Module 29 - Orthodontics and Oral Surgery 160306

National Orthodontics Programme Module 29 Orthodontics & Oral Surgery
British Orthodontic Society 1

National Orthodontics Programme
British Orthodontic Society

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About the National Orthodontics Programme

The National Orthodontics Programme was launched in December 2004 following a successful British
Orthodontic Society Foundation Award application. A primary aim of the project was to develop a modular
learning resource housed in a Virtual Learning Environment for postgraduates in orthodontics
(www.ole.bris.ac.uk). This consists of 40 online modules and a series of online assessments. The
resource aims to maximize the use of academic staff time and significantly reduce the amount of travelling
to teaching bases by Specialist Registrars.
The resource has been developed by all UK dental schools as authors or co-authors. It is at the discretion of
each dental school as to how the resource is best used in their courses.

We hope you enjoy using this unique and pioneering resource.

Personal Welcome
Welcome to Module 29. This Module is designed to provide a foundation in the understanding of treatment
needs of those patients who require combined orthodontic and surgical management. In particular it should
provide:
1. A thorough knowledge of the theory, indications and applications of combined orthodontic/oral
surgery treatments.
2. Specific aspects involved in orthodontic treatment of orthognathic/surgical cases.

Before commencing this module you should have completed
Module 11 - Cephalometrics

At the end of this module you should be able to
Understand the indications and sequences of combined orthodontic and surgical treatment for
dentofacial deformity.
Diagnose skeletal disproportion that is of such severity that routine orthodontic procedures cannot
achieve a result without the use of combined orthodontics and surgery.
Plan treatment for facial disharmony.
Have an understanding of the practical clinical skills needed to use orthodontic appliances in
orthognathic cases.
Understand the surgical techniques and the consequences and sequelae of surgery.
Diagnose some common dentoalveolar problems, understand dentoalveolar surgical procedures and
carry out associated orthodontic treatment.
For module support and guidance, Use the discussion board available on Blackboard.

Module Authors
Nicola Parkin / Fiona Dyer / Melanie Stern / Derrick Willmot
What you will learn
This module will take you through 6 sections addressing the interplay between orthodontics and surgical
treatment
1. The indications and sequences of combined orthodontic and surgical treatment for dentofacial
deformity.
2. The range of facial disharmony and diagnostic procedures used to identify the site of facial
disharmony and know how treatment is planned.
3. Pre-surgical orthodontic procedures and techniques used to decompensate the dentition, co-
ordinate the arches and prepare the patients for surgery.
4. The surgical procedures used for Orthognathic surgery.
5. Post surgical orthodontics
6. Dentoalveolar procedures in relations to: Exposure of maxillary incisors
Exposure of impacted canine teeth


Assessment

The assessment of this module will be made through a combination of tasks for self-directed learning,
shared discussion and quiz at the end of the module to be returned to the coordinator. At the end of your
training programme you may also be assessed by means of a specific written examination and/or viva or
part of a written question and or viva, which examines the involvement of orthodontists in multidisciplinary
orthodontic oral surgical care.
Your experience should include attendance at joint orthognathic clinics and treatment of patients of
combined orthodontic /oral surgery care. All should have had additional experience with the in patient
management of orthognathic patients in the immediate post-operative period and have observed (and or
assisted) during the surgical procedure.
It is the module coordinators opinion however that three years of specialist training in orthodontics does not
qualify you to diagnose and successfully treat patients needing orthognathic care. It is recommended that a
further 2 years of training in the form of a FTTA placement is required in order to achieve competence in
this skill.
Timing

The total time required for the Module and assessment is 15 hours.
The discussion board for this module is available on Blackboard
(www.ole.bris.ac.uk)

Section 1: Overview of Indications and Sequences in Orthognathic
treatment
Indications

Dentofacial problem too severe for orthodontics alone.
Orthognathic surgery is carried out in non-growing adults, surgery in growing children is prone to
relapse owing to reversion of the original growth pattern.
In growing children with cranio-facial syndromes and severe dentofacial abnormalities, distraction
osteogenesis may be considered.
Examples of indications

1. Severe anteroposterior discrepancies (Class 2/Class III malocclusions)
2. Vertical discrepancies (AOB/deep overbite)
3. Transverse discrepancies
4. Skeletal Asymmetry


Sequences of treatment

Diagnosis
Treatment planning
Orthodontic preparation for surgery (presurgical orthodontics). Duration 6-18 months.
Surgical procedure (Osteotomy)
Post-surgical orthodontics. Duration 3-6 months.
Retention

Now read Chapter 22 of the Third Edition of Contemporary Orthodontics by W R Proffit Pages 674 709.
This will give you an overview of Combined Surgical and Orthodontic Treatment before examining some
specific issues in the rest of the module.

Take 2 hours
Section 2: Diagnosis of facial disharmony
Introduction

Welcome to section 2. This section considers the range of facial disharmony and disproportion, the
diagnostic procedures used to identify the site of facial disharmony, the presurgical orthodontic procedures
and techniques used to decompensate the dentition and prepare the patient for surgery.
Aims

Be able to diagnose the site of disharmony using various diagnostic guides and know how treatment is
planned.
Cephalometric Analysis of the facial Skeleton

The relationships of the various parts of the facial skeleton can be visualised by direct examination of the
patient. The use of a cephalometric technique during orthognathic procedures is for three reasons:
1. To provide precise details of the relationships of the parts of the dentofacial complex as part of the
diagnosis.
2. To plan tooth angulation movements and osteotomy cuts and movements prior to treatment
commencement.
3. To provide baseline data against which later treatment response can be measured.


A wide range of cephalometric techniques and analyses are used in different units throughout the United
Kingdom and indeed the World.
Tracing versus digitisation

Tracings allow easier visualisation of the pattern of relationships and easier identification of landmarks used
in measurements. There is nothing conceptually different between hand tracing and measuring linear and
angular relationships by hand or on a computer but the latter adds the convenience of speed and storage.
(Harradine and Birnie 1985)
A range of computerised systems are used in the United Kingdom. Typical systems are OPAL, Dolphin
and Quick Ceph. The above picture shows the Quick Ceph computerised cephalometric analysis and
planning system.

Task for a demonstration of your local cephalometric system from your Consultant or FTTA and then try
planning a case yourself.
Template versus measurement analysis

Figure 1


The object of diagnosis in dentofacial disharmony cases is to display, detect and quantify the
disproportionate relationships between the naso-maxillary complex, the mandible, the maxillary dentition
and the mandibular dentition and study the relationship with the cranial base. This can be done by
measurement analysis but an alternative method is the display normal data in the form of a template. A
prepared template such as normal data from the Bolton Analysis can be superimposed upon cephalometric
data either as acetate tracings in the clinic or as computerised data in software. A hand-traced
superimposition is shown on page 5.
The above superimposition indicates that the principle cause of disharmony is the mandibular prognathism.
Aesthetic analysis of the face - What is important in examination of aesthetics?
Symmetry, balance and morphology

Right-left symmetry. Few faces are perfectly symmetrical however obvious asymmetries should be
noted. These may be limited to the lower face or may include the eyes and eyebrows.
General facial balance refers to the upper, middle & lower facial thirds being nearly equal in vertical
height.
General facial morphology.
The aesthetic facial evaluation is carried out with the patient in natural head position in a systematic fashion
using a millimetre ruler. The patient must be examined both from the side and from the front.

Take 20 minutes to examine the PowerPoint presentation Aesthetic analysis of the face

In pairs, measure and record the measurements overleaf. See power point presentation for help with
identifying the various aesthetic lines and angles. Means are taken from (Arnett and Bergman 1993 Part I;
Arnett and Bergman 1993 Part II).


Frontal analysis:
Tr = Trichion (hairline)
Gb = Glabella (between eyebrows)
Sn = Subnasale
Me = Menton
Sn Me
=60 68 mm
Gb Sn
=60 - 68 mm
Tr Gb
=60 - 68 mm
Upper lip
19 -22 mm
Lower lip
42-48 mm
1/3rd
2/3rd

Figure 2
Measurements:

1) Vertical
Upper 1/3rd 60 -68 mm
Middle 1/3rd 60 68 mm
Lower 1/3rd 60 68 mm
Upper Lip Height 19 -22 mm
Interlabial gap 1 5 mm
Lower Lip height (lower stomion menton) 42 -48 mm
Upper Lip height : Lower Lip Height Ratio 1:2
Maxillary incisor show at rest *

2 5 mm
Mxillary incisor show smiling ; Crown
Gingival
8mm
2mm

* greater in females


2) Midlines

Nasal bridge & tip: look for deviations
Maxillary incisors to midline
Mandibular incisors to midline
Chin point to midline

3) Others

Facial levels: level of maxillary & mandibular canine tips
Width of alar base: This should be approximately the same as inter-canthal width (34mm)
Malar eminence: Flat, normal, prominent
Eyes: ocular imbalance, presence of scleral show often indicates midfacial deficiency
Profile analysis
Figure 3
NLA (90-110)
E plane (lower lip
-2 +/-2)
Depth of labiomental
fold (approx 4mm)
Throat length approx
56mm


Upper 1/ 3
Shape of forehead: Note any frontal bossing or supra-orbital hypoplasia.

Middle 1/ 3
Naso Labial Angle (94-110 degrees). Formed tangentially between the columella and upper lip. When this
angle is abnormal, care must be taken to distinguish between an upper lip posture problem and an abnormal
columella angulation.

Lower 1/ 3
Lip protrusion: Rickettss e-plane/Steiner s-plane
Labiomental fold: deep, average, shallow
Prominence/shape of pogonion
Neck-throat angle & length (length approx 56mm)
Psychological assessment

Psychological assessment is also a vital part of the overall assessment and allows identification of any
potential problems at an early stage (Cunningham and Feinmann 1998). Those patients that show signs of
Body Dismorphic Disorder, inappropriate motivation to seek treatment or that present with associated
psychiatric disorders should be assessed by a psychologist.
Planning orthodontic and surgical movements with cephalometrics

Historically hand tracings were used to plan treatment by a cut and paste method. Below is an acetate
showing predicted movements using this method. The methodology is clearly outlined in Contemporary
Orthodontics by Proffitt pages 625-628.

Figure 4
Modern computerised platforms allow the superimposition of the cephalometric tracing and the digital lateral
photograph to form a composite. From this composite, movements performed in orthognathic surgery can
be simulated. This is particularly useful for providing the patient with information on their final appearance.
It must however be emphasised that the prediction is an estimate of the final appearance and by no means
is the same as the actual result.


Below is a prediction using the Dolphin programme. The simulation is a mandibular forward slide. A
prediction log may be printed out together with the simulation.

Figure 5a Figure 5b

Can you produce a similar output from your local system?
Section 3: Pre-surgical orthodontic procedures
Introduction

Pre-surgical orthodontic treatment is essential for the combined orthodontic/orthognathic case. The
orthodontic treatment objectives for an orthognathic case are, in the vast majority of cases, entirely opposite
those that might be employed if the case were to be treated by conventional orthodontic methods. The
overall objective is to allow maximum possible correction of the underlying skeletal deformity with minimal
occlusal interferences by orthodontic decompensation. Jacobs and Sinclair 1983.

The aims of pre-surgical orthodontics

1. Dental decompensation to return incisors to their normal inclinations relative to the alveolar base. It
may also be necessary to decompensate transversely if surgical expansion is planned. This will
involve uprighting of the premolars and molars.
2. Level and align. Relieve all crowding. This will lead to the need for extractions in the majority of
cases where space is required to relieve crowding and return incisors to normal inclinations.
3. Arch co-ordination Many cases require expansion of the upper arch prior to surgery. This may be
carried out orthodontically (if the discrepancy is small) or surgically.
4. Flatten curves (where indicated).


5. Maintain curves (where indicated).
6. Produce three planes in one arch for segmental surgery.
7. Band and bond all teeth which are fully erupted and will be fully functional after surgery.
8. Correction of centrelines if this is not to be done surgically.
9. Provide a stable occlusal result with good interdigitation for improved stability of the surgical result.

Prior to the commencement of any orthodontic treatment full records should be taken. It is essential for all
older adult patients that this includes a full pocket depth charting and assessment of the periodontal status.
No orthodontic treatment can proceed if there is any active periodontal disease. Further problems arise in
adults with the status of their dentition with heavily restored posterior and anterior teeth, crowns and even
bridges. Restorative opinion may be required to determine the long-term prognosis of all teeth, if required
bridges should be sectioned prior to placement of orthodontic appliances.

Any tooth size discrepancies should also be established early on to enable the orthodontic treatment plan to
accommodate these discrepancies by either maintaining disto-lateral spaces or enamel reduction in the lower
arch. Unless these tooth tissue discrepancies are accounted for then the anterior occlusal interdigitation is
liable to suffer post-operatively. Achieving a Class I canine relationship immediately postoperatively is
important for stability.
The Orthodontic Appliance Pre-surgery

Some thought to the type of orthodontic appliance should be made at the initial planning phase. An 022
slot should be used to allow the use of full thickness wires; 21 x 25 wires are often used during the
finishing stage. The authors discourage the use of ceramic brackets in orthognathic cases due to their
potential for fracture especially post-operatively when the forces may be high (Sinclair, Thomas and Tucker
1993). The improvement in cosmetic/aesthetic appearance overall is minimal when the patient undergoes
their definitive surgical care. The use of smaller brackets may also be difficult as these have a reduced
surface area and are potentially more prone to debond failures. Brackets used during orthognathic surgery
need to have a reasonable profile to allow the placement of auxiliaries. In the final stages wire ligatures are
placed often in combination with Kobiashy ligatures and seating elastics. Our unit is now using low friction
self-ligating brackets, these allow rapid decompensation, increased cleanliness and eliminates the need to
replace modules with stainless steel ligatures.
The authors also prefer to band all posterior teeth as this enables better rotational and torque control.
Bonding terminal molars has been reported to lead to failure during the surgical phase and the author is
aware of a case where this has resulted in loss of a bond in the surgical site.
Brackets should be placed as for standard orthodontics on the FACC point. Modifications to bracket
placement such as changes in torque for palatally placed upper lateral incisors with the placement of upper
lateral brackets upside down should still be employed.
The methods used to prepare a case fully prior to orthognathic surgery will be dealt with in the following 4
sections:
1. Intra-arch.

In the initial phases of orthodontic decompensation the objectives are similar to those of conventional
orthodontic mechanics. A space analysis of the models is required to determine the need for space creation
and the need for orthodontic extractions. The extraction pattern demanded in an orthognathic case is the
often the reverse of that seen in a comparable orthodontic case. The classic pattern of compensating
extractions in a Class II case with extraction of upper fours and lower fives is often reversed in a class II
skeletal pattern case as we aim to return the incisors to their normal inclinations, retroclining proclined lower
incisors and often maintaining or proclining upper incisors. The objective of this extraction pattern is to

maximise the overjet and to achieve at least a full-unit Class II molar and canines relationship, thus allowing
maximum possible surgical correction of the underlying skeletal deformity.
Intra-arch mechanics in orthognathic cases should be designed to achieve the ultimately desired post-
surgical interdigitation and allow for the establishment of Class I canine and molar relationships after
surgical treatment. Levelling and aligning may take time especially in adult cases where the molars are
mesially tipped or rotated. Beware of premature contacts arising due to dumping of palatal cusps when all
terminal molars are engaged in the appliance. This is the result of inadequate torque control and is seen
particularly with the inclusion of third molars.
During this initial phase of treatment the patients malocclusion will appear worsened and the patient should
be carefully advised of this change before commencing care.

Figure 6a Figure 6b
The above patient demonstrates the effect of pre-surgical orthodontics on the profile.
Levelling of the occlusal plane is not always indicated prior to orthognathic surgery hence the necessity to
have a thorough understanding of the plan prior to starting orthodontic care. In many cases maintaining
curves with curved archwires is indicated and examples where this is necessary will be dealt with later in this
section.
Normally by the end of this phase extraction spaces should be closed (unless segmental surgery) and the
fixed appliances have full thickness archwires in place (either 19 x 25 SS or 21x 25 SS). Residual spaces may
however remain in a case with tooth size discrepancies with small disto-lateral spaces in the maxilla.

2. Anteroposterior (sagittal) objectives

Dentoalveolar compensation of the teeth is found in most malocclusions in which there is a severe
underlying skeletal deformity. This is essentially the effort of the teeth to maintain some occlusal contact and
interdigitation by the teeth compensating in their positions for the skeletal problem.
This effect is seen transversely with flaring of the upper molars and the rolling lingually of the lower molars
in an attempt to compensate for transverse discrepancies between the arches. This effect is also evident in
the AP or sagittal dimension.
With Class II skeletal cases commonly seen dental compensations include lower incisor proclination and the
upper incisors often appear upright (Figure 1). With Class III skeletal cases lower incisor retroclination due
to the force of the lower lip and upper incisor proclination is commonly seen (Figure 2). These
compensations will need correcting during the presurgical orthodontic phase.


Figure 7: Decompensation of class II case Figure 8: Decompensation of class III case

As discussed previously extractions may be indicated in order to decompensate or normalise these incisor
inclinations. The exception to this is with Class III cases where the lower incisors need uprighting. In many
class III malocclusions the lower incisors can be returned to normal positions without the need for
extractions, however, care must be taken in mildly crowded cases where there amount of alveolar bone and
ginigival support may limit the amount of proclination the lower incisors can be subjected to. To avoid
compromised periodontal gingival health it may be necessary to extract either premolars or even a lower
incisor (in a class III case) to enable alignment of the lower labial segment accepting that full
decompensation may not be possible.

Figure 9a and Figure 9b

The use of intra arch mechanics is commonly required prior to surgery as the full decompensation is
achieved with Class II or Class III elastics bilaterally. Elastics should only be used on full thickness 19 x 25
SS archwires. Therefore Class II elastics are often required in Class III cases to procline the lower incisors
and retrocline the uppers. Conversely, Class III elastics in Class II cases retrocline the lower incisors and
procline the uppers.

Figure 10: Class III elastics to
attempt to increase the
overjet and achive full
unit Class II buccal
segment relationships.

With maximum decompensation, allowing full skeletal correction to be achieved, significant facial changes
can be achieved:


Figures 11a to 11g.
3. Transverse Objectives

The need for maxillary expansion during the presurgical phase depends on whether the problem manifested
is skeletal or dental in nature. The pre-treatment models are then hand articulated into the proposed
position to enable an estimate as to the amount of expansion required.
This is particularly relevant for Class II skeletal patterns were the initial presenting malocclusion has no
transverse discrepancy. Posturing the mandible forward to and edge-to-edge position reveals the true nature
of the transverse problem and in many cases maxillary arch expansion will be required. Conversely in Class
III cases in centric relation the malocclusion may suggest a transverse discrepancy with bilateral crossbites
however in edge-to-edge relationship the transverse relation is no longer a concern and expansion is not
indicated.


Methods of maxillary arch expansion relate to 3 factors:
1. The amount of discrepancy and the amount of expansion required.
2. The torque of the buccal segments, i.e. are the buccal segments flared in an effort to compensate
for a transverse discrepancy
3. The proposed surgical procedure. (i.e. single jaw, segmental).

In some cases a Quad Helix palatal arch may provide sufficient upper arch expansion. However expansion
greater then 4 mm is difficult to achieve with this technique and expansion with molar flaring may result. To
achieve more skeletal than dental expansion the need for a Rapid Palatal Expansion appliance should be
made. In adolescents prior to 15 years it is possible to be effective with these appliances achieving good
skeletal changes with minimal dental side effects. As the mid palatal suture fuses and the resistance around
the zygomatic buttress increases, the ability to produce stable expansion reduces and surgery is required.
Surgical expansion may be in the form of SARPE (surgically assisted rapid palatal expansion). This procedure
involves para-sagittal cuts to release pressure from the circum-maxillary structures and separating the
maxillae by malleting a thin osteotome between the upper incisors (Betts 1995, Curtin & Cuenin 1999). It is
normally performed prior to placement of fixed appliances and requires an additional general anaesthetic. An
alternative of surgically expanding the maxilla is to carry out a segmental approach. This is executed at the
same time as the definitive osteotomy. The maxilla is segmentalised using a horse-shoe shaped midline split
as shown in the diaghram below. It is believed that more expansion can be achieved using SARPE, especially
in the anterior (inter-canine) region but little is known with regards to the difference in stability.

Figure 12: Expansion of the
maxilla using a
segmental
approach.
The cuts are most
commonly made distal
to the lateral incisors
but can also be made
distal to 3s & 4s,
depending on
archform and where
the expansion is
required.

Correcting the transverse dimension is very difficult and surgeons still are unsure about stability regardless
of technique. The literature is week with regard to long term effects of surgical expansion. It is generally
recommended to overcorrect with the aim of building in surgical and orthodontic relapse.

Take 2 hours to review the literature below and make notes:

Proffit WR. Contemporary Orthodontics. 1999; Cureton and Cuenin: Chapter 8 Pages
256-260, Chapter 16 pages 534-538.


4. Vertical Objectives

The main objectives for orthodontic treatment prior to orthognathic surgery are to avoid adverse dental
relapse potential together with maximising the speed and efficiency of treatment (Jacobs and Sinclair 1983).

a) Open Bite / High Angle cases
Maximising pre-surgical orthodontics will lead to minimal post-surgical mechanics being required. This is
important for cases where the lower face height is to be reduced during treatment for example in open bite
cases. Where only minimal to moderate curves, in either arch, are evident at the commencement of
treatment then it may be appropriate to level the arches with continuous arch wires.
The overall aim is to avoid extrusion of the anterior region and intrusion of the posterior region during the
pre-surgical orthodontic phase. In cases with marked curves pre-operatively this can only be avoided by a
segmental procedure.

b) Deep Bite Cases with Short Anterior Face height
In these cases the levelling of the mandibular occlusal plane should be delayed until after the surgical
procedure. The maxillary arch however can be levelled prior to surgery. Maintaining the curve during the
pre-surgical phase will allow the maximum increase in the anterior face height and the best aesthetic
improvement for the patient as possible.
Following surgery and the achievement of a three point contact, vertical elastics or box elastics can be
used to level the occlusal plane and achieve full buccal segment interdigitation. There is some debate as to
whether a full thickness surgical archwire or more flexible archwire should be in place in the non-levelled
mandibular arch at the time of the operation. Certainly a flexible archwire will be necessary in the post-
operative phase to allow levelling. However, it may be difficult to achieve the correct incisor inclination on
flexible archwire alone.
Timing of surgery

The majority of orthodontists in the UK carry out most of the orthodontics prior to surgery with the aim of
the models fitting together optimally so that very little active therapy needs to be done post-surgery.
Advantages are as follows:
Good buccal interdigitation achieved in the early period will have a positive effect on stability.
Surgical planning can be more precise.
We feel that there is a psychological advantage to the patient in having appliances removed soon
after surgery.
However (Lee 1994) suggested that there is a considerable advantage in delaying the major component of
orthodontic treatment until after the surgery. This may certainly be true where a strap like lower lip
prevents decompensation of the lower incisors. Lee found a reduction in overall treatment time and felt that
this was due to more biologically favourable tooth movement, more predictable occlusal results and better
management by the orthodontist.

Luther, Morris and Hart (2003) reported on 65 consecutively treated cases finding that the mean duration of
pre-operative orthodontics was 17 months (range 7-47 months). The need for extractions added only 0.3
months to the treatment time. Neither age nor sex had a significant effect on the duration of treatment.
There was a suggestion that the starting malocclusion may affect the length of treatment but with the small
numbers recorded it was difficult to make any conclusions.


For cases in our unit the average length of treatment recorded was 18 months. Knowing through audit the
length and outcome of patients treated in your unit allows the patient to be fully informed and appraised
prior to consenting to treatment.

Take 2 hours to carry out a simple Audit
From the records of the last 20 cases treated in your unit establish the
outcomes of the patients in terms of length of pre- and post operative
orthodontic treatment length.
Consenting patients for surgery

All patients for whom a combined approach will be required should be appropriately informed and consent
obtained from the outset of orthodontic treatment. In our unit patients meet the Maxillofacial surgeon prior
to any commitment to treatment. At this visit all risks and benefits of treatment should be fully explained
and the surgical procedures outlined. Patients are given information with regard to the length of treatment
time, and are advised that the pre-surgical orthodontic phase is an average of 18 months.
Patients are all given the BOS Patients Information leaflet Orthognathic Surgery (or a Trust approved local
patient information leaflet). The opportunity to discuss the surgery outcomes with a patient who has
undergone the treatment is provided if the patient wishes.
The maxillofacial surgeon is responsible at the joint clinic for discussing fully the risks of the surgical
procedure and the patient is advised of the potential for permanent parasthesia (25 % - following a BSSO or
< 5% following a VSSO : Departmental Audit Values). A full discussion on the need for surgical plates or
intermaxillary fixation is made. The post-op dietary requirements are also discussed.
If the patient is still happy to go ahead with treatment following the joint consultation they are then placed
on the surgical waiting list. Patients wait an average of 6 -9 months before starting pre-surgical orthodontic
alignment thus ensuring that they are committed to the treatment and not being rushed through. In the past
our unit has had a small number of patients each year who decline surgery once they are fully
decompensated despite being fully informed at the being of treatment. With improved patient
communication, written information and the opportunity to discuss treatment with a previous patient we
have found that this number has reduced further.

Pre-surgical Planning
Once the pre-surgical goals of orthodontics are achieved and the full thickness archwires are in place then
the patient should be returned to the surgeon for a joint pre-surgical planning appointment. This is normally
held 3-4 months prior to the surgical date time to allow any minor modifications to tooth position and time
to allow the appliance to become totally passive. If modifications to tooth positioning are more demanding
then the surgical date can be delayed.
At this appointment the following should be available:

Pre-surgical Rims (Check Models)
For all patients prior to planning the aims and objectives of the pre-surgical orthodontic treatment should be
confirmed. Rims of the patient will allow an adequate assessment of the arch co-ordination achieved. Rims
can be used to confirm that there is sufficient transverse co-ordination and that there will be no premature
contacts with under-torqued posterior teeth (this is especially true for upper molars). They will also confirm
the expected fit of the buccal teeth while achieving an adequate overjet and overbite. The rims should be
held together with the canines class I. If the centre-line is not corrected or if a Class I canine relationship
cannot be achieved then consideration should be given to the possible effects of a tooth size discrepancy,
bracket position errors or inadequate torque of the incisors. It may be necessary to create spaces distal to
the lateral incisors or perform inter-dental stripping of the lower labial segment.


Figure 13a Figure 13b

Holding rims together with canines in class I allows inspection of the post-op result. This case requires
buccal root torque to lift the palatal cusp of the upper molars further arch levelling; the aim is to achieve
improved buccal interdigitation so that the amount of post op orthodontics is reduced.

Pre-planning Lateral Cephalogram
This radiograph must confirm that the goals of incisal inclination have been achieved prior to surgery.
If further decompensation is required at this stage then the use of elastics and interdental stripping can then
be discussed to further adjust the incisor inclination.

Photographs
The use of photographs at this stage will be essential especially if a prediction planning program is
employed. Care must be taken to ensure that the profile view taken is identical to the profile held during the
lateral cephalogram. The soft tissues should be relaxed and lip incompetence evident if this is the case.

Two Weeks Prior to Surgical Date
At this date the patient should be asked to return for impressions for the splint construction.
Rectangular SS archwires (0.19 x 0.025 SS minimum) should be in situ and all elastic modules removed and
wire ligatures placed with care. In all of our surgical cases we routinely place surgical hooks between the
posterior and anterior teeth. We prefer the use of crimpable hooks as these can be easily placed with the
wires in or out of the mouth (although in practice are better out of the mouth with the wires correctly
marked as to their placement position). These hooks aid the surgeons, giving sufficient traction sites for the
surgeon to use in the final placement of the jaws. They are also relatively comfortable for the patients as
they have a smooth ball at the end. Sandy, Irvine and Leach (2001) recommend placing the crimpable hooks
onto a bracket pad prior to placement on the wire as they can be very fiddly to work with. The archwires
should be passive, this means that rectangular SS archwires should have been in place for a minimum of 3
months. A common fault is not to leave heavy archwires in for long enough before the impression is
recorded for the immediate wafer.
Impressions can then be taken leaving the archwires in place, however, it will be necessary to block out the
gingival aspect of the appliances to allow removal of the impressions. Methods used are the application of
wax (ribbon wax or protection wax), or the use of Moretight. In either case the occlusal surfaces of the
teeth are the most important details and should be accurate as their replication is critical to the fit of the
surgical wafer.


A face-bow transfer is required for the majority of cases and should be conducted with care to allow the
placement of the models on a semi-adjustable articulator. Only in this way can the model surgery attempt to
predict accurately the necessary surgical movements required. Planning errors are always of concern and
may occur at many stages during the bite registration and face-bow record. The use of semi-adjustable
articulators allows the construction of intermediate and final wafers for two jaw procedures. They also allow
checking the validity of the planned bone cuts and magnitude of movements including autorotation of the
mandible. A simple-hinge articulator may however, be adequate for a mandibular procedure alone. OMalley
and Milosevic (2000) compared the use of three types of semi-adjustable articulators for planning
orthognathic surgery. Both the Denar and Dentatus articulators showed flattening of the occlusal plane by 5
and 6.5 respectively. The authors felt this flattening could affect the positioning of the maxillary incisors
during surgery adversely. They conclude that whatever articulator is used, clinicians should be able to check
the accuracy of the mounted study casts, in particular the steepness of the occlusal plane, before the
technician makes the model.
The planned post-surgical occlusion should be carefully checked on the articulator by the orthodontist prior
to manufacture of the wafer. The wafer should be tried in preoperatively to ensure a good fit, if the fit is
inadequate, new impressions need to be retaken and the wafer remade. Interestingly in many parts of
America, all model surgery is performed by the surgeon with little or no input from the orthodontist.
Inter-Operative Splint Use

For single jaw surgery only one wafer is required. If a two-jaw procedure is required then an intermediate
wafer will be required prior to the final wafer. The intermediate wafer is required to determine the correct
positioning of the maxilla. Once the maxilla is plated then the wafer is removed and the mandibular surgical
cuts undertaken. The final wafer allows confirmation of the mandibular movements in relation to the newly
corrected maxilla once in place the mandible can then be secured.
The best surgical wafers are thin, with minimal occlusal separation with the teeth in their final position.
Securing the wafer to the teeth is either by small holes drilled into the lateral aspects of the splint or through
the creation of small wire loops which are included into the lateral aspects of the wafer. These wafers can
then be wired into place around the fixed appliance. The wafers may remain in place for 1 week to 5 weeks
depending on the preference of the orthodontist and surgeon and whether rigid fixation with plates or IMF is
provided.
Initial placement of the surgical wafer is usually helpful to patients to provide guidance of the mandible into
the correct position in the immediate post-operative phase where proprioception is often difficult. Overall the
stability of the occlusion may be enhanced, and during fixation changes in tooth position due to loss of
bands or broken bonds are minimized.
Section 4: Surgical treatment
You should have already read chapter 22 Combined Surgical and Orthodontic Treatment in the Third
Edition of Contemporary Orthodontics by W R Proffit Pages 674 709. This will have given you an
overview of the surgical treatment.

Further information can be read in:
Harris and Reynolds, Fundamentals of Orthognathic surgery Chapter 5 pages 88-141.
Epker BN, Fish LC. Dentofacial Deformities Integrated Orthodontic and Surgical Correction. J Clin Orthod
1987; 21: 654-64.


All surgery is conducted as an inpatient in this country and involves the need for nasal endotracheal tube
intubations. Patients must be fit and well pre-operatively with normal blood film and chest x-ray. The need
for transfusions during or after the operation is extremely unlikely but some units still group and save and
cross match as a precaution.
It is essential that even before the orthodontic treatment starts that the patients are full investigated for all
possible medical complications. A history of bleeding should be fully investigated and may prevent the
progression on to surgery. Emotionally unstable patients are difficult to determine and there is certainly a
case for suggesting that patients should be routinely seen by a psychologist prior to commencing care.
Each unit will have their own requests for pre-medication and drugs given preoperatively and
postoperatively. The use of post-operative antibiotics appears to be universal for a limited time only. Steroids
are also prescribed to help reduce post-operative swelling these can help the patients feel positive post-
operatively only to take a low when the steroids are no longer given.
For an excellent insight to the effects of orthognathic surgery it is recommended that you watch the video
Diary of a patient aged 34 by Mrs Tania Murphy who as an Orthodontic SpR underwent Bimaxillary
osteotomy. She leads clinicians to challenge many of the supposedly encouraging words that we routinely
give to patients in the immediate post-operative period.

Obtain a copy of the video to be produced during 2005 and watch it (30 minutes)
Video presentation Diary of a patient aged 34 by Mrs Tania Murphy


Typical Surgical Procedures

There are many surgical procedures used in combination with orthodontic treatment. The principle common
operations used in the United Kingdom are briefly reviewed below.
Common operations are:
The Obwegeser sagittal split osteotomy

Described first in 1957 (Trauner and Obwegeser) this versatile operation can be used to move the mandible
forwards or backwards. It is not recommended in patients with anterior open bite without considering a
simultaneous maxillary operation to reduce posterior facial height. The diagram (Figure 8) below show the
cuts used.

Figure 14

The photographs below show the cuts at operation (courtesy of Mrs F M Dyer and Prof P Robinson).



The Vertical Sub Sigmoid osteotomy (VSSO)

This can be used to manage mandibular prognathism. The main advantage is that there is a much lower
incidence of paraesthesia than with the Sagittal Split procedure. Nationally permanent paraesthesia is approx
5% for VSSO versus 25% BSSO. The disadvantage of VSSO is that intermaxillary fixation is required because
access for rigid fixation is very difficult.

Figure 16
The Le Fort 1 Maxillary Osteotomy

A universal operation that allows the surgeon to move the maxilla in all three planes of space at the le fort 1
level. It is used to treat maxillary deficiency (AP & vertical) and maxillary excess (vertical). In our hospital,
the maxilla has never been set back using this type of procedure. With vertical maxillary deficiency, the
maxilla is moved downwards (to increase incisal show). A bone graft is usually required for this procedure.
Figure 17

There are many other surgical procedures used. The above must represent the commonest in
current use. What other procedures do you know of? If you knowledge is weak you should
find out about them. Further information in:

Proffit WR, White RP, Sarver DM. Contemporary Treatment of Dentofacial Deformity. 2003; Mosby: Review
Part III Surgical Treatment page 269 onwards.


Section 5: Post surgical orthodontics
Post surgical orthodontic usually takes some 3-6 months to complete. The aims of post surgical orthodontics
are:
1. Final tooth positioning
2. Root paralleling
3. Vertical movements of buccal segments with inter-arch elastics
4. Retention
It is important that once any splint (or intermaxillary fixation if used) is removed the orthodontist should see
the patient and place new working archwires to bring the teeth to their final position. Ideally the
orthodontist, not the surgeon should remove any splint. Light vertical elastics with any necessary horizontal
component with a vector to support the sagittal correction are placed. These override any proprioceptive
impulses from the teeth and muscles which could cause the patient to seek an undesirable position of inter-
cuspation.

Light round wires (e.g. 0.016 steel) with any appropriate 1st or 2nd order bends will achieve minor tooth
movements and work well with box elastics.
Torque can be maintained with rectangular 0.021 X 0.025 braided steel used in a similar manner.
Retention and Stability

Retention for dental relapse after orthognathic surgery is no different to that for other adult orthodontic
patients. Numerous studies have been carried out on the stability of the jaws after surgical repositioning
with varied results.
Stability is believed to depend on the following:

1. Direction of movement
2. Type of fixation used
3. Surgical technique employed
4. Magnitude of movement
5. Adaptive capacity of muscle fibres
6. Buccal interdigitation.
A number of factors can lead to relapse and be broadly placed into Surgical Factors, Orthodontic Factors or
Patient Factors.

Surgical Factors can be down to poor planning of the case with inappropriate movements. Large movements
of the jaws increase the risk of surgical relapse. The maxilla is only able to move a maximum of 6mm
forward. Movements of the mandible greater than 10mm are difficult to achieve. Distraction of the condyles
during surgery is a constant problem for all surgical cases and the position must be carefully controlled
during the operation. The importance of adequate fixation is essential to maintain the new bony positions.
The extrusion of the teeth during the pre-surgical phase will result in relapse in the retention phase with
opening of the overbite in anterior open bite cases if care is not taken. Soft tissue effects may also result in
post-treatment changes as teeth are moved into unstable areas of soft-tissue balance.

Patient factors which may lead to relapse may include the failure to attend for follow-up appointments or
non-cooperation with elastic wear post-operatively. Anterior open bite cases are notoriously difficult to treat
successfully and these patients should be aware of the potential for relapse.

The most stable surgical procedure is superior positioning of the maxilla and the most unstable is
lengthening of the height of the mandibular ramus (Proffit, Turvey et al. 1996)


One year after surgery physiological adaptation and morphological change are usually almost complete. Most
cases are quite stable after 1 year. However the long-term (greater than 5 year) studies show surprising
amounts of cumulative change over time. Long-term changes, especially in high angle Class II patients, are
thought to be due to PCR (posterior condylar resorption). This results in a downward and backward
repositioning of the mandible which clinically manifests as a reduction in overbite and increase in overjet.
The decision whether to wear long term retaining devices can be difficult and is subject to much variance of
operator opinion.

Mobarak KA et al. Mandibular advancement surgery in high angle and low angle Class II patients: Different
long term skeletal responses. Am J Orthod Dentofacial Orthop 2001; 119: 368-81.
Section 6: Dentoalveolar surgical procedures
Introduction

Section 6 considers dento-alveolar procedures in relation to orthodontic treatment. It also describes
orthodontic procedures required for their alignment.
Aetiology, diagnosis and treatment options of the palatally displaced ectopic canine are covered in module
30.
A) Impacted incisors
Aims
To understand the surgical principles of exposing unerupted central incisors and ectopic canines.
Be aware of mechanics that can be used in subsequent orthodontic alignment
Surgical management of unerupted central incisors

Surgical exposure can be performed in 3 ways:
Excision of mucosa overlying incisor. This is the minimalist approach that may be employed if the
incisor is close to the surface and attached gingival can be preserved at the gingival margin.
Apically repositioned flap.
Closed eruption procedure. A buccal flap is raised and an orthodontic attachment bonded to the
incisor. The bracket should be bonded as palatally as possible so that early fenestration does not
occur to avoid unfavourable gingival contour. The flap is sutured back into place.

It is likely that position of the incisor (i.e. distance from alveolar crest, rotation and inclination) will be the
main factor influencing choice of technique. If the incisor is fairly high and out of attached gingivae, the
latter two techniques should be used. Varnarsdal and Corn (1977) used a split thickness apically repositioned
flap on 75 cases and found no marginal bone loss or gingival recession after orthodontic treatment. Some
authors believe the closed eruption technique to be the method of choice (Kokich and Mathews 1993;
Becker, Brin et al. 2002) in terms of aesthetic and periodontal outcomes. It is supposed to replicate natural
tooth eruption. Vermette, Kokich et al. (1995) examined the differences between surgical exposure of
incisors with an apically repositioned flap and using the closed eruption technique. Photographic examination
revealed vertical relapse of the uncovered teeth in the apically repositioned group. It was concluded that


those teeth exposed with an apically repositioned flap have more unaesthetic sequelae than those
uncovered with a closed eruption technique.

The method of closed eruption has never been the subject of a randomised controlled trial and the cost
effectiveness of techniques such as bonding gold chain has obvious implications.

Royal College of Surgeons guidelines on manangement of the UE central incisor.
Orthodontic alignment

2 x 4 appliance. Place pre-surgery if practical.
Extraction c/c may be required at time of exposure for space creation.
Wait until a rigid wire (0.018 SS or greater) is in situ before applying traction. Use a light accessory
archwire (piggy back) threaded through a link of the gold chain and ligated to the adjacent teeth.
Elastic chain or zing string may be used, but beware of oral hygiene issues and potential to apply
too great a force.
Following alignment, the incisor should be retained with a bonded retainer to prevent intrusive
relapse.

Power point presentation on 2 X 4 appliances

For completion, an alternative technique involves utilising magnetic forces to align unerupted teeth (Sandler
PJ, 1991). The technique involves attachment of a prepared neodymium iron boron magnet to the
unerupted tooth using the acid etch technique. A second larger magnet is incorporated to a removable
appliance. Careful positioning of the two magnets is essential to ensure optimum direction of pull. It may be
advantageous in terms of patient comfort as no manipulation of wires, springs or elastic chain is required.
Magnets produce a low continuous force that increases over time and is apparently very versatile. It is
however technique sensitive as correct placement of magnets is crucial, it also relies on patient compliance,
full-time wear of the removable appliance is essential.

What do you think has a higher risk of debond, magnet or eyelet? What would be the sequelae to a
debonded magnet?


B) Surgical management of impacted canines

The following will be covered:
Measures that can be taken to improve the position of a palatally placed canine followin.g diagnosis.
Description of two surgical techniques used to align palatally ectopic canines.
The most appropriate surgical technique for exposing labially ectopic canines.
Mechanics involved in the orthodontic alignment of the ectopic canine.
Interceptive measures to improve the position of the palatally placed canine

Extraction of deciduous canine between the ages of 10-13 with well aligned, uncrowded arches
(Ericson and Kurol 1988). This work is not evidence based, no control group was available.
Presently, there is only one controlled clinical trial (Leonardi, Armi et al. 2004). The study compares
two interceptive approaches; i.e. extraction of the deciduous canine alone and in association with
cervical headgear. It was found that the use of headgear in addition to extraction of the deciduous
canine induced successful eruption in 80% of cases. The removal of the deciduous canine in
isolation showed 50% success, which was not significantly greater than the success rate in the
control group.

One hour Obtain and read the following 2 well recognised articles:

Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary
canines. Eur J Orthod 1988; 10: 283-95.

Leonardi M et al. Two interceptive approaches to palatally displaced canines: a prospective longitudinal
study. Angle Orthod 2004; 74: 581-6.

Surgical Techniques used to expose palatal canines

Despite the frequency of canine ectopia, there is a shortage of well- controlled research on the best method
of surgically exposing these teeth (Burden, Mullally et al. 1999). Much of the evidence supporting current
methods of management has been derived from case studies and a consensus of clinical experience.
In the United Kingdom and elsewhere two different methods of surgical exposure of palatally ectopic canines
have evolved.

One technique involves the surgical excision of the overlying palatal mucosa after removal of the
covering bone. A surgical pack is then placed over the exposed tooth for 7-10 days to prevent re-
closure of the tissues during the healing period. Following removal of the surgical pack the ectopic
canine is left to erupt spontaneously for a period of time before orthodontic traction is commenced.
This technique is often referred to as the open technique and the canine is moved into the correct
position within the arch above the palatal mucosa.



The left maxillary canine has been exposed using the open procedure. It is brought into alignment supra-
mucosally with initially with elastic chain and later, with an accessory 014 Sentalloy archwire.

An alternative technique involves a similar degree of palatal bone removal but the palatal mucosa is
left intact and no excision of the overlying mucosa is carried out. Instead, an attachment is bonded
to the crown of the exposed canine at operation. A gold chain is tied to this attachment and the
palatal mucosa is sutured back into place with the end of the gold chain extending into the mouth
through the wound margin. Orthodontic traction is then applied to the ectopic canine via the gold
chain. This technique is referred to as the closed technique. If the canine is situated deep within
bone, it is generally moved into alignment beneath the mucosa.


Closed eruption technique. The canine is moved into position above the mucosa.

Considerable controversy surrounds the exact operative technique employed when surgically exposing
palatally ectopic canines. The more extensive surgical exposure involving excision of palatal mucosa has
been criticised for several reasons. Some authors have argued that the periodontal health of the ectopic
canine is compromised when the palatal mucosa is excised (Lappin, 1951; Hitchin, 1956; Kettle, 1958;
Johnston, 1969; von der Heydt, 1975; Heaney and Atherton, 1976; Vanarsdall and Corn, 1977; Becker et al.,
1983; Kohavi et al., 1984). However, none of the above authors validated their conclusions using
randomised clinical trials. It has also been argued that the use of surgical packs commits the surgeon to aim
for healing by secondary intention, which is less hygienic and less comfortable for the patient (Becker et al,
1996). There is also the risk of mucosal coverage of the excised area overlying the canine following pack
removal and the need for re-exposure.


The more conservative surgical technique where the palatal mucosa remains intact is considered to promote
healing by primary intention obviating the need for a surgical pack. A long-term retrospective study
(Quirynen et al, 2000) looked at 38 patients who had received a closed exposure and found that there were
no significant differences between test and control teeth with regard to probing depth and bone levels.
However, gingival width was 1mm larger for the control teeth.

Some clinicians feel that the conditions that prevail at operation are not conducive to effective acid-etch
bonding (Fournier, 1982). It is felt that the presence of blood and saliva can lead to subsequent bond failure
necessitating a second surgical exposure. Indeed, a recent study, comparing patients treated in two
hospitals using different surgical techniques found that the complication rate was lower when the surgical
exposure did not involve bonding an attachment at operation (Pearson et al, 1996). The authors concluded
that the surgical technique which did not include bonding an attachment at operation reduced the operation
time and facilitated day-stay anaesthesia.

Whichever technique is used, it is the way the soft tissues and periosteum are handled intra-operatively that
is crucial, they must be handled with great care and bone removal should be kept to a minimum, without
exposing the cemento-enamel junction. McDonald and Yap (1982) found that the more bone removed at
surgery, the greater the bone loss after orthodontic treatment.

One hour: Read the ppt. presentation ectopic canines

Familiarise yourself with the following articles:

Burden DJ et al. Palatally ectopic canines: closed eruption versus open eruption. Am J Orthod Dentofacial
Orthop 1999; 115: 640-4.

Pearson et al 1997: Management of palatally impacted canines: the findings of a collaborative study. Eur J
Orthod 1997; 19: 511-5.

Bishara SE. Impacted canines: a review. Am J Orthod Dentofacial Orthop 1992; 101: 159-71.

Surgical technique for exposing labially impacted canines

Three methods are available:
Excisional uncovering
Apically repositioned flap (ARP)
Closed eruption technique

The technique of choice depends on 4 criteria (Kokich 2004)
The labio-lingual position. If the canine is labial, any technique can be used as there is very little or
no bone covering the canine. If the canine is positioned centrally, within the alveolus, the closed
procedure should be employed.
The vertical position of the canine relative to the mucogingival junction. If most of the canine is
positioned coronal to the mucogingival junction, any technique can be used. If the canine is
positioned more apically (as in the photograph below) an excisional technique would be
inappropriate because it would not result in any gingival over the labial surface of the tooth after it
had erupted. If the canine is very high, then an ARP should be avoided as there is a risk the canine
may re-intrude after orthodontic treatment due to healing of the ARF.
The amount of gingiva in the area of the impacted canine. If there were insufficient gingival in the
area of the canine, the only technique that predictably would produce more gingiva is an ARF.
Mesio-distal position. If the crown were positioned mesially, over the root of the lateral, an ARF
should be used so that the orthodontist knows exactly where the tooth is being moved to.


If you want to avoid the result shown below, NEVER perform an excisional gingivectomy if the canine is
positioned apical to the muco-gingival junction.


Lack of attached gingivae has lead to an increase in clinical crown height in the final result.
Orthodontic alignment of ectopic canines

Anchorage
Consider the use of a Transpalatal Arch. This may be helpful for antero-posterior, vertical and transverse
anchorage, the latter two being particularly important if the canine is considerably displaced in the palate.

Methods of applying traction include:
1) Piggy back technique using a light accessory archwire. Light forces should be used to minimise loss of
alveolar bone support and potential injury to the tooth during traction
2) Elastic chain or zing string may be preferable in the early stages, particularly if the canine is very
displaced.

Regardless of the material used, the direction of the applied force should initially move the impacted tooth
away from the roots of the neighbouring teeth. After creating sufficient space for the canine, the space
should be maintained by placement of closed coil spring or tying back the teeth either side with a long
ligature. The base wire should be sufficiently rigid to minimize the rollercoaster effect caused by intrusion of
the anchor teeth

Removable appliances
McDonald & Yap (1982) suggested the use of a Hawley type of appliance designed to transfer anchorage
demands to the palatal vault and the alveolar ridge. Such appliances might be useful in patients with
multiple missing teeth when the use of fixed appliances is not recommended.

Using lower arch for anchorage
This may be in the form of lower removable appliance (Orton 1995) or a fixed lower lingual arch (Sinha &
Nanda 1999). The advantage of this technique is that the orthodontist has more control over force and
direction of applied traction. For labially impacted canines, try and avoid mechanics that move the tooth
labially which could produce bony dehiscence and accelerate migration of the labial gingival margin.

What could be the reason(s) for alignment of the ectopic canine to fail?


Suggested reading
Arnett GW, Bergman RT. Faci al keys to orthodontic diagnosis and treatment planning. Part II. Am J Orthod
Dentofacial Orthop 1993; 103: 395-411.
Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J Orthod
Dentofacial Orthop 1993; 103: 299-312.
Becker A, et al. Closed-eruption surgical technique for impacted maxillary incisors: a postorthodontic
periodontal evaluation. Am J Orthod Dentofacial Orthop 2002; 122: 9-14.
Burden DJ et al. Palatally ectopic canines: closed eruption versus open eruption. Am J Orthod Dentofacial
Orthop 1999; 115: 640-4.
Cunningham SJ, Feinmann C. Psychological assessment of patients requesting orthognathic surgery and the
relevance of body dysmorphic disorder. Br J Orthod 1998; 25: 293-8.
Cureton SL, Cuenin M. Surgically assisted rapid palatal expansion: orthodontic preparation for clinical
success. Am J Orthod Dentofacial Orthop 1999; 116: 46-59.
Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary
canines. Eur J Orthod 1988; 10: 283-95.
Harradine NW, Birnie DJ. Computerized prediction of the results of orthognathic surgery. J Maxillofac Surg
1985; 13: 245-9.
Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofacial
Orthop 2004; 126: 278-83.
Kokich VG, Mathews DP. Surgical and orthodontic management of impacted teeth. Dent Clin North Am
1993; 37: 181-204.
Lee RT. The benefits of post-surgical orthodontic treatment. Br J Orthod 1994; 21: 265-74.
Leonardi M et al. Two interceptive approaches to palatally displaced canines: a prospective longitudinal
study. Angle Orthod 2004; 74: 581-6.
Mobarak KA et al. Mandibular advancement surgery in high angle and low angle Class II patients: Different
long term skeletal responses. Am J Orthod Dentofacial Orthop 2001; 119: 368-81.
Proffit WR et al. Orthognathic surgery: a hierarchy of stability. Int J Adult Orthodon Orthognath Surg 1996;
11: 191-204.
Vermette ME, et al. Uncovering labially impacted teeth: apically positioned flap and closed-eruption
techniques. Angle Orthod 1995; 65: 23-32; discussion 33.

Discussion Board

Visit the discussion board to discuss any of the thoughts outlined above.

Congratulations - You have now completed Module 29.
Please remember to complete the module assessment so we can keep improving the module content.

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