Pre and post surgical orthodontics

Pre and Post SurgicalPre and Post Surgical
OrthodonticsOrthodontics
www.indiandentalacademy.com

Pre and Post Surgical Orthodontics
Dr. Punit Thawani
IntroductionIntroduction
1.1. Pre Orthodontic Preparation – Control ofPre Orthodontic Preparation – Control of
pathologic problemspathologic problems
2.2. Pre-surgical orthodonticsPre-surgical orthodontics
3.3. Final surgical preparationsFinal surgical preparations
4.4. Surgery and postoperative careSurgery and postoperative care
5.5. Post-surgical orthodonticsPost-surgical orthodontics
6.6. RetentionRetention

Dr. Punit Thawani
Before OrthodonticsBefore Orthodontics
• Adult PatientsAdult Patients
a)a) Chronic systemic diseasesChronic systemic diseases
b)b) PregnancyPregnancy
c)c) Prolonged use of drugsProlonged use of drugs
d)d) Dental problemsDental problems

Dr. Punit Thawani
a) Chronic systemic diseasesa) Chronic systemic diseases
– Hypertension and diabetesHypertension and diabetes
– Taxes patient complianceTaxes patient compliance
– Drugs and diet alterationDrugs and diet alteration
b) Pregnancyb) Pregnancy
– general anesthesiageneral anesthesia
– surgery must be delayed for 4-6 monthssurgery must be delayed for 4-6 months
after deliveryafter delivery

Dr. Punit Thawani
c) Prolonged use ofc) Prolonged use of
DrugsDrugs
– interactions withinteractions with
general anestheticsgeneral anesthetics
– ProstaglandinsProstaglandins
Prostaglandin inhibitors
Corticosteroids and NSAIDs Other drugs
Chronic Arthritis
Tricyclic antidepressants,
antiarrtiarrhythmic drugs,
antimalarial drugs

Dr. Punit Thawani
• PhenytoinPhenytoin
– gingival overgrowthgingival overgrowth
– seizures may be exacerbated by orthodonticseizures may be exacerbated by orthodontic
appliancesappliances
• Dryness of the mouthDryness of the mouth
– irritation due to the orthodontic applianceirritation due to the orthodontic appliance
– smooth appliancesmooth appliance
– oral hygieneoral hygiene

Dr. Punit Thawani
d) Dental Diseased) Dental Disease
• Caries controlCaries control
– 0.05% NaF0.05% NaF
mouthrinsemouthrinse
• Missing teethMissing teeth
– Bridges – needBridges – need
removalremoval
– Riding ponticRiding pontic

Dr. Punit Thawani
• Metal crownsMetal crowns
• Porcelain crownsPorcelain crowns
• Acrylic crownsAcrylic crowns

Dr. Punit Thawani
Periodontal problemsPeriodontal problems
• oral hygieneoral hygiene
maintainancemaintainance
• Hopelessly mobileHopelessly mobile
teethteeth
– Offer betterOffer better
stabilization duringstabilization during
surgery thansurgery than
removable partialremovable partial
dentures.dentures.

Dr. Punit Thawani
Mucogingival considerationsMucogingival considerations

Dr. Punit Thawani
• Mucogingival considerationsMucogingival considerations ––
Maintenance of attached gingivaMaintenance of attached gingiva
• Orthodontic expansion of the dentalOrthodontic expansion of the dental
archesarches
• Surgical incisions in the vestibule.Surgical incisions in the vestibule.
– Class III correction & GenioplastyClass III correction & Genioplasty
• Ressective osseous surgeryRessective osseous surgery

Dr. Punit Thawani
Implications of reduced periodontal supportImplications of reduced periodontal support
• Lighter forceLighter force
• Greater counter-moments are needed forGreater counter-moments are needed for
tooth movementtooth movement

Dr. Punit Thawani
Impacted andImpacted and
unerupted teeth.unerupted teeth.
• GrowingGrowing
childrenchildren ––
unerupted teethunerupted teeth
may be encounteredmay be encountered
during theduring the
osteotomy cuts.osteotomy cuts.

Dr. Punit Thawani
• AdultsAdults – maxillary canines and third– maxillary canines and third
molars can be removed at the time ofmolars can be removed at the time of
LeFort I osteotomyLeFort I osteotomy

Dr. Punit Thawani
Mandibular 3Mandibular 3rdrd
molarsmolars
• Remove 6 months before a BSSO, so that theRemove 6 months before a BSSO, so that the
socket is properly healed at the time of surgerysocket is properly healed at the time of surgery
• Complications -Complications -
– Bad splitBad split
– Chances of infectionChances of infection
– Difficult to use rigid internal fixation, due to theDifficult to use rigid internal fixation, due to the
space occupied by the tooth.space occupied by the tooth.
– Increased chances of fractureIncreased chances of fracture

Dr. Punit Thawani
Surgical and orthodontic treatmentSurgical and orthodontic treatment
BASIC OUTLINEBASIC OUTLINE
• Pre-surgical orthodonticsPre-surgical orthodontics
- removes dental- removes dental
compensations, andcompensations, and
positions the teethpositions the teeth
properly in relationshipproperly in relationship
to the individual skeletalto the individual skeletal
bases.bases.

Dr. Punit Thawani
• Heavy archwires are placed and theHeavy archwires are placed and the
appliance is used for stability andappliance is used for stability and
fixation during surgery.fixation during surgery.

Dr. Punit Thawani
• Active orthodontics is reinitiated toActive orthodontics is reinitiated to
refine the occlusion.refine the occlusion.

Dr. Punit Thawani
Pre-Surgical OrthodonticsPre-Surgical Orthodontics
Goals –Goals –
1.1. Align and level teeth without concern forAlign and level teeth without concern for
dental occlusion.dental occlusion.
2.2. Establish proper anterior-post. andEstablish proper anterior-post. and
vertical position of the incisors.vertical position of the incisors.
3.3. Achieve arch compatibility.Achieve arch compatibility.

Dr. Punit Thawani
General guideline -General guideline -
• Post surgical orthodontics (Between 4-6Post surgical orthodontics (Between 4-6
months)months)
If the patient is not properly prepared –If the patient is not properly prepared –
• Surgery cannot be carried out effectively,Surgery cannot be carried out effectively,
• Quality of the result is diminishedQuality of the result is diminished
• Post surgical orthodontic treatment timePost surgical orthodontic treatment time
increasesincreases

Dr. Punit Thawani
• Selection of the applianceSelection of the appliance
1.1. StabilityStability
2.2. EstheticsEsthetics
3.3. Slot SizeSlot Size
4.4. Bonding vs BandingBonding vs Banding

Dr. Punit Thawani
StabilityStability
• Stabilize the teeth againstStabilize the teeth against
stresses encountered atstresses encountered at
surgery and during IMFsurgery and during IMF
• PAE is recommenedPAE is recommened
• Begg appliance for surgicalBegg appliance for surgical
patientspatients
– rectangular wire in therectangular wire in the
ribbon mode.ribbon mode.

Dr. Punit Thawani
EstheticsEsthetics
Lingual appliancesLingual appliances
• Impossible to use the appliance for IMFImpossible to use the appliance for IMF
• Post op – patients have difficulty inPost op – patients have difficulty in
mouth openingmouth opening
• Hugo et alHugo et al (J Adult Orthod &Orthognath Surg 2000)(J Adult Orthod &Orthognath Surg 2000)
– use of labial appliances just before theuse of labial appliances just before the
surgery and thereafter until the end of thesurgery and thereafter until the end of the
treatment.treatment.

Dr. Punit Thawani
• Width of the labialWidth of the labial
brackets have beenbrackets have been
reduced to increasereduced to increase
estheticsesthetics
• Extremely narrowExtremely narrow
brackets have poorbrackets have poor
rotational and tiprotational and tip
control.control.

Dr. Punit Thawani
Tooth colored bracketsTooth colored brackets
• Plastic bracketsPlastic brackets
– FractureFracture
– Poor torque controlPoor torque control
• Ceramic bracketsCeramic brackets
– Good torque controlGood torque control
– Brittle and can fractureBrittle and can fracture
– Should be prepared with alternativeShould be prepared with alternative
measuresmeasures

Dr. Punit Thawani
Slot SizeSlot Size
Either slot size – 18 or 22Either slot size – 18 or 22
• 17x 25 ss for 18 slot17x 25 ss for 18 slot
• 21x25 ss or TMA for 22 slot21x25 ss or TMA for 22 slot
• segmented arch mechanics - 22 slotsegmented arch mechanics - 22 slot
Bonding vs bandingBonding vs banding ––
• bond anteriors, and band posteriors.bond anteriors, and band posteriors.
• perio problems, bands are to be avoidedperio problems, bands are to be avoided

Dr. Punit Thawani
Appliance modificationsAppliance modifications
1. Extreme prescriptions must be avoided.1. Extreme prescriptions must be avoided.
“Extraction series” – too much tip“Extraction series” – too much tip
Opposite side bracket should not be usedOpposite side bracket should not be used

Dr. Punit Thawani
2. Include all teeth in2. Include all teeth in
strap upstrap up
Mand. 2Mand. 2ndnd
molars –molars –
before surgerybefore surgery
Max. 2Max. 2ndnd
molars – aftermolars – after
surgerysurgery
3. Auxillary molar tubes3. Auxillary molar tubes
and headgear tubesand headgear tubes
• lingual attachments -lingual attachments -
Cross elasticsCross elastics

Dr. Punit Thawani
4.4. BracketsBrackets with adequate mesio-distal andwith adequate mesio-distal and
rotational control – twin brackets ½ the m-drotational control – twin brackets ½ the m-d
width of the toothwidth of the tooth
single brackets with rotational wingssingle brackets with rotational wings
• Integral hooks in the bracketsIntegral hooks in the brackets
– Help in stabilizationHelp in stabilization
– Long hooks should be avoidedLong hooks should be avoided
– brackets may get dislodged if these hooks are usedbrackets may get dislodged if these hooks are used
for stabilization, hooks on the archwire preferred.for stabilization, hooks on the archwire preferred.

Dr. Punit Thawani
Alignment of theAlignment of the
archarch
• Principles ofPrinciples of
alignment remainalignment remain
the same.the same.
• Initial tippingInitial tipping
– undersizes, roundundersizes, round
and resilient wires.and resilient wires.
– free sliding, freedomfree sliding, freedom
to tip and lightto tip and light
continuous forces.continuous forces.

Dr. Punit Thawani
Leveling of the ArchLeveling of the Arch
PresurgicalPresurgical PostsurgicalPostsurgical
Intrusion Extrusion

Dr. Punit Thawani
• Final vertical heightFinal vertical height ➫➫
Position of the lower incisorsPosition of the lower incisors
– Increase the face height the lower incisors→Increase the face height the lower incisors→
should not be intrudedshould not be intruded
– In patients with normal or excessive faceIn patients with normal or excessive face
height, the lower incisors must be intrudedheight, the lower incisors must be intruded
pre-surgicallypre-surgically

Dr. Punit Thawani
Final position of the incisors isFinal position of the incisors is
determined pre surgicallydetermined pre surgically

Dr. Punit Thawani
Segmental proceduresSegmental procedures ➫➫
Teeth should be leveled within theTeeth should be leveled within the
segmentssegments

Dr. Punit Thawani
Ant – post positioning of the incisorsAnt – post positioning of the incisors
• Affects the sagittal placement of the jawsAffects the sagittal placement of the jaws
during surgeryduring surgery
• dental compensations must be removeddental compensations must be removed
• Movements opposite to camouflageMovements opposite to camouflage

Dr. Punit Thawani
• Extraction pattern in surgical patientsExtraction pattern in surgical patients
– Opposite to camouflageOpposite to camouflage
– Worsening of the occlusionWorsening of the occlusion
– Extraction of teeth during the surgery itselfExtraction of teeth during the surgery itself

Dr. Punit Thawani

Dr. Punit Thawani
Over – treatmentOver – treatment
• Orthodontic relapse + IMFOrthodontic relapse + IMF
• Wire fixation with IMFWire fixation with IMF
– Mandible tends to slip backMandible tends to slip back
– Low. Ant . Procline, U ant. RetroclineLow. Ant . Procline, U ant. Retrocline
• Rigid fixationRigid fixation
– Very short period of IMFVery short period of IMF
– No need to overcorrect.No need to overcorrect.

Dr. Punit Thawani
Segmental surgeriesSegmental surgeries
• Establish torque of incisors pre surgicallyEstablish torque of incisors pre surgically
• ½ extraction site left open½ extraction site left open

Dr. Punit Thawani
Anchorage considerationAnchorage consideration
• Opposite directions of movementOpposite directions of movement
• Intermaxillary elasticsIntermaxillary elastics
• Extra oral forces rarely neededExtra oral forces rarely needed
• Small amount of space can be left openSmall amount of space can be left open

Dr. Punit Thawani
Arch compatibilityArch compatibility
• Shape and widthShape and width
• Co-ordinated arch wireCo-ordinated arch wire

Dr. Punit Thawani
• Torquing of rootsTorquing of roots
• Not more than 5Not more than 5
mm of dentalmm of dental
expansionexpansion
• ½ cusp cross-bite½ cusp cross-bite
can be correctedcan be corrected
post-surgicallypost-surgically

Dr. Punit Thawani
Confirming compatibility of arches –Confirming compatibility of arches –
• Class II patientClass II patient
– Protrude the mandibleProtrude the mandible
• Class III patientClass III patient
– Frequent modelsFrequent models

Dr. Punit Thawani
• At the end of the pre-surgical phase, theAt the end of the pre-surgical phase, the
patient should be in apatient should be in a full sizedfull sized
rectangular steelrectangular steel wire which will helpwire which will help
stabilize the teeth during surgerystabilize the teeth during surgery

Dr. Punit Thawani
Stabilizing wiresStabilizing wires
• Full dimension, filling the slotFull dimension, filling the slot
– 17 x 25 ss for 18 slot17 x 25 ss for 18 slot
– 21 x 25 ss or TMA for 22 slot21 x 25 ss or TMA for 22 slot
– 19 x 25 wire in a 22 slot is acceptable19 x 25 wire in a 22 slot is acceptable
• Attachments for IMFAttachments for IMF
– Attachments on the arch-wire are preferredAttachments on the arch-wire are preferred
– Kobayashi hooks not usefulKobayashi hooks not useful
• The stabilizing wireThe stabilizing wire must be passivemust be passive

Dr. Punit Thawani
Stabilizing wiresStabilizing wires

Dr. Punit Thawani
Final surgical PlanningFinal surgical Planning
2 weeks before surgery2 weeks before surgery
• OPGOPG
• Lat. CephLat. Ceph
• CastsCasts
• Photos – intra and extra-oralPhotos – intra and extra-oral
• PA ceph – if there is facial asymmetryPA ceph – if there is facial asymmetry
• IOPAs and occlusal view if needed.IOPAs and occlusal view if needed.
• Face bow transfer onto an articulator if neededFace bow transfer onto an articulator if needed

Dr. Punit Thawani
• OPGOPG
– Root proximity at osteotomy siteRoot proximity at osteotomy site
– Confirm with IOPAsConfirm with IOPAs
• Lateral Ceph.Lateral Ceph.
– For pre surgical predictionFor pre surgical prediction
• ModelsModels
– Model surgeryModel surgery
– Preparation of the splintPreparation of the splint

Dr. Punit Thawani
Need for a facebow transferNeed for a facebow transfer
1.1. Mand. dentition – condylar relation maintainedMand. dentition – condylar relation maintained
Mand. is required to auto-rotateMand. is required to auto-rotate
Segmental subapical procedures of the mandible.Segmental subapical procedures of the mandible.
2.2. In case of 2 jaw surgeriesIn case of 2 jaw surgeries

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

Dr. Punit Thawani
Model SurgeryModel Surgery
Purpose of model surgeryPurpose of model surgery
• 1) To verify that the planned movements1) To verify that the planned movements
are possibleare possible
• 2) To relate the mandibular and2) To relate the mandibular and
maxillary dentitions in the positionmaxillary dentitions in the position
where the surgical splint will be made.where the surgical splint will be made.

Dr. Punit Thawani
Model SurgeryModel Surgery
Model surgery – 4 weeks afterModel surgery – 4 weeks after
stabilizing wire is placedstabilizing wire is placed

Dr. Punit Thawani
Model Surgery - 2 jaw surgeryModel Surgery - 2 jaw surgery
ImpressionsImpressions
Face-bow recordFace-bow record
Wax bite to recordWax bite to record
Pre surgical occlusionPre surgical occlusion

Dr. Punit Thawani
Casts mounted on semi-adjustable articulatorCasts mounted on semi-adjustable articulator

Dr. Punit Thawani
Mounting of maxillary cast with spacerMounting of maxillary cast with spacer

Dr. Punit Thawani
Blue plaster used for initial mountingBlue plaster used for initial mounting

Dr. Punit Thawani
Jig positioned in articulatorJig positioned in articulator

Dr. Punit Thawani
Maxillary cast stabilized with puttyMaxillary cast stabilized with putty

Dr. Punit Thawani
Initial mounting plaster removedInitial mounting plaster removed

Dr. Punit Thawani
Maxillary impactionMaxillary impaction

Dr. Punit Thawani
Measurement of amount of impactionMeasurement of amount of impaction

Dr. Punit Thawani
Simulation of mandibular autorotationSimulation of mandibular autorotation

Dr. Punit Thawani
Intermediate splintIntermediate splint

Dr. Punit Thawani
Mandible advanced to desired positionMandible advanced to desired position

Dr. Punit Thawani
Final splint fabricatedFinal splint fabricated

Dr. Punit Thawani
Final SplintFinal Splint

Dr. Punit Thawani
If the jig is not available, markings can be madeIf the jig is not available, markings can be made
on the caston the cast

Dr. Punit Thawani
Model Surgery – ‘Piggy-back’ splintModel Surgery – ‘Piggy-back’ splint
Casts mounted on articulatorCasts mounted on articulator

Dr. Punit Thawani
Max. cast sectioned and positioned as requiredMax. cast sectioned and positioned as required

Dr. Punit Thawani
Duplication of maxillary castDuplication of maxillary cast

Dr. Punit Thawani
Mandibular cast positioned – hinge articulatorMandibular cast positioned – hinge articulator

Dr. Punit Thawani
Wires made as requiredWires made as required

Dr. Punit Thawani
Final splint madeFinal splint made

Dr. Punit Thawani
Final splint placed back on original mountingFinal splint placed back on original mounting

Dr. Punit Thawani
Intermediate splint made with final splint in placeIntermediate splint made with final splint in place

Dr. Punit Thawani
Intermediate and final splintsIntermediate and final splints

Dr. Punit Thawani
‘‘Piggy – back splints’Piggy – back splints’

Dr. Punit Thawani
Piggy – back splint on the castsPiggy – back splint on the casts

Dr. Punit Thawani
Requirements of the splintRequirements of the splint
• Fit the teethFit the teeth
accuratelyaccurately
• Minimum thicknessMinimum thickness
– not more than 2– not more than 2
mmmm

Dr. Punit Thawani
Requirements of the splintRequirements of the splint
• Excess acrylicExcess acrylic
should be trimmedshould be trimmed
off the buccaloff the buccal
aspect, to allow foraspect, to allow for
proper visualproper visual
verification duringverification during
surgery and oralsurgery and oral
hygienehygiene
maintenance.maintenance.

Dr. Punit Thawani
Model Surgery - ProblemsModel Surgery - Problems
• Dental interferences – Further pre-Dental interferences – Further pre-
surgical orthodontics?surgical orthodontics?
Interference in second molar regionInterference in second molar region
• Usually caused due toUsually caused due to notnot bonding lowerbonding lower
22ndnd
molar and bonding upper 2nd molar.molar and bonding upper 2nd molar.

Dr. Punit Thawani
• Condylar distractionCondylar distraction
• Trim cusp or prolong pre-surgicalTrim cusp or prolong pre-surgical
orthodonticsorthodontics

Dr. Punit Thawani
• Incompatibility of canineIncompatibility of canine
widthswidths
– Easy to check in Class II –Easy to check in Class II –
not Class IIInot Class III
– Can result in ant. Open-biteCan result in ant. Open-bite
– Go back to lighter wireGo back to lighter wire
• Lack of space between rootsLack of space between roots
to place osteotomy cutsto place osteotomy cuts

Dr. Punit Thawani
During SurgeryDuring Surgery
• Splint used to help attain final occlusionSplint used to help attain final occlusion
• Segmental osteotomies – wire placementSegmental osteotomies – wire placement
• IMF with splint in placeIMF with splint in place
• Teeth might penetrate thro splintTeeth might penetrate thro splint
• Splint should be in place until start ofSplint should be in place until start of
post surgical orthodonticspost surgical orthodontics

Dr. Punit Thawani
Post Operative EventsPost Operative Events
• HospitalizationHospitalization
– 2-3 days for single jaw2-3 days for single jaw
– 4-5 days for double jaw4-5 days for double jaw
• Facial edema – 2-3 weeksFacial edema – 2-3 weeks
• Resumes partial function in 2 weeksResumes partial function in 2 weeks
• Mastication after 6-8 weeksMastication after 6-8 weeks
• Complete bone healing – 6 monthsComplete bone healing – 6 months

Dr. Punit Thawani
Post Operative CarePost Operative Care
• 1 week soft diet1 week soft diet
– Milk, mashed potatoes, scrambled eggsMilk, mashed potatoes, scrambled eggs
• After 2 weeks – more chewingAfter 2 weeks – more chewing
– Chapattis,Chapattis, vegetables, and meat in smallvegetables, and meat in small
piecespieces
• Progress to normal dietProgress to normal diet
• Normal diet in 6-8 weeksNormal diet in 6-8 weeks

Dr. Punit Thawani
Post Operative PhysiotherapyPost Operative Physiotherapy
• As soon as the initial intracapsular jointAs soon as the initial intracapsular joint
edema has resolved – after about 1 week.edema has resolved – after about 1 week.
– 1st week after surgery – open and close1st week after surgery – open and close
mouth gently within comfortable limitsmouth gently within comfortable limits
– Over next 2 weeks – 3 10-15 minute sessionsOver next 2 weeks – 3 10-15 minute sessions
of opening and closing and lateralof opening and closing and lateral
movements.movements.
– 3rd – 8th weeks, range of motion is3rd – 8th weeks, range of motion is
increased, and should be normal in 8 weeks.increased, and should be normal in 8 weeks.

Dr. Punit Thawani
• Orthodontist should see the pt within theOrthodontist should see the pt within the
1st week – review the occlusal status and1st week – review the occlusal status and
check the status of the orthodonticcheck the status of the orthodontic
appliance.appliance.
• Post surgical orthodonticsPost surgical orthodontics
– adequate bone healingadequate bone healing
– adequate mouth openingadequate mouth opening

Dr. Punit Thawani
• Rigid internal fixation and jaw exercisesRigid internal fixation and jaw exercises
➫➫ 2-3 weeks2-3 weeks
• Wire fixation and IMFWire fixation and IMF ➫➫ 3-4 weeks after3-4 weeks after
the IMF is released.the IMF is released.
• Splint and light elastics to guideSplint and light elastics to guide
occlusionocclusion

Dr. Punit Thawani
Post Surgical OrthodonticsPost Surgical Orthodontics
• After adequate healing of boneAfter adequate healing of bone
(surgeon’s opinion)(surgeon’s opinion)
• Splint and stabilizing wires should beSplint and stabilizing wires should be
removedremoved togethertogether
• Splint and wires provide solidSplint and wires provide solid
occlusionocclusion
• Prevent CO-CR discrepancyPrevent CO-CR discrepancy

Dr. Punit Thawani
• Working archwires placedWorking archwires placed
– 0.016” steel0.016” steel
– 21 x 25 NiTi or Braided Steel21 x 25 NiTi or Braided Steel
– Stabilizing wire left in place in 1 archStabilizing wire left in place in 1 arch

Dr. Punit Thawani
• Maxillary segmental proceduresMaxillary segmental procedures
– Teeth across the osteotomy site should beTeeth across the osteotomy site should be
ligated tightlyligated tightly
– Box elastics are placed on both sides of theBox elastics are placed on both sides of the
osteotomy site – from one side to the otherosteotomy site – from one side to the other
– ??

Dr. Punit Thawani
• Light box elasticsLight box elastics
– Extrude teethExtrude teeth
– Guide occlusionGuide occlusion
– Elastics crossing osteotomy site?Elastics crossing osteotomy site?
• ProtocolProtocol
– 11stst
month – full time, including while eatingmonth – full time, including while eating
– 22ndnd
month – Full time, remove while eatingmonth – Full time, remove while eating
– 33rdrd
month – Night time onlymonth – Night time only

Dr. Punit Thawani
• Good amount of settling in first monthGood amount of settling in first month
• Step bends in archwiresStep bends in archwires

Dr. Punit Thawani
• Headgears and extra oral forcesHeadgears and extra oral forces
• Heavy intermaxillary elasticsHeavy intermaxillary elastics
• Overlay wire for transverse stabilizationOverlay wire for transverse stabilization

Dr. Punit Thawani
• Finishing with positionersFinishing with positioners
– Parasthesia after surgeryParasthesia after surgery
– Variable biting forceVariable biting force
• At the endAt the end
– Proper settlingProper settling
– Root parallelism – esp. osteotomy siteRoot parallelism – esp. osteotomy site

Dr. Punit Thawani
RetentionRetention
• Not very different from routineNot very different from routine
orthodontics.orthodontics.
• Transverse retentionTransverse retention
• Fixed retainersFixed retainers

Dr. Punit Thawani
SummarySummary
BeforeBefore
surgerysurgery
AlignmentAlignment
Leveling – by intrusionLeveling – by intrusion
Arch compatibilityArch compatibility
Preparation of osteotomy sitePreparation of osteotomy site
Before and/orBefore and/or
after surgeryafter surgery
Post. crossbite correction – ifPost. crossbite correction – if
orthodontic expansion is plannedorthodontic expansion is planned
Leveling by extrusionLeveling by extrusion
After surgeryAfter surgery Settling and leveling by extrusionSettling and leveling by extrusion
Root paralleling at osteotomy sitesRoot paralleling at osteotomy sites
Detailed tooth positioningDetailed tooth positioning

Dr. Punit Thawani
Clinical Management Of SomeClinical Management Of Some
Commonly Encountered OrthognathicCommonly Encountered Orthognathic
Surgical PatientsSurgical Patients
1.1. Mand. Deficiency with normal orMand. Deficiency with normal or
reduced facial heightreduced facial height
2.2. Excessive face height (long face)Excessive face height (long face)
3.3. Class III problemsClass III problems
4.4. Facial asymmetryFacial asymmetry
5.5. Crossbite and open biteCrossbite and open bite

Dr. Punit Thawani
Mand Deficiency with normal orMand Deficiency with normal or
• Horizontal growthHorizontal growth
patternpattern
• Class II molar andClass II molar and
Canine relationship –Canine relationship –
often with a div. 2often with a div. 2
pattern.pattern.
• Excessive curve of speeExcessive curve of spee
in the lower arch.in the lower arch.
• Incisor crowdingIncisor crowding
• Deep bite – usuallyDeep bite – usually
causing some gingivalcausing some gingival
irritationirritation

Dr. Punit Thawani
• Chin button wellChin button well
developeddeveloped
• Deficiency near theDeficiency near the
lower lip region –lower lip region –
seen as a deepseen as a deep
mentolabial sulcus,mentolabial sulcus,
a curl of the lowera curl of the lower
lip and an agedlip and an aged
appearance.appearance.
• TMJ disorders –TMJ disorders –
(disputed)(disputed)

Dr. Punit Thawani
Surgical planSurgical plan
• In most of theseIn most of these
patients, -patients, -
– MandibularMandibular
deficiency needs todeficiency needs to
be correctedbe corrected
– Height of the faceHeight of the face
must be increased.must be increased.

Dr. Punit Thawani
Mandibular subapical procedure vs. BSSOMandibular subapical procedure vs. BSSO
Subapical procedureSubapical procedure
– When face ht. is not to be increasedWhen face ht. is not to be increased
BSSOBSSO
– To increase face heightTo increase face height

Dr. Punit Thawani

Dr. Punit Thawani
• Rotation of mandibleRotation of mandible
– chin moved back and incisors forwardchin moved back and incisors forward
• Genioplasty if neededGenioplasty if needed
– Reduce chin prominenceReduce chin prominence
– Further increase face heightFurther increase face height
• No maxillary surgery to increase faceNo maxillary surgery to increase face
heightheight

Dr. Punit Thawani
Pre surgical OrthodonticsPre surgical Orthodontics
Position of the incisors –Position of the incisors –
vertically and sagittallyvertically and sagittally
Vertical – Determines final face heightVertical – Determines final face height
Sagittal – Determines amount of movementSagittal – Determines amount of movement

Dr. Punit Thawani
• Expansion of arch may be necessaryExpansion of arch may be necessary
– Wider part of mandible comes forwardWider part of mandible comes forward
– Can be done orthodontically or surgicallyCan be done orthodontically or surgically
– Extractions may not be requiredExtractions may not be required

Dr. Punit Thawani
• Considerations during model surgeryConsiderations during model surgery
– Face bow transfer rarely requiredFace bow transfer rarely required
– Maintain bilateral symmetry – even ifMaintain bilateral symmetry – even if
crossbite developscrossbite develops
– KeepKeep skeletalskeletal midlines matchingmidlines matching
• Post surgical orthodontics –Post surgical orthodontics –
– Level COS by extrusionLevel COS by extrusion

Dr. Punit Thawani
Long Face ProblemsLong Face Problems
• Vertical excess ofVertical excess of
post maxillapost maxilla
• ↑↑mand planemand plane
angleangle
• Incisor exposureIncisor exposure
• Incompetent lipsIncompetent lips

Dr. Punit Thawani
• Gummy smileGummy smile
• Narrow maxillaNarrow maxilla
• Cross-biteCross-bite

Dr. Punit Thawani
Surgical considerationsSurgical considerations
• impacting to maxilla – mandibularimpacting to maxilla – mandibular
autorotationautorotation
• Rotating the mandible upwards andRotating the mandible upwards and
forwards after a BSSOforwards after a BSSO
• Chin proceduresChin procedures

Dr. Punit Thawani
• Maxillary procedure – Stable – CorrectsMaxillary procedure – Stable – Corrects
most of the problemmost of the problem
• BSSO with rotation – Soft tissue stretchBSSO with rotation – Soft tissue stretch
– Unstable– Unstable
• Chin procedures – used as adjunctsChin procedures – used as adjuncts

Dr. Punit Thawani
Pre surgical OrthodonticsPre surgical Orthodontics
• Orthodontist must know 2 things –Orthodontist must know 2 things –
– Maxilla in 1 piece or segmented? – howMaxilla in 1 piece or segmented? – how
many pieces, and wheremany pieces, and where
– Chin position? - or is proper lip – chinChin position? - or is proper lip – chin
balance going to be achieved by orthodonticbalance going to be achieved by orthodontic
treatmenttreatment

Dr. Punit Thawani
• Segmented proceduresSegmented procedures
– Align within the segmentAlign within the segment
– Stabilize with a wire with step, or segmentsStabilize with a wire with step, or segments
of 21 x 25 SS wireof 21 x 25 SS wire
– Roots of adjescent teethRoots of adjescent teeth
• LevelingLeveling
– If mild, by intrusionIf mild, by intrusion
– If severe - surgicallyIf severe - surgically

Dr. Punit Thawani
• ExpansionExpansion
– OrthodonticallyOrthodontically
– SurgicallySurgically
– But not bothBut not both
– Causes more relapseCauses more relapse

Dr. Punit Thawani
• Maxillary impactionMaxillary impaction
– ↑↑ wrinkles on the cheekwrinkles on the cheek
– Drastic reduction in incisor exposureDrastic reduction in incisor exposure
– Widening of alar basesWidening of alar bases
– Aged appearanceAged appearance
– More tolerated in younger individuals thanMore tolerated in younger individuals than
adultsadults

Dr. Punit Thawani
• If maxilla is moved back -If maxilla is moved back - ↓↓lip supportlip support
• Maxilla may have to be moved forward toMaxilla may have to be moved forward to
get good lip supportget good lip support
• Genioplasty – avoid major jaw surgeryGenioplasty – avoid major jaw surgery

Dr. Punit Thawani
Before model surgeryBefore model surgery
• How much is the maxilla going to beHow much is the maxilla going to be
movedmoved
• How to reduce residual overjet (if any)How to reduce residual overjet (if any)
• Surgical expansion? – Prepare overlaySurgical expansion? – Prepare overlay
wirewire

Dr. Punit Thawani
Post surgical OrthodonticsPost surgical Orthodontics
• Segmental procedures – torque onSegmental procedures – torque on
anteriorsanteriors
– Flexible rectangular wires in upperFlexible rectangular wires in upper
– 0.016” SS in lower0.016” SS in lower
• Stabilizing transverse correctionsStabilizing transverse corrections

Dr. Punit Thawani

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

Dr. Punit Thawani
• Natural compensationNatural compensation
– Flared upper incisors, retroclined lowerFlared upper incisors, retroclined lower
incisors.incisors.
– Spacing between lower teeth – should thinkSpacing between lower teeth – should think
of large tongueof large tongue
– Maxilla may have small or even missingMaxilla may have small or even missing
teeth.teeth.
– Check for attached gingiva in lower anteriorCheck for attached gingiva in lower anterior
– labial region.– labial region.

Dr. Punit Thawani
• Surgical techniquesSurgical techniques
1.1. Mandibular –Mandibular –
1.1. (BSSO)(BSSO)
2.2. Mandibular sub apical proceduresMandibular sub apical procedures
2.2. Maxillary –Maxillary –
1.1. Lefort I osteotomy - high levelLefort I osteotomy - high level
2.2. ExpansionExpansion
3.3. GenioplastyGenioplasty

Dr. Punit Thawani
• Jaw at fault should be operatedJaw at fault should be operated
• If mandible too prognathic – both jawsIf mandible too prognathic – both jaws
– Too much setbackToo much setback ➫➫ Double chinDouble chin
• Maxillary impaction in case ofMaxillary impaction in case of
hyperdivergent jawshyperdivergent jaws

Dr. Punit Thawani
• Jacobs – ‘two patient’ conceptJacobs – ‘two patient’ concept
• Incisors should be positioned as ideallyIncisors should be positioned as ideally
as possible to their respective jaw bases,as possible to their respective jaw bases,
without concern for inter-arch occlusion.without concern for inter-arch occlusion.
• MaxillaMaxilla
– require extractions and significant retractionrequire extractions and significant retraction
• MandibleMandible
– Non extraction or extraction for molarNon extraction or extraction for molar
correctioncorrection
– Molar inclination correctionMolar inclination correction

Dr. Punit Thawani
• If upper expansion is neededIf upper expansion is needed
– Teeth should be aligned within the segmentsTeeth should be aligned within the segments
– Arches should NOT be co-ordinatedArches should NOT be co-ordinated
presurgicallypresurgically
– Gross coordination surgicallyGross coordination surgically
– Final coordination post surgicallyFinal coordination post surgically

Dr. Punit Thawani
• Frequent progress modelsFrequent progress models
• Before surgery, patients should beBefore surgery, patients should be
informed about –informed about –
– Possibility of late mandibular growthPossibility of late mandibular growth
– Large amount of setback – double chin, mayLarge amount of setback – double chin, may
require second soft tissue surgeryrequire second soft tissue surgery
– Possibility of nasal changes – alar basePossibility of nasal changes – alar base
widening and upturning of the nose.widening and upturning of the nose.

Dr. Punit Thawani
Post surgical orthodonticsPost surgical orthodontics
Basic principles to be followedBasic principles to be followed
Check for relapse tendencyCheck for relapse tendency

Dr. Punit Thawani
Tendency towards relapseTendency towards relapse
• Moderate class III elastics (200-300Moderate class III elastics (200-300
gms)– heavier rectangular wires neededgms)– heavier rectangular wires needed
• Upper incisors can be flared to an extentUpper incisors can be flared to an extent
• Interproximal reduction, andInterproximal reduction, and
retroclination of lower incisorsretroclination of lower incisors
• Leave larger overjet and overbiteLeave larger overjet and overbite

Dr. Punit Thawani
• If relapse is still expected, the retentionIf relapse is still expected, the retention
appliance can be made with hooks forappliance can be made with hooks for
attachment of light class III elastics whileattachment of light class III elastics while
sleepingsleeping

Dr. Punit Thawani

Dr. Punit Thawani
Dento-facial AsymmetryDento-facial Asymmetry
• More through diagnosisMore through diagnosis
– PA viewPA view
– Submento-vertexSubmento-vertex
– CT scanCT scan

Dr. Punit Thawani
Surgery in childrenSurgery in children
• Severe or progressive asymmetrySevere or progressive asymmetry
– Hemifacial microsomiaHemifacial microsomia
– mandibular ankylosis due to condylarmandibular ankylosis due to condylar
fracturefracture

Dr. Punit Thawani
• Principle of treatment –Principle of treatment –
– Modify growth to its full potential so that theModify growth to its full potential so that the
child grows out of the deformitychild grows out of the deformity
• Initial functional appliance treatmentInitial functional appliance treatment
– Eliminate need for surgeryEliminate need for surgery
– Make surgery easierMake surgery easier
– Help in muscular adaptationHelp in muscular adaptation

Dr. Punit Thawani
• Role of orthodontist –Role of orthodontist –
– Growth guidance after surgeryGrowth guidance after surgery
– Maintenance of normal joint functionMaintenance of normal joint function
– Alignment of permanent teethAlignment of permanent teeth

Dr. Punit Thawani
Asymmetry problems in adolescentsAsymmetry problems in adolescents
• Continue growth guidanceContinue growth guidance
– prevents bimaxillary problemsprevents bimaxillary problems
• Problems ofProblems of excessive growthexcessive growth
– Hemifacial hypertrophyHemifacial hypertrophy
• Orthognathic surgery at the end ofOrthognathic surgery at the end of
growthgrowth

Dr. Punit Thawani
Problems of excessive growthProblems of excessive growth
• Diagnosis –Diagnosis – 99m99m
Tc scanTc scan
• After growth – surgical correctionAfter growth – surgical correction

Dr. Punit Thawani
• In severe cases – surgical correctionIn severe cases – surgical correction
before growth is completedbefore growth is completed
– Only mandibular surgeryOnly mandibular surgery
– cant of occlusal plane corrected bycant of occlusal plane corrected by
functional appliancesfunctional appliances

Dr. Punit Thawani
Asymmetry in adultsAsymmetry in adults
• Extent of surgery –Extent of surgery –
– Correct asymmetry at its sourceCorrect asymmetry at its source
– CamouflageCamouflage
• Pre and post surgical orthodonticsPre and post surgical orthodontics
– similar to any other casesimilar to any other case

Dr. Punit Thawani
Guidelines –Guidelines –
• More concern about transverse thanMore concern about transverse than
vertical asymmetryvertical asymmetry
• More concern about chin position thanMore concern about chin position than
mandibular anglesmandibular angles
• Maxillary midline more critical thanMaxillary midline more critical than
mandibular midlinemandibular midline

Dr. Punit Thawani
• If nose and jaw are deviated to the sameIf nose and jaw are deviated to the same
side, both should be correctedside, both should be corrected
• Asymmetry of higher structures - infra-Asymmetry of higher structures - infra-
orbital rims, Zygomatic arch – onlayorbital rims, Zygomatic arch – onlay
grafts should be consideredgrafts should be considered

Dr. Punit Thawani
• Pre-surgical orthodonticsPre-surgical orthodontics
– Matching skeletal and dental midlinesMatching skeletal and dental midlines
• Asymmetric extractionsAsymmetric extractions
• Asymmetric elastics and cross elasticsAsymmetric elastics and cross elastics
• Loops and springsLoops and springs
– Know the type of surgeryKnow the type of surgery
• GenioplastyGenioplasty
• Ramus osteotomyRamus osteotomy

Dr. Punit Thawani
• Post surgical orthodonticsPost surgical orthodontics
– Leveling by extrusionLeveling by extrusion
– May be longer in such patientsMay be longer in such patients

Dr. Punit Thawani

Dr. Punit Thawani
Cross bites and Open bites in AdultsCross bites and Open bites in Adults
Adults with cross-bite can be divided into 3Adults with cross-bite can be divided into 3
groupsgroups
• Patients with a narrow maxilla – (RMEPatients with a narrow maxilla – (RME
would have been done)would have been done)
• Large mandibleLarge mandible
• Patients with mandibular arch lockedPatients with mandibular arch locked
within the maxilla (Scissors bite ifwithin the maxilla (Scissors bite if
unilateral or Brodie bite if bilateral.)unilateral or Brodie bite if bilateral.)

Dr. Punit Thawani
Surgically assisted RMESurgically assisted RME
• Preferable in patients below 25Preferable in patients below 25
• Not very predictable between 25-35Not very predictable between 25-35
• Never done above 35 yrs of ageNever done above 35 yrs of age
Osteotomy in the lateral buttress area isOsteotomy in the lateral buttress area is
preferred.preferred.

Dr. Punit Thawani

Dr. Punit Thawani
Patients with a wide mandiblePatients with a wide mandible
• Try to treat the jaw at faultTry to treat the jaw at fault
• When in doubt – widen the maxillaWhen in doubt – widen the maxilla
• Mandibular narrowingMandibular narrowing
– Step ostectomy in anterior mandibleStep ostectomy in anterior mandible
– Remove bone in premolar region & setbackRemove bone in premolar region & setback

Dr. Punit Thawani
Interlocking crossbiteInterlocking crossbite
(scissors bite, Brodie bite,(scissors bite, Brodie bite,
‘X’ Occlusion)‘X’ Occlusion)
• Severe overlapping ofSevere overlapping of
teethteeth
• Upper jaw has to beUpper jaw has to be
moved superiorly andmoved superiorly and
laterally (unilateral)laterally (unilateral)
• Mandible can be widenedMandible can be widened
if necessary – (distractionif necessary – (distraction
osteogenesis) - orosteogenesis) - or
advancedadvanced

Dr. Punit Thawani
Pre surgical orthodonticsPre surgical orthodontics
• ShortShort
• Bonding to lower arch not possibleBonding to lower arch not possible
• Only upper alignmentOnly upper alignment
• Lower arch stabilized by directly bondingLower arch stabilized by directly bonding
19 gauge wire to teeth during surgery19 gauge wire to teeth during surgery

Dr. Punit Thawani
Post – surgical orthodonticsPost – surgical orthodontics
• Longer than usualLonger than usual
• Aligning lower arch, and refiningAligning lower arch, and refining
occlusionocclusion

Dr. Punit Thawani
Adults with open-biteAdults with open-bite
• Segmental procedures to impactSegmental procedures to impact
posterior maxillaposterior maxilla
• Segmental procedure to elevateSegmental procedure to elevate
mandibular anteriorsmandibular anteriors
• If teeth do not respond to orthodonticsIf teeth do not respond to orthodontics

Dr. Punit Thawani
• Segmental procedure to elevate mand.Segmental procedure to elevate mand.
anteriorsanteriors

Dr. Punit Thawani
• Pre surgical orthodonticsPre surgical orthodontics
– Align within the segmentsAlign within the segments
– Prepare osteotomy sitePrepare osteotomy site
• Orthodontic movement should not beOrthodontic movement should not be
done to correct the defect – relapsedone to correct the defect – relapse
• Post surgical orthodontics – stabilizationPost surgical orthodontics – stabilization
of expansion – at least 6 monthsof expansion – at least 6 months

Dr. Punit Thawani
Surgery in Patients with TMJSurgery in Patients with TMJ
ProblemsProblems
• General guideline for managementGeneral guideline for management

Dr. Punit Thawani
Surgery in Patients with TMJSurgery in Patients with TMJ
ProblemsProblems
• Orthodontics and/or surgery to correctOrthodontics and/or surgery to correct
occlusionocclusion
• TMJ surgeryTMJ surgery
– Not responding to reversible therapyNot responding to reversible therapy
– Progressive internal joint pathologiesProgressive internal joint pathologies

Dr. Punit Thawani
Stability of Surgical CorrectionsStability of Surgical Corrections
The stability of orthognathic surgicalThe stability of orthognathic surgical
procedures depends on the following –procedures depends on the following –
1.1. Direction of movementDirection of movement
2.2. Type of fixation usedType of fixation used
3.3. Surgical technique employedSurgical technique employed

Dr. Punit Thawani
Hierarchy of StabilityHierarchy of Stability
Mandibular advancemetMandibular advancemet (short and normal face)(short and normal face)
GenioplastyGenioplasty
Maxillary advancementMaxillary advancement
Max. up + Mand. forwardMax. up + Mand. forward
Mandible backMandible back
Maxilla downMaxilla down
Maxillary wideningMaxillary widening

Dr. Punit Thawani
• Most stable procedureMost stable procedure
• Mandible auto-rotates to maintain the freewayMandible auto-rotates to maintain the freeway
spacespace
• Wire/IMF vs RIF equally good resultsWire/IMF vs RIF equally good results
• Wire/IMFWire/IMF
– 6 weeks after the surgery - 20% of patients showed6 weeks after the surgery - 20% of patients showed
2-4 mm of change in the upward direction2-4 mm of change in the upward direction
– 6weeks to 1 year - that much downward movement6weeks to 1 year - that much downward movement
of the maxof the max

Dr. Punit Thawani

Dr. Punit Thawani
RIF or wire/IMF seemed to make noRIF or wire/IMF seemed to make no
significant differences in stability.significant differences in stability.
More than 90% chance of max being withinMore than 90% chance of max being within
2 mm of post surgical position after 12 mm of post surgical position after 1
yearyear
• Bishara et al 1988Bishara et al 1988
• Denison et al 1989Denison et al 1989
• Proffit et al 1992Proffit et al 1992

Dr. Punit Thawani
Mandibular advancement (BSSO)Mandibular advancement (BSSO)
• normal or short face height is considerednormal or short face height is considered
Wire/IMFWire/IMF
• first 6 weeks post surgeryfirst 6 weeks post surgery
– the mand had a tendency to move slightly back.the mand had a tendency to move slightly back.
• 6 weeks to one year6 weeks to one year
– the changes seemed to be recoveredthe changes seemed to be recovered
• functionfunction

Dr. Punit Thawani
RIFRIF
• smaller tendency to move backsmaller tendency to move back
• greater chance of slight forward movementgreater chance of slight forward movement
90% chance of stability90% chance of stability
• Kouma et al 1991Kouma et al 1991
• Gomes et al 1993Gomes et al 1993
• Ingervall et al 1994Ingervall et al 1994

Dr. Punit Thawani
• BSSO with rotation to close an open biteBSSO with rotation to close an open bite
– Soft tissue stretchSoft tissue stretch
– RIF more stable than wire/IMFRIF more stable than wire/IMF
– Interpositional bone grafts and heavy platesInterpositional bone grafts and heavy plates
• Ritzik et al 1990Ritzik et al 1990

Dr. Punit Thawani
Maxillary impaction & mand. AdvancementMaxillary impaction & mand. Advancement
Wire/IMFWire/IMF
• Individual proceduresIndividual procedures
– MaxillaMaxilla ↑↑
– Mandible ←Mandible ←
• UnlikeUnlike the individual proceduresthe individual procedures
– No recovery between 6 mo to 1 year andNo recovery between 6 mo to 1 year and
relapse continued in 1/3rd of the patientsrelapse continued in 1/3rd of the patients

Dr. Punit Thawani
By the end of 1 year, only 60% of theBy the end of 1 year, only 60% of the
patients were judged to have excellentpatients were judged to have excellent
clinical resultsclinical results
• Post surgical bite opening tendency isPost surgical bite opening tendency is
seenseen

Dr. Punit Thawani
RIFRIF
• RIF in mandible improved stabilityRIF in mandible improved stability
• Slight relapse of the mandible between 6 weeksSlight relapse of the mandible between 6 weeks
to 1 yearto 1 year
• Over 90% patients were judged to have goodOver 90% patients were judged to have good
clinical outcomesclinical outcomes
• No bite opening tendency is seen.No bite opening tendency is seen.
• Hennes et al – 1988Hennes et al – 1988
• Sinclair et al – 1991Sinclair et al – 1991
• Proffit et al – 1992Proffit et al – 1992
• Ayoub et al – 1993Ayoub et al – 1993

Dr. Punit Thawani
Maxillary advancementMaxillary advancement
• If moved only anteriorly – 80% stableIf moved only anteriorly – 80% stable
• If simultaneous downward movement –If simultaneous downward movement –
unstableunstable
• Proffit et al – 1991Proffit et al – 1991
• Bishara , Chi - 1992Bishara , Chi - 1992

Dr. Punit Thawani
Mandibular setbackMandibular setback
• BSSO and Trans-oral vertical ramusBSSO and Trans-oral vertical ramus
osteotomy (VRO).osteotomy (VRO).
• VRO seemed to be more stable thanVRO seemed to be more stable than
BSSOBSSO

Dr. Punit Thawani
VROVRO
• chance of further backwardchance of further backward
• but forward relapse also occurredbut forward relapse also occurred
With BSSOWith BSSO
• no post surgical backward movement,no post surgical backward movement,
but forward relapse occuredbut forward relapse occured
• RIF with BSSO seemed to make relapseRIF with BSSO seemed to make relapse
tendencies worsetendencies worse

Dr. Punit Thawani
VROVRO
• improper positioning of condyles in fossaimproper positioning of condyles in fossa
resulted in backward movementresulted in backward movement
Both proceduresBoth procedures
• Change in ramus inclination resulted inChange in ramus inclination resulted in
forward relapseforward relapse
• Proffit et al (1991)Proffit et al (1991)

Dr. Punit Thawani
Inferior repositioning of the maxillaInferior repositioning of the maxilla
• wire/IMF - almost all the inferior movement iswire/IMF - almost all the inferior movement is
lost.lost.
• RIF – strong relapse tendency.RIF – strong relapse tendency.
• occlusal forcesocclusal forces
• Ways of maintaining the correction are –Ways of maintaining the correction are –
– use of heavy fixation bars from zygomatic arch touse of heavy fixation bars from zygomatic arch to
the maxillary posterior teeth,the maxillary posterior teeth,
– use of interpostional bone grafts, oruse of interpostional bone grafts, or
– simultaneous ramus osteotomysimultaneous ramus osteotomy

Dr. Punit Thawani
Widening of the maxillaWidening of the maxilla
• 11 year later, almost 50% of the expansion wasyear later, almost 50% of the expansion was
lost in the second molar regionlost in the second molar region
• Reduction in post surgical width of about 2Reduction in post surgical width of about 2
mm in 2/3rd of the patients.mm in 2/3rd of the patients.
• Proffit et al 1992.Proffit et al 1992.
• Stretching of the palatal mucosaStretching of the palatal mucosa
• Modest overcorrection and stringent retentionModest overcorrection and stringent retention

Dr. Punit Thawani
3 Basic principles that influence post3 Basic principles that influence post
surgical stability –surgical stability –
• Stability is greatest when soft tissues areStability is greatest when soft tissues are
relaxed during surgery and least when they arerelaxed during surgery and least when they are
stretched.stretched.
• Neuromuscular adaptationNeuromuscular adaptation
• Neuromuscular adaptation affects muscleNeuromuscular adaptation affects muscle
length and not muscle orientation.length and not muscle orientation.

Dr. Punit Thawani
Long term Prognosis of BSSO Mandibular RelapseLong term Prognosis of BSSO Mandibular Relapse
and its Relation to Different Facial Typesand its Relation to Different Facial Types
Yoshida et alYoshida et al
Angle Orthodontist – March 2000Angle Orthodontist – March 2000
• 15 patients – BSSO mandbibular setback15 patients – BSSO mandbibular setback
• Wire/IMFWire/IMF
• Followed for 10.3 years post surgeryFollowed for 10.3 years post surgery
• 2 types of facial patterns –2 types of facial patterns –
– MesoprosopicMesoprosopic
– EuryprosopicEuryprosopic

Dr. Punit Thawani
Long term Prognosis of BSSO Mandibular RelapseLong term Prognosis of BSSO Mandibular Relapse
and its Relation to Different Facial Typesand its Relation to Different Facial Types
Yoshida et alYoshida et al
Angle Orthodontist – March 2000Angle Orthodontist – March 2000
• Relapse tendencyRelapse tendency
– Euryprosopic – forward rotation of mandEuryprosopic – forward rotation of mand
– Mesoprosopic – backward rotation of mand.Mesoprosopic – backward rotation of mand.
• Suggestions to reduce relapseSuggestions to reduce relapse
– Euryprosopic – Sufficient setbackEuryprosopic – Sufficient setback
– Mesoprosopic – adequate overbiteMesoprosopic – adequate overbite
– Good post-treatment occlusionGood post-treatment occlusion

Dr. Punit Thawani
EuryprosopicEuryprosopic MesoprosopicMesoprosopic

Dr. Punit Thawani
Long Term stability of Surgical Open biteLong Term stability of Surgical Open bite
Correction by Le Fort I osteotomyCorrection by Le Fort I osteotomy
Proffit, Bailey, Phillips, TurveyProffit, Bailey, Phillips, Turvey
AO Feb 2000AO Feb 2000
• 54 patients of open bite54 patients of open bite
• 26 - maxillary impaction only26 - maxillary impaction only
• 26 - had max impaction and mandibular26 - had max impaction and mandibular
advancementadvancement
• Immidiate post surgical records, 1 yearImmidiate post surgical records, 1 year
post surgical, and at leastpost surgical, and at least 3 years3 years postpost
surgical cephs were taken.surgical cephs were taken.

Dr. Punit Thawani
• In both the goups, there isIn both the goups, there is
– a tendency for the maxilla and mandible toa tendency for the maxilla and mandible to
move slightly downwardsmove slightly downwards
– maxillary and mandibular posterior teeth tomaxillary and mandibular posterior teeth to
erupterupt
– mand anterior teeth to erupt.mand anterior teeth to erupt.
• Hence – increase in mand plane angleHence – increase in mand plane angle
and face heightand face height

Dr. Punit Thawani

Dr. Punit Thawani
• Despite skeletal changes, almost noDespite skeletal changes, almost no
changes in occlusionchanges in occlusion
• Authors attribute the change toAuthors attribute the change to
– Continued growth into adult yearsContinued growth into adult years
– Inadequate physiologic adaptation inInadequate physiologic adaptation in
maintaining the freeway spacemaintaining the freeway space

Dr. Punit Thawani
Long term stability of mandibular setback surgery: ALong term stability of mandibular setback surgery: A
follow-up of 80 bilateral sagittal split osteotomyfollow-up of 80 bilateral sagittal split osteotomy
patientspatients
Mobarak, Espeland, Krogstad and LybergMobarak, Espeland, Krogstad and Lyberg
Int J of Ad. Orthod & Orthognath. Surg 2000Int J of Ad. Orthod & Orthognath. Surg 2000
• During surgery – proximal segmentDuring surgery – proximal segment
tended to rotate clockwise, changing thetended to rotate clockwise, changing the
orientation of the ramus to a moreorientation of the ramus to a more
upright positionupright position
• Follow up – Ramus returned to originalFollow up – Ramus returned to original
inclinationinclination

Dr. Punit Thawani
Stability of Le Fort I osteotomy in maxillary inferiorStability of Le Fort I osteotomy in maxillary inferior
positioning: Review of the literaturepositioning: Review of the literature
Costa et alCosta et al
• Starling’s law states that a stretchedStarling’s law states that a stretched
muscle has increased contractile strengthmuscle has increased contractile strength
• Fixation techniquesFixation techniques
– Wire fixation and IMFWire fixation and IMF
– Rigid fixation onlyRigid fixation only
– Rigid fixation and bone graftingRigid fixation and bone grafting
– Rigid fixation and alloplastic materialsRigid fixation and alloplastic materials
(porous block hydroxyapetite)(porous block hydroxyapetite)

Dr. Punit Thawani
• Wire/IMF – highest relapse – 50%Wire/IMF – highest relapse – 50%
overcorrectionovercorrection
• RIF – more stable upto 2 mmRIF – more stable upto 2 mm
• Rigid fixation with autogenous bone -Rigid fixation with autogenous bone -
stable, and predictablestable, and predictable

Dr. Punit Thawani
• Rigid fixation with porous blockRigid fixation with porous block
hydroxyapetite showed excellent stabilityhydroxyapetite showed excellent stability
2 studies2 studies
• Greater relapse in the posterior part ofGreater relapse in the posterior part of
the maxillathe maxilla

Dr. Punit Thawani
Mandibular advancement surgery in high angle andMandibular advancement surgery in high angle and
low angle Class II patients: Different long termlow angle Class II patients: Different long term
skeletal responses.skeletal responses.
AJO 2001AJO 2001
• 61 patients61 patients
• BSSO only, no additional procedureBSSO only, no additional procedure
performed, and Rigid internal fixation (RIF)performed, and Rigid internal fixation (RIF)
followed for 3 years after surgeryfollowed for 3 years after surgery
• 20 patients (20.820 patients (20.8 ++ 4.8) - Low angle group4.8) - Low angle group
• 20 patients (4320 patients (43 ++ 4) - High angle group4) - High angle group
• Remaining 21 patients in the normal groupRemaining 21 patients in the normal group

Dr. Punit Thawani
AJO 2001AJO 2001
• Stability of increasing MPAStability of increasing MPA
• Dental changesDental changes
– retroclination of the lower incisors, while theretroclination of the lower incisors, while the
upper incisors remained more or lessupper incisors remained more or less
upright.upright.

Dr. Punit Thawani
AJO 2001AJO 2001
Timing of relapse –Timing of relapse –
• Low angle group about 98% of theLow angle group about 98% of the
relapse occurred within the first 2relapse occurred within the first 2
monthsmonths
• High angle group, the relapse was moreHigh angle group, the relapse was more
gradual –gradual –
• 30 % in the first 2 months30 % in the first 2 months
• 25 % between 2 months to 1 year25 % between 2 months to 1 year
• 38% in the between 1 year to 3 years38% in the between 1 year to 3 years

Dr. Punit Thawani
AJO 2001AJO 2001
• Relapse due to –Relapse due to –
– Intersegment mobilityIntersegment mobility
– Distraction of condyleDistraction of condyle
• Implant studies (Rubenstein et al - 93,Implant studies (Rubenstein et al - 93,
Rebellato et al -94)Rebellato et al -94)
• Most of the relapse due to repositioningMost of the relapse due to repositioning
of condyle in fossaof condyle in fossa

Dr. Punit Thawani
AJO 2001AJO 2001
• Other possible causes for late changesOther possible causes for late changes
– late mandibular growth in the originallate mandibular growth in the original
directiondirection
– residual effects of incompletely adaptedresidual effects of incompletely adapted
suprahyoid musculaturesuprahyoid musculature
– Condylar resorptionCondylar resorption

Dr. Punit Thawani
ReferencesReferences
• Contemporary treatment of DentofacialContemporary treatment of Dentofacial
Deformity – Proffit, White & SarverDeformity – Proffit, White & Sarver
• Surgical Orthodontic Treatment – Proffit andSurgical Orthodontic Treatment – Proffit and
WhiteWhite
• Contemporary Orthodontics – ProffitContemporary Orthodontics – Proffit
• Orthognathic surgery: A hierarchy of StabilityOrthognathic surgery: A hierarchy of Stability
– Proffit et al - Int. J or Adult Orthod– Proffit et al - Int. J or Adult Orthod
Orthognath Surg 1996Orthognath Surg 1996

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

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

Pre and post surgical orthodontics

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