Documente Academic
Documente Profesional
Documente Cultură
Kamal F. Busaidy, BDS, FDSRCS, Associate Professor, Dept. Oral and Maxillofacial Surgery.
Primary references:
Modern Practice in Orthognathic Reconstructive Surgery (Edited by William H. Bell)
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What is success?
In the eyes of the patient success is measured by
Addressing the original complaint Absence of adverse outcomes Stability of result Assuming there is no underlying psychiatric issue!
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OMFS Evaluation
Stage 1 Stage 2 Stage 3 Initial evaluation/Feasibility Pre surgical evaluation Post surgical evaluation (Long term)
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Coordination of Care
Referring Practitioner
OMFS:1st Evaluation
Ortho:1st Evaluation
Ortho Treatment
Patient Evaluation
1. Complaint + History 2. Health Status 3. Assessment of Facial Esthetics 4. Routine Dental Examination 5. Orthodontic Evaluation 6. Cephalometric Evaluation 7. Photos 8. Dental casts * Psychological Assessment
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Facial Esthetics
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Facial Esthetics
1/3
1/3
1/3
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Facial Esthetics
ULL 21mm (+/- 2 mm) Men ULL 19 mm (+/-2 mm) Women
1/3 2/3
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Facial Esthetics
Nasofacial Angle 30 - 40 o o Nasomental Angle 120 -132 o o Mentocervical Line 80 95 to Vertical o o Mentocervical Line 110 120 to Nasomental Line o o Nasolabial Angle 100 - 110
Powell and Humphreys: Proportions of the Aesthetic Face. New York, Thieme-Stratton, 1984
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Dental Esthetics
Tooth Location (Midline)
Tooth Size
Tooth Shape Tooth Number Tooth Orientation Emergence Tooth Color
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Dental Esthetics
Arch Form Occlusal Plane Occlusal Level Overbite Overjet Buccal Corridor Surrounding Tissues
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Case Example
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Case Example
SMILE REST
12 mm
9 mm
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Case Example
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Case Example
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Case Example
Class II Skeletal Pattern (*mandible) Increased incisal show No increased LFH! Close bite (?traumatic) Maxillary cant
Ocular dystopia
Unstable occlusion. Poor bridges (shape/color)
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Radiographs
Lateral Cephalogram Panoramic Dental Xray Periapicals SMV PA Cephalogram Others (MRI/CT/Bone scan/Wrist Films)
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PA Cephalogram
Symmetry (particularly gonial angles, symphysis) Position of proximal segment post op Position of internal fixation post op
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SMV
Thickness of mandible (Superseded by CBCT!) Flaring of rami (vertical ramus osteotomy) Position of proximal segment post op Position of internal fixation post op
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Periapicals
Periodontal bone loss Proximity of apices (multi-piece segments) Periodontal bone loss post op
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Panoramic Radiograph
Third Molars Inferior alveolar nerve position Intraosseus pathology (best screening tool) Position of fixation post op Position of condylar head post op
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Lateral Cephalogram
Skeletal proportions Growth prediction Cessation of growth Soft tissue measurements Planning (primary tool)
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Cone Beam CT
Dolphin Imaging
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Lateral Cephalogram
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Lateral Cephalogram
Nasion Pt point Porion Basion Xi Point Gonion Pm Point Pogonion Menton Gnathion PNS Orbitale ANS A Point
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Ba- Basion: the lowest point on the anterior margin of the foramen magnum, at the base of the clivus Po-Porion: the midpoint of the upper contour of the external auditory canal (anatomic porion); or, the midpoint of the upper contour of the metal ear rod of the cephalometer (machine porion) Pt- the point at about 11 0clock on the outline of the pterygomaxillary fissure adjacent to the foramen rotundum Or-Orbitale: the lowest point on the inferior margin of the orbit ANS-anterior nasal spine: the tip of the anterior nasal spine Point A: the innermost point on the contour of the premaxilla between the anterior nasal spine and the incisor tooth Pog-Pogonion: the most anterior point on the contour of the chin Pm-Suprapogonion: the point where the anterior curvature of the mandible changes from concave to convex Me- Menton: the most inferior point on the mandibular symphysis Na-Nasion: the anterior point of the intersection between the nasal and frontal bones Go- Gonion: the midpoint of the contour connecting the ramus to the body of the mandible Gn-Gnathion: the most outward and everted point on the mandibular symphysis PNS-Posterior nasal spine: the tip of the posterior nasal spine of the palatine bone, at the junction of the hard and soft palate Xi- The point in the middle of the ramus, approximately in line with the occlusal plane FH-Frankfort Plane: the horizontal reference plane in the heads natural position extending from the porion to orbitale
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Hands-on Exercise
Lateral Ceph Pencil Protractor/Ruler
Identify the points marked in the previous slides, (then trace the outlines of the skeleton as described), and start measuring the pertinent angles using Ricketts analysis.
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Lateral Cephalogram
MARK THESE POINTS ON YOUR CEPHALOGRAM Porion Basion Xi Point Pt point Orbitale PNS ANS A Point Nasion
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Pogonion
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20
90 Basion
Skull Base
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A point
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A point
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A point
Pogonion
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Xi
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ANS Xi 47
o
Pm Point
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130 +/-6
o
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Other Analyses
32 +/-5
Approximately Parallel
90 +/-7
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UFH: 130
o
100-110
LFH: 120-132
o
o
85-95
CHECK THAT THE PATIENT IS IN REPOSE, KB 2010 WHICH THIS PATIENT IS NOT
Clinical Photography
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Clinical Photographs
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Clinical Photographs
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Take the impressions Interocclusal records Face bow record Mount the casts Measuring in 3 planes of space
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Impressions
2 sets of upper impressions 2 sets of lower impressions Block out brackets with wax to prevent distortion of the impression Avoid bubbles/voids in pour-up
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Interocclusal Record
Record occlusion in centric relation (Potential
disparity with centric relation when asleep)
Alternatives:
Record occlusal relationship supine Deprogramming Short general anesthetic!
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Facebow Recording
Find Frankfort Horizontal (Easier said than done!)
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The Frankfort plane identified clinically should correlate with the Frankfort plane on the articulator AND the lateral Ceph
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Radiographic Frankfort
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Facebow Recording
Find Frankfort Horizontal (Easier said than done!) Ensure the facebow is centered on the face Lock down the hinges to prevent distortion of record
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B
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3 Planes of Measurement
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3 Planes of Measurement
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3 Planes of Measurement
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3 Planes of Measurement
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When I hand articulate the models can I get a good occlusion? Segmental maxilla / (Segmental mandible) / More Ortho
No Yes
Proceed to Next
Proceed to Next
Maxillary osteotomy
Mandible acceptable?
No No. There is an AOB Yes
Mandibular osteotomy
No
Yes
Genioplasty
Finished
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Trace the cephalogram and indicate in the mandible where the osteotomy will be placed
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Take a new piece of tracing paper and trace over the original: only trace structures in the maxilla and above. Trace the soft tissues of the nose and upper lip.
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Reposition the prediction tracing on the original such that the maxillary teeth of the prediction tracing meet the mandibular teeth on the original tracing in class 1 Trace the mandible ANTERIOR to the osteotomy line, including the teeth. Trace the soft tissues of the lower lip and chin.
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Reposition the prediction tracing such that the skull bases and orbits coincide. Rotate the prediction tracing around the axis of rotation in the condylar head until the inferior border of the proximal mandibular segment seems aligned with the inferior border of the distal segment. Trace the proximal mandibular segment. Note the degree of overlap. This corresponds to the amount of mandibular setback.
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Trace the cephalogram and indicate in the maxilla where the osteotomy will be placed
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Take a second piece of tracing paper and trace again all the structures that will NOT move during the osteotomy (i.e. above the osteotomy cut). Stop tracing the soft tissue of the nose at the supra-tip break. Mark a horizontal line that corresponds to the level of desired maxillary incisal vertical height
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Rotate the top sheet around the axis of rotation in the condylar head until the tip of the lower incisors protrude above the horizontal line by 2 to 3 mm. This represents the overbite. Trace the entire mandible and the soft tissue of the neck and chin up to the labiomental fold.
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Reposition the top tracing over the original such that the maxillary dentition occludes with the new mandibular dentition in class 1. Pay particular attention to the incisal relationship. Trace the maxilla and the maxillary teeth. Trace the remainder of the nose and upper lip, then complete the tracing of the lower lip.
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Reorient the prediction tracing on the original such that the skull bases and orbits coincide. Examine the degree of movement of the maxilla in 2 planes. Make a note of these measurements. Examine the degree of autorotation of the mandible. Examine also the effect on the chin prominence and assess whether a genioplasty is required.
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Trace the cephalogram and indicate in the maxilla AND mandible where the osteotomies will be placed
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Take a new sheet of tracing paper and trace over the original: only trace structures that will NOT move in either the maxillary or mandibular osteotomies. Stop tracing the soft tissue of the nose at the supra-tip break Indicate the desired vertical height of the incisal edges of the maxillary teeth with a horizontal line. Indicate with a vertical line the desired AP position of the incisal edge of the maxillary incisors
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Rotate the top sheet around the axis of rotation in the condylar head until the tip of the lower incisors protrude above the horizontal line by 2 to 3 mm. This represents the overbite. Trace the mandible.
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The degree of reverse overjet indicates the amount the mandible must be set back.
Reposition the prediction tracing such that the maxillary incisal edge rests in the indicated ideal position. Align the maxillary occlusal plane with the occlusal plane of the mandibular teeth on the prediction tracing. (Note that the maxillary teeth NEED NOT be in class 1 occlusion with the mandibular teeth at this point!) Trace the maxilla and the maxillary teeth. Trace the remainder of the nose and the upper lip.
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Your prediction tracing should look like this now. Label this tracing IPT (Intermediate Prediction Tracing)
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Take a new sheet of tracing paper and trace over all hard structures on the first prediction tracing except the mandible. It is recommended that you use a different color pencil. Trace soft tissues down to and including the upper lip. Label this tracing FPT (Final Prediction Tracing)
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Place the Final prediction tracing (FPT) over the Intermediate Prediction Tracing (IPT) in such a way that the maxillary teeth on the FPT meet the mandibular teeth on the IPT in class 1. Trace the mandible ANTERIOR to the mandibular osteotomy line. Trace the mandibular teeth.
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Reposition the FPT on the IPT such that the skull bases and orbits coincide. Rotate the FPT around an axis of rotation on the condylar head until the inferior border of the proximal mandibular segment aligns with the inferior border of the distal mandibular segment. Trace the proximal mandibular segment. The overlap indicates the amount of mandibular setback.
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Place the FPT on the original tracing of the cephalogram such that the lower incisor and symphysis of both coincide. Estimate the predicted chin and lower lip shape.
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Your FPT should now look like this. Measure the vertical and AP predicted movement of the maxilla and mandible and record the measurements. Note that the post-surgical occlusal plane in this example was determined by the occlusal plane of the mandible after rotation; however the occlusal plane can be adjusted (within limits) to fit the needs of the individual case.
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Setback
Chin 90% Lower Lip 90% Upper Lip 20%
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Setback
Upper Vermillion 50% - 60% (Less with VY) Subnasale 30% (Less with VY) Upper Lip 10%
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Superior
Subnasale 20% up Nasal Tip 20% up Lip 10% up (Less if VY)
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0-Meridian: Perpendicular to FH from soft tissue forehead. Chin should be 0-3mm ahead of this line
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78 +/- 10
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8 +/- 2
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Model Surgery
1. Calculate the new measurements that would give the desired new maxillary cast position (AP, Vertical and Transverse). Segmentalize the upper segment if necessary and make occlusal adjustments to give best intercuspation Mount maxillary model to new position using the Erickson model block and platform Mount mandibular model to new position (in occlusion with upper model) on the articulator Verify movements correlate with intention Note magnitude of movements in all planes Verify movements are surgically feasible Construct splints
2. 3.
4.
5. 6. 7. 8.
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Record where occlusal adjustments are made so that they can be duplicated intraoperatively
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Final Splint
Final Splint capable of being wired into maxillary dentition to support maxillary fixation
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Intermediate Splint
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Summary
Take the records meticulously Verify that the A casts match the B casts Verify that the mounted casts match the clinical picture Perform the model surgery on one set of casts Construct the splints in correct sequence for the planned surgery.
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Condylar Malposition
Condylar sag: Inferior displacement of the condylar head within the glenoid fossa
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Condylar Resorption
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Large mandibular advancement Counterclockwise rotation IMF Posterior repositioning of condylar head in fossa Increase in ramus length
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Pts without symptoms from TMJ pathology can become symptomatic after orthognathic surgery Pts with anterior disc displacement prior to BSSO will most likely not improve, and may get worse IVRO in a pt with ADD improves disc-condyle relationships and pain
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Goncalves et al (JOMS April 2008). Retrospective cohort study, looking at 51 pts with pre-op TMJ symptoms and compared concomitant TMJ + orthognathic surgery to orthognathic surgery alone. Demonstrated improved stability and relief of symptoms in the former group after 31 months follow up
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Summary
Perform a baseline TMJ exam on every patient Avoid intra-operative trauma to the TMJ that might cause intra-articular edema Take care with positioning and fixation of the segments Orthognathic surgery may induce symptoms from the TMJ Consider treating the TMJ first if disease is present
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Stability Issues
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Instability
Early: From the time of surgery up to week 8 After 8 weeks
Late:
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LESS STABLE
LESS STABLE
Setback
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Tear of palatal mucosa during segmentalization Condylar sag (very difficult to plan for) Failure to check condylar position post-op Setback of mandible in presence of a flat chin-throat angle Planning for >6mm posterior maxillary impaction Weak brackets/hooks at time of surgery
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