracture
– Poor torque control

• Ceramic brackets
– Good torque control
– Brittle and can fracture
– Should be prepared with alternative measures

Slot Size
Either slot size – 18 or 22
• 17x 25 ss for 18 slot
• 21x25 ss or TMA for 22 slot
Bonding vs banding –
• bond anteriors, and band posteriors.
• perio problems, bands are to be avoided

Alignment of the arch
 Principles of
alignment remain
the same.
 Initial tipping

 undersizes, round and
resilient wires.
 free sliding, freedom
to tip and light
continuous forces.

Leveling of the Arch
Presurgical

Postsurgical

Intrusion

Extrusion


• Final vertical height ➫
Position of the lower incisors
– Increase the face height → the lower incisors
should not be intruded
– In patients with normal or excessive face height,
the lower incisors must be intruded pre-surgically

Final position of the incisors is
determined pre surgically


Segmental procedures ➫
Teeth should be leveled within the segments


Ant – post positioning of the incisors
• Affects the sagittal placement of the jaws
during surgery
• dental compensations must be removed
• Movements opposite to camouflage


• Extraction pattern in surgical patients
– Opposite to camouflage
– Worsening of the occlusion
– Extraction of teeth during the surgery itself


Segmental surgeries
• Establish torque of incisors pre surgically
• ½ extraction site left open


Anchorage consideration
• Opposite directions of movement
• Intermaxillary elastics
• Extra oral forces rarely needed
• Small amount of space can be left open


Arch compatibility
• Shape and width
• Co-ordinated arch wire


• Torquing of roots
• Not more than 5 mm
of dental expansion
• ½ cusp cross-bite can
be corrected postsurgically


• At the end of the pre-surgical phase, the
patient should be in a full sized rectangular
steel wire which will help stabilize the teeth
during surgery


Stabilizing wires
• Full dimension, filling the slot
– 17 x 25 ss for 18 slot
– 21 x 25 ss or TMA for 22 slot
– 19 x 25 wire in a 22 slot is acceptable

• The stabilizing wire must be passive


Stabilizing wires


Final surgical Planning
2 weeks before surgery
• OPG
• Lat. Ceph
• Casts
• Photos – intra and extra-oral
• PA ceph – if there is facial asymmetry
• IOPAs and occlusal view if needed.
• Face bow transfer onto an articulator if
needed

• OPG
– Root proximity at osteotomy site
– Confirm with IOPAs

• Lateral Ceph.
– For pre surgical prediction

• Models
– Model surgery
– Preparation of the splint

Need for a facebow transfer
1.Mand. dentition – condylar relation maintained
Mand. is required to auto-rotate
Segmental subapical procedures of the
mandible.
2.In case of 2 jaw surgeries

• Condyle - mandibular dentition relation is to
be chanced during surgery, a facebow transfer
is not needed.
• Mounting on a simple articulator will do.


Model Surgery
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.


Model Surgery
Model surgery – 4 weeks after stabilizing
wire is placed


Model Surgery - 2 jaw surgery
Impressions
Wax bite to record
Pre surgical occlusion

Face-bow record



Casts mounted on semi-adjustable articulator



Mounting of maxillary cast with spacer



Intermediate splint


Mandible advanced to desired position


Final Splint

Model Surgery – ‘Piggy-back’ splint

Mandibular cast positioned – hinge articulator


Wires made as required


Final splint placed back on original mounting


Intermediate splint made with final splint in place


Intermediate and final splints


Piggy – back splint on the casts

Requirements of the splint
• Fit the teeth
accurately
• Minimum thickness
– not more than 2
mm


Requirements of the splint
• Excess acrylic should
be trimmed off the
buccal aspect, to
allow for proper
visual verification
during surgery and
oral hygiene
maintenance.

Model Surgery - Problems
• Condylar distraction
• Trim cusp or prolong pre-surgical orthodontics


Model Surgery - Problems
• Incompatibility of canine
widths
– Easy to check in Class II –
not Class III
– Can result in ant. Open-bite
– Go back to lighter wire

• Lack of space between roots
to place osteotomy cuts


During Surgery
• Splint used to help attain final occlusion
• Segmental osteotomies – wire placement
• IMF with splint in place
• Teeth might penetrate thro splint
• Splint should be in place until start of post
surgical orthodontics

Post Operative Events
• Hospitalization
– 2-3 days for single jaw
– 4-5 days for double jaw

•
•
•
•

Facial edema – 2-3 weeks
Resumes partial function in 2 weeks
Mastication after 6-8 weeks
Complete bone healing – 6 months

Post Operative Care
• 1 week soft diet
– Milk, mashed potatoes, scrambled eggs

• After 2 weeks – more chewing
– Chapattis, vegetables, and meat in small pieces

• Progress to normal diet
• Normal diet in 6-8 weeks


Post Operative Physiotherapy
• As soon as the initial intracapsular joint
edema has resolved – after about 1 week.
– 1st week after surgery – open and close mouth
gently within comfortable limits
– Over next 2 weeks – 3 10-15 minute sessions of
opening and closing and lateral movements.
– 3rd – 8th weeks, range of motion is increased, and
should be normal in 8 weeks.


Post Operative Care
• Orthodontist should see the pt within the 1st
week – review the occlusal status and check
the status of the orthodontic appliance.
• Post surgical orthodontics
– adequate bone healing
– adequate mouth opening


Post Operative Care
• Rigid internal fixation and jaw exercises ➫ 2-3
weeks
• Wire fixation and IMF ➫ 3-4 weeks after the
IMF is released.
• Splint and light elastics to guide occlusion


Post Surgical Orthodontics
• Working archwires placed
– 0.016” steel
– 21 x 25 NiTi or Braided Steel
– Stabilizing wire left in place in 1 arch


• Good amount of settling in first month
• Step bends in archwires


• Headgears and extra oral forces
• Heavy intermaxillary elastics
• Overlay wire for transverse stabilization


• Finishing with positioners
– Parasthesia after surgery
– Variable biting force

• At the end
– Proper settling
– Root parallelism – esp. osteotomy site


Retention
• Not very different from routine orthodontics.
• Transverse retention
• Fixed retainers


Summary
Before
surgery

Alignment
Leveling – by intrusion
Arch compatibility

Preparation of osteotomy site
Before and/or Post. crossbite correction – if
after surgery
orthodontic expansion is planned
Leveling by extrusion
After surgery Settling and leveling by extrusion
Root paralleling at osteotomy sites
Detailed tooth positioning

Clinical Management Of Some
Commonly Encountered Orthognathic
Surgical Patients
1.Mand. Deficiency with normal or reduced
facial height
2.Excessive face height (long face)
3.Class III problems
4.Facial asymmetry
5.Crossbite and open bite

Mand Deficiency with normal or
reduced facial height
• Horizontal growth pattern
• Class II molar and Canine
relationship – often with a
div. 2 pattern.
• Excessive curve of spee in
the lower arch.
• Incisor crowding
• Deep bite – usually causing
some gingival irritation


• Chin button well
developed
• Deficiency near the
lower lip region –
seen as a deep
mentolabial sulcus, a
curl of the lower lip
and an aged
appearance.
• TMJ disorders –


Surgical plan
• In most of these
patients, – Mandibular
deficiency needs to
be corrected
– Height of the face
must be increased.

Mandibular subapical procedure vs. BSSO
Subapical procedure
– When face ht. is not to be increased

BSSO
– To increase face height

• Rotation of mandible
– chin moved back and incisors forward

• Genioplasty if needed
– Reduce chin prominence
– Further increase face height

• No maxillary surgery to increase face height


Mandibular Deficiency with normal or
Pre surgical Orthodontics
Position of the incisors –
vertically and sagittally
Vertical – Determines final face height
Sagittal – Determines amount of movement


• Expansion of arch may be necessary
– Wider part of mandible comes forward
– Can be done orthodontically or surgically
– Extractions may not be required


• Considerations during model surgery
– Face bow transfer rarely required
– Maintain bilateral symmetry – even if crossbite
develops
– Keep skeletal midlines matching

• Post surgical orthodontics –
– Level COS by extrusion

Dr. Punit Thawani


Long Face Problems
• Vertical excess of post
maxilla
• ↑mand plane angle
• Incisor exposure
• Incompetent lips


Long Face Problems
• Gummy smile
• Narrow maxilla
• Cross-bite


Long Face Problems
Surgical considerations
• impacting to maxilla – mandibular
autorotation
• Rotating the mandible upwards and forwards
after a BSSO
• Chin procedures


Long Face Problems
• Maxillary procedure – Stable – Corrects most
of the problem
• BSSO with rotation – Soft tissue stretch –
Unstable
• Chin procedures – used as adjuncts


Long Face Problems
Pre surgical Orthodontics
• Orthodontist must know 2 things –
– Maxilla in 1 piece or segmented? – how many
pieces, and where
– Chin position? - or is proper lip – chin balance
going to be achieved by orthodontic treatment


Long Face Problems
• Segmented procedures
– Align within the segment
– Stabilize with a wire with step, or segments of 21
x 25 SS wire
– Roots of adjescent teeth

• Leveling
– If mild, by intrusion
– If severe - surgically

Long Face Problems
• Expansion
– Orthodontically
– Surgically
– But not both
– Causes more relapse


Long Face Problems
• Maxillary impaction
– ↑ wrinkles on the cheek
– Drastic reduction in incisor exposure
– Widening of alar bases
– Aged appearance
– More tolerated in younger individuals than adults


Long Face Problems
• If maxilla is moved back - ↓lip support
• Maxilla may have to be moved forward to get
good lip support
• Genioplasty – avoid major jaw surgery


Long Face Problems
Before model surgery
• How much is the maxilla going to be moved
• How to reduce residual overjet (if any)
• Surgical expansion? – Prepare overlay wire


Long Face Problems
Post surgical Orthodontics
• Segmental procedures – torque on anteriors
– Flexible rectangular wires in upper
– 0.016” SS in lower

• Stabilizing transverse corrections


Long Face Problems


Class III patients
• Flatness in the lower 1/3rd
of the face – especially in
the labio-mental fold.
• Soft tissues seem to be
tight.
• Midface deficiency
–“sunken in” appearance is
seen.
• Thin vermillion border, and
reduced maxillary incisor
exposure at rest.


Class III patients
• Natural compensation
– Flared upper incisors, retroclined lower incisors.
– Spacing between lower teeth – should think of
large tongue
– Maxilla may have small or even missing teeth.
– Check for attached gingiva in lower anterior –
labial region.


Class III patients
• Surgical techniques
1.Mandibular –
1.(BSSO)
2.Mandibular sub apical procedures

2.Maxillary –
1.Lefort I osteotomy - high level
2.Expansion

3.Genioplasty


Class III patients
• Jaw at fault should be operated
• If mandible too prognathic – both jaws
– Too much setback ➫ Double chin

• Maxillary impaction in case of hyperdivergent
jaws


Class III patients
• Jacobs – ‘two patient’ concept
• Incisors should be positioned as ideally as
possible to their respective jaw bases, without
concern for inter-arch occlusion.
• Maxilla
– require extractions and significant retraction

• Mandible
– Non extraction or extraction for molar correction
– Molar inclination correction

Class III patients
• If upper expansion is needed
– Teeth should be aligned within the segments
– Arches should NOT be co-ordinated presurgically
– Gross coordination surgically
– Final coordination post surgically


Class III patients
• Frequent progress models
• Before surgery, patients should be informed
about –
– Possibility of late mandibular growth
– Large amount of setback – double chin, may
require second soft tissue surgery
– Possibility of nasal changes – alar base widening
and upturning of the nose.

Class III patients
Post surgical orthodontics
Basic principles to be followed
Check for relapse tendency


Class III patients
Tendency towards relapse
• Moderate class III elastics (200-300 gms)–
heavier rectangular wires needed
• Upper incisors can be flared to an extent
• Interproximal reduction, and retroclination of
lower incisors
• Leave larger overjet and overbite

Class III patients
• If relapse is still expected, the retention
appliance can be made with hooks for
attachment of light class III elastics while
sleeping


Class III patients


Dento-facial Asymmetry
• More through diagnosis
– PA view
– Submento-vertex
– CT scan


Surgery in children
• Severe or progressive asymmetry
– Hemifacial microsomia
– mandibular ankylosis due to condylar fracture


• Principle of treatment –
– Modify growth to its full potential so that the child
grows out of the deformity

• Initial functional appliance treatment
– Eliminate need for surgery
– Make surgery easier
– Help in muscular adaptation


• Role of orthodontist –
– Growth guidance after surgery
– Maintenance of normal joint function
– Alignment of permanent teeth


Asymmetry problems in adolescents
• Continue growth guidance
– prevents bimaxillary problems

• Problems of excessive growth
– Hemifacial hypertrophy

• Orthognathic surgery at the end of growth


Problems of excessive growth
• Diagnosis – 99mTc scan
• After growth – surgical correction


• In severe cases – surgical correction before
growth is completed
– Only mandibular surgery
– cant of occlusal plane corrected by functional
appliances


Asymmetry in adults
• Extent of surgery –
– Correct asymmetry at its source
– Camouflage

• Pre and post surgical orthodontics
– similar to any other case


Guidelines –
• More concern about transverse than vertical
asymmetry
• More concern about chin position than
mandibular angles
• Maxillary midline more critical than
mandibular midline


• If nose and jaw are deviated to the same side,
both should be corrected
• Asymmetry of higher structures - infra-orbital
rims, Zygomatic arch – onlay grafts should be
considered


• Pre-surgical orthodontics
– Matching skeletal and dental midlines
• Asymmetric extractions
• Asymmetric elastics and cross elastics
• Loops and springs

– Know the type of surgery
• Genioplasty
• Ramus osteotomy


• Post surgical orthodontics
– Leveling by extrusion
– May be longer in such patients


Surgery in Patients with TMJ Problems
• General guideline for management


Surgery in Patients with TMJ Problems
• Orthodontics and/or surgery to correct
occlusion
• TMJ surgery
– Not responding to reversible therapy
– Progressive internal joint pathologies


Stability of Surgical Corrections
The stability of orthognathic surgical
procedures depends on the following –
1.Direction of movement
2.Type of fixation used
3.Surgical technique employed


Hierarchy of Stability
Maxillary impaction
• Most stable procedure
• Mandible auto-rotates to maintain the
freeway space
• Wire/IMF vs RIF equally good results
• Wire/IMF
– 6 weeks after the surgery - 20% of patients
showed 2-4 mm of change in the upward direction
– 6weeks to 1 year - that much downward
movement of the max

RIF or wire/IMF seemed to make no significant
differences in stability.
More than 90% chance of max being within 2
mm of post surgical position after 1 year
» Bishara et al 1988
» Denison et al 1989
» Proffit et al 1992


Mandibular advancement (BSSO)
• normal or short face height is considered
Wire/IMF
• first 6 weeks post surgery
– the mand had a tendency to move slightly back.

• 6 weeks to one year
– the changes seemed to be recovered

• function

RIF
• smaller tendency to move back
• greater chance of slight forward movement
90% chance of stability
» Proffit et al 1990
» Kouma et al 1991
» Gomes et al 1993
» Ingervall et al 1994


• BSSO with rotation to close an open bite
– Soft tissue stretch
– RIF more stable than wire/IMF
– Interpositional bone grafts and heavy plates
» Ritzik et al 1990


By the end of 1 year, only 60% of the patients
were judged to have excellent clinical results
• Post surgical bite opening tendency is seen


Maxillary advancement
• If moved only anteriorly – 80% stable
• If simultaneous downward movement –
unstable
» Proffit et al – 1991
» Bishara , Chi - 1992


Mandibular setback
• BSSO and Trans-oral vertical ramus osteotomy
(VRO).
• VRO seemed to be more stable than BSSO


VRO
• chance of further backward
• but forward relapse also occurred
With BSSO
• no post surgical backward movement, but
forward relapse occured
• RIF with BSSO seemed to make relapse
tendencies worse

VRO
• improper positioning of condyles in fossa
resulted in backward movement
Both procedures
• Change in ramus inclination resulted in
forward relapse
» Proffit et al (1991)


Widening of the maxilla
• 1 year later, almost 50% of the expansion was
lost in the second molar region
• Reduction in post surgical width of about 2
mm in 2/3rd of the patients.
» Proffit et al 1992.

• Stretching of the palatal mucosa
• Modest overcorrection and stringent

3 Basic principles that influence post surgical
stability –
• Stability is greatest when soft tissues are
relaxed during surgery and least when they
are stretched.
• Neuromuscular adaptation
• Neuromuscular adaptation affects muscle
length and not muscle orientation.

Euryprosopic
Mesoprosopic

Surgeries are only treatment in
• Congenital anomalies affecting (cranio-)facial
regions.
• Excessively large or small jaw dimensions on
account of abnormal growth coupled with
abnormal placement (in one or more planes
namely, sagittal, vertical and transverse) in
adult patients.
• Asymmetrical jaw growth.
Dr. Punit Thawani


• Anatomic limitations, which hinder the
orthodontic tooth movement.

Dr. Punit Thawani


References
• Contemporary treatment of Dentofacial
Deformity – Proffit, White & Sarver
• Surgical Orthodontic Treatment – Proffit and
White
• Contemporary Orthodontics – Proffit
• Orthognathic surgery: A hierarchy of Stability
– Proffit et al - Int. J or Adult Orthod
Orthognath Surg 1996

References
• Lingual Orthodontics and Orthognathic
surgery – Int. J or Adult Orthod Orthognath
Surg 2000
• Stability of Le Fort I osteotomy in maxillary
inferior positioning: Review of the literature Costa et al - Int. J or Adult Orthod Orthognath
Surg 2000
• Long term stability of mandibular setback
surgery: A follow-up of 80 bilateral sagittal
split osteotomy patients - Mobarak, et al - Int.
J or Adult Orthod Orthognath Surg 2000

References
• Long Term stability of Surgical Open bite
Correction by Le Fort I osteotomy - Proffit,
Bailey, Phillips, Turvey – AO Feb 2000
• Long term Prognosis of BSSO Mandibular
Relapse and its Relation to Different Facial
Types - Yoshida et al - AO March 2000
• Mandibular advancement surgery in high
angle and low angle Class II patients: Different
long term skeletal responses - Mobarak,
Espeland, Krogstad and Lyberg – AJO 2001

Thank you
For more details please visit

Dr. Punit Thawani


Pre and post surgery final /certified fixed orthodontic courses by Indian dental academy

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