Guide Dr. Chandralekha B Prof & HOD Vydehi Institute Of Orthodontics By Dr.

Nilofer Vevai PG Student Vydehi Institute Of Orthodontics

The main reason people come to an orthodontic professional is .

 Most problems of embarrassed smiles can be treated

Orthodontically. That is with the sole movement of teeth.

 The area of the body which primarily determines

physical attractiveness is the face.

Facial deformity has its own psychological effects.

Environment

Attributes of attractive people

Growth and development

More eye contact & affection. Father expected to be more involved. Perceived by others as better behaved and friendlier.
Perceived by others as warmer. More sensitive Kinder More interesting Perceived as more trustworthy More likeable More persuasive Greater control over job efforts Perceived as more successful Better social relationships with peers Higher parental expectations for schoolwork

Social Interactions

Work

Education

Environment Provide private setting with min people Include significant family member Differentiate between sensitive info and sharing

Attributes of attractive people Use open ended question, silence after questions to elicit response. Use pt education materials Dont give high expectations Avoid the word fix The patients jaw is not BROKEN use Change or alter

 The word orthognathic means straight jaws, just as

orthodontics mean straight teeth. Earlier, the term surgical orthodontics or facial orthopedics was used to describe the field.
Orthognathic surgery combines orthodontic

treatment with surgery of the jaw to correct or establish a stable functional balance between the teeth, jaws and facial structures.

Dental, skeletal, and profile problems come in all combinations and it is our responsibility as practicing orthodontists to develop an individual diagnosis and treatment plan for each patient so that optimum dental and esthetic results can be achieved. Since the Surgical orthodontics concept goes more into skeletal deformities it is important to know a bit about skeletal discrepancies.

 Skeletal Classification according to Heath Johnson

Skeletal Class I Skeletal Class II Skeletal Class III

 Ballard (1948) classified facial skeletal patterns as

a) Skeletal class I The bones of the face and jaws were in harmony with one another and with rest of the head. The profile was orthognathic. Division 1: Local mal-relations of incisors, canines or premolars. Division 2: Maxillary incisor protrusion Division 3: Maxillary incisors in linguoversion Division 4: Bimaxillary protrusion.

 Skeletal class II:

Subnormal distal mandibular development in relation to the maxilla. Division 1: Maxillary dental arch was narrower than the mandibular and there was crowding in the canine region, with crossbite and reduced vertical height and protrusion of the maxillary anterior teeth. The profile was retrognathic. Division 2: Lingual inclination of the maxillary incisors. The lateral incisors could be normal or in labioversion.

 Skeletal class III: Overgrowth of the mandible with the

obtuse mandibular angle and the profile was prognathic at the mandible.

 Orthodontic problems could originate in numerous tissue

sites Osseous; Muscular; and Dental. Treatment of skeletal problems may be of the following; GROWTH MODIFICATION CAMOUFLAGE TREATMENT SURGICAL TREATMENT.

 Profitt & Ackerman gave the Envelope of discrepancy

in Graber Swain 1st ed 1985 It shows the amount of change in all 3 planes of space that could be produced by 1)Orthodontic tooth movement alone 2)Orthodontic tooth movement combined with growth modification in a growing child 3) Orthognathic surgery.

 Envelope of discrepancy thus outlines the limit of hard

tissue change toward ideal occlusion, if other limits due to the major goals of treatment do not apply.

Drawback: soft tissue limitations not reflected in the

envelope of discrepancy are often a major factor in the decision for camouflage or surgical-orthodontic treatment.

Team Effort
Successful orthognathic surgery requires the

cooperation of the oral/maxillofacial surgeon, orthodontist and general dentist.

Other specialists may include periodontists,

prosthodontists, endodontists, neurosurgeons, ophthalmologist, otolaryngologists, plastic surgeons and speech pathologist. These professionals work as a team to provide the diagnosis, treatment plan and actual execution of the treatment.

The Basic Therapeutic goals According to Raymond Fonseca in Oral and maxillofacial surgery : Orthognathic Surgery are : Function: Normal chewing, speech, ocular (eye) function, respiratory function. Esthetics: Establish facial harmony and balance Stability: Avoid short and long term relapse Minimize treatment time: Provide efficient and effective treatment.

 The specific goal for orthognathic surgery vary from

patient to patient, depending on the actual diagnosis. - correction of swallowing abnormalities. - correction of functional occlusion normalization of occlusal relationship, overbite, overjet, occlusal plane angulation, and transerse dimension. - correct inability to open or close the jaws - Correct structural abnormalities occuring from excessive over/ underdevelopment.

- Decrease myofacial pain. - Correction of abnormalities leading to respiratory compromise Apnoea, airway obstruction, snoring, nasal polyps, enlargemeny of turbinates. - Correct speech problems. - improve stability of orthodontic results. - improve dental and periodontal results. - improve psyche

 Systematic Patient Evaluation acc to Johan P Reyneke 1. General Patient evaluation. 2. Sociophysiologic Evaluation 3. Esthetic Facial Evaluation 4. Lateral Cephalometric evaluation. 5. PA Cephalometric Radiographic Evaluation. 6. Full mouth IOPARs 7. Panoramic Radiographic evaluation. 8. Occlusion and study cast evaluation. 9. TMJ evaluation.

Esthetic Facial Evaluation.

Examination of the profile should be done in NHP

(because this can have profound effect on Chin position, chin throat angle, and chin throat length) & with relaxed lips.
Relaxed lips is however not possible with vertical

maxillary deficiency or closed bites for such cases a wax bite may be placed.

 Frontal analysis

facial form: ht to width proportion 1.3: 1 females 1.35:1 males Transverse dimensions: Rule of fifths followed. Facial Symmetry : Soft tissue line traced. Upper and lower dental midlines checked irt each other and facial midline.

 Vertical relationship

Upper third of the face : can be masked with an appropriate hairstyle. Middle third : Nose, center of lips and chin should be in a straight line.

 Mid face deficiency

tends to show sclera below the iris of the eye.

For the Middle third of the face Any interruption in the smoothness of this curve is an indication of an apparent skeletal deformity. Checks: Zygoma maxilla nasal base

 Lower third of the face middle to lower third 5:6 ratio.

Normal upper lip length 20+/- 2 mm for females

22+/-2 for males. Lower lip length 40+/-2 females 44+/-2 males Bigonial width is 30% less than BZW

 Profile analysis:

Upper third of the face :supraorbital rims are 5-10 mm beyond most anterior projection of the globe of the eye. NOSE : Dorsum : Normal, concave, convex. Anterior to the globes by 5-8 mm Nose tip

 Nasal tip projection evaluated using method of Goode

Cheek Similar to above.

Paranasal Areas : Ratio from Nasal tip to Subnasale

and subnasale to alar base is 2:1.

 Lower third of the face

Lips AP extent checked with E line or S line Subnasale- Pog aka Lower facial plane (5.5/2.5) Labiomental fold. Nasolabial Angle Chin Chin Throat Area.

Principles of orthodontic mechanics in orthognathic surgery cases

The orthodontic treatment objectives for an

orthognathic case are, in the vast majority of cases, entirely opposite to those that might be employed if the case were to be treated by conventional orthodontic methods alone.

Intra-arch objectives
In the initial stages of treatment, orthognathic and

conventional orthodontic mechanics have some similar objectives. Correction of arch length deficiencies, elimination of rotations, and overall archalignment are all common features.

 Achievement of these objectives will require that the

maxillary and mandibular teeth be positioned in as "ideal" relationships to their underlying osseous bases as possible. Effecting this result will often make the malocclusion look worse than it did originally, as the full extent of the underlying skeletal deformity is thus revealed.

Anteroposterior (sagittal) objectives

In most malocclusions in which there is a severe

underlying skeletal deformity, the dentition has often maintained some occlusal contact and interdigitation by the teeth compensating in their positions for the skeletal problem. These dental compensations are manifested in all three planes of space but are most apparent in the sagittal dimension.

 In skeletal Class II cases, commonly seen dental

compensations include very protrusive mandibular incisors and upright maxillary incisors. Conversely, in skeletal Class III cases, the mandibular incisors are often found to be retroclined while the maxillary incisors are commonly flared forward.

 Achievement of these "decompensation" objectives

will often necessitate the use of Class III elastics in Class II patients to upright the mandibular incisors and reciprocally advance the maxillary molars. Conversely, Class II elastics might be used in Class III patients to retract the maxillary incisors and to bring the mandibular molars forward.

 Similar principles apply to anchorage requirements.

In Class II orthognathic cases the greatest anchorage requirement is in the mandibular arch for retraction of the usually proclined incisors.

Extraction Pattern

Camouflage treatment

Surgical Management

 Class III cases often require maximum anchorage in

the maxilla and minimal anchorage in the mandible in association with a pattern of extraction of maxillary first premolars and mandibular second premolars where this is indicated to alleviate the dental compensations and produce a full-step Class III molar relationship prior to surgical intervention.

Extraction Pattern

Camouflage treatment

Surgical Treatment

 Correct presurgical orthognathic mechanics "builds

in" dental relapse potential in the direction opposite that of potential skeletal relapse, thus increasing the chances of maintaining optimal occlusal relationships postoperatively should any skeletal relapse, indeed, occur.

Transverse objectives
When considering the need for orthognathic mechanics to correct problems in the transverse dimension, it is essential to determine whether the problem manifested is skeletal or dental in nature. This determination cannot be based on the patient's diagnostic casts in their original centric occlusion relationship. The study models must be hand articulated into the anticipated postsurgical Class I canine relationship in order that transverse dimension problems may be accurately diagnosed.

 When it has been determined whether the problems

identified are skeletal or dental in nature and whether they involve absolute or relative discrepancies, the optimum course of treatment becomes obvious. Compensations such as tipped molars and premolars should be corrected, and the correct buccal segment torque should be established prior to surgical intervention

 Failure to achieve these goals may result in the surgical

expansion being found inadequate, as postsurgical orthodontic correction of these problems will usually involve some lingual movement of the maxillary buccal cusps. Pre-existing gingival recession in the buccal segments will also serve as a contraindication to attempts at any purely mechanical crossbite correction.

 In cases in which there is an isolated skeletal

transverse discrepancy and no other maxillary surgery is anticipated, a lateral maxillary osteotomy (corticotomy) followed by rapid palatal expansion may be the procedure of choice. Where a skeletal maxillary discrepancy is combined with other maxillary problems, multiple-segment maxillary surgical procedures are indicated.

Vertical objectives
The two principal objectives of orthognathic

mechanics in the vertical plane prior to surgery are the avoidance of adverse dental relapse potential and the maximizing of the speed and efficiency of treatment.

 In cases in which anterior facial height is to be reduced

surgically (open bites or open bite tendencies) the major portion of orthodontic tooth movement should be accomplished prior to surgery. Maximizing presurgical orthodontics will lead to minimal postsurgical mechanics (with its inherent biteopening tendencies) being required

 Any postsurgical extrusion of the maxillary molars

may lead to the return of an open bite. Avoidance of intrusive mechanics in the posterior region and concurrent avoidance of any extrusive mechanics in the anterior region will also facilitate maximum surgical correction of the deformity.

 In those patients who exhibit a deep bite tendency and

short anterior face height, the major portion of the orthodontic mechanics, especially relative to the leveling of the mandibular occlusal plane, is generally postponed until after the surgery.

 In this way the difficult leveling process in the

mandible may be easily accomplished mechanically after surgery by means of vertical elastics, since the postsurgical occlusion will be primarily on the molars and incisors. Presurgical leveling would have to overcome the heavy bite forces often associated with deep bites.

This treatment sequence tends to enhance the stability of mandibular advancement procedures, since the presence of a deep bite presurgically will facilitate the introduction of an opening component of rotation of the mandible during the advancement. This opening rotation tends to be more stable than straightforward or closing rotations, which include an increase in posterior face height.

 The presence of a deep bite prior to surgery will also

facilitate the maximum esthetic improvement in the patient's short facial height, since the downward and forward mandibular movement will augment the increase in anterior facial height

Postsurgical and retention objectives

Orthodontic objectives following surgery are generally

similar to those considered in finishing a conventional orthodontic case. Final tooth alignment, maximum interdigitation, finalizing torque, and artistic positioning are all completed at this time. One should strive for an ideal overjet/overbite relationship compatible with a mutually protected occlusion where CO equals CR.

 Scroll.
Throat form 2 angles

Lip-Chin-Throat angle:
An Obtuse angle occurs in a) Chin deficiency b) Retropositioned Mandible Both cause slackening of the musculature. C) Lower lip procumbency d) Excessive submental fat e) Low Hyoid Bone position Obtusenesss thru its effect on attachment on submental musculature.

Chin Neck Angle

aka cervico mental Angle

Ideal esthetics 90 deg Variation of 105-120 More obtuse in females than males

 Orthodontics Camouflage:

Class II camouflage a) Retraction of protruding maxillary incisors. Best done when the problem is incisor protrusion rather than chin deficiency.

b) Displacement of teeth of both arches moving upper teeth back and lower teeth forward. Unstable rotates the occlusal plane downwards anteriorly. In such cases genioplasty helps increase the stability.
Chinless appearance. Gummy smile. Higher relapse chances.

 Repositioning of the chin and nose. Genioplasty and rhinoplasty can be viewed as a form

of camouflage as it does not change the underlying jaw structure.

Class III CAMOUFLAGE retracting the upper incisors. Protracting the lower incisors Surgical Chin correction only Downward rotation of the mandible.

 Orthodontic camouflage is much more useful in Class

II deformity than in Class III deformity.

Camouflage of Assymetry can be done with

Correcting maxillary dental midline. Moving the chin laterally with lower body osteotomy. Addressing nasal assymetry.

Surgical Camouflage.
To remove the appearance of Jaw deformity without

correcting the underlying problem.

Genioplasty. Rhinoplasty. Onlay grafts.

Chin Surgery
2 methods.

- Augmentation with bone, cartilage or other alloplastic materials. - Inferior body osteotomy for repositioning.

Advancement of the Chin

To correct asymmetries the chin might be moved

laterally and material added to the side from which it is moved.

Forward sliding also makes the chin move upward so

graft may be required inferiorly.

Posterior movement increases the vertical height

needs to be addressed with if required by removing a wedge of bone.

 Advantage of chin augmentation via inferior body

osteotomy is basically that ratio of soft tissue to hard tissue is quite predictable. During advancement the soft tissue moves forward by about 60% as much as the hard tissue.
Reduction genioplasty soft tissue change is about 50%

of the hard tissue change.

 Soft tissue changes secondary chin advancement

occur in 1:1 ratio during advancement. Advantage Regression does not occur in the sliding genioplasty. In advancement genioplasty the genial tubercles the genial tubercles are also advanced (Esthetics).

Disadvantage -Mental nerve damage chances. - Have to be careful to prevent notching at the lateral borders by suitable augmentation. This occurs on advancement of 5 mm or more

 Alloplastic chin implants.

Intraoral/ Extraoral Approach depending on the size of the implant. A large implant requires an extraoral approach since it might lead to wound dehiscence if executed intraorally. Advantages: Less risk of sensory loss. Possible to remove if patient is unhappy. Possibility of lateral augmentation if required providing greater width to the lower face.

 Disadvantage:

Possibility of anterior cortical plate of the mandible. Soft tissue tension after closure. Leading to resorption. Chances of infection and subsequent removal. On removal of mersiline implant may cause dimpling of the chin

 Materials used

Silicone (problematic) Meshed polymers (Mersiline) Gore tex Gore S.A.M High density polyethylene ( Med Pore) Synthetic hydroxylapatite. Alloderm trade name for human cadavertic derms.

 Implant can be placed

Supraperiosteally Subperiosteally Alloplastic material is placed between mentalis muscle and anterior mandible. This leads to certain loss of muscle attachment if resorption of bone occurs may lead to ptosis.

Reduction Genioplasty.
Osseuos procedure. Horizontal, vertical, both.
2 methods

Inferior body osteotomy Osteoplasty (not recommended)

Disadvantage Loss of skin elasticity. Boxy appearance of the chin.

Nasal Surgeries.
Formon and Bell in Rhinoplasty New Concepts Illinois

1970 described 3 categories of nasal features according to racial Background.

Leptorrhine : Long high narrow nose. Whites Caucasians Rx: Tip rotation & elevation. Modification of nasal dorsum

 Mesorrhine:

Lack of dorsal height & collumellar support. Asians. Rx: Augmentation of dorsum projection projection via septal cartilage grafts and tipplasty to narrow the tip.

 Platyrrhine

Flat, broad nose and wide nostrils. Alar cartilages are usually frail & contribute little to tip support. Smaller and thinner septum. Acute NLA. Blacks. Rx: Lateral nasal osteotomies. Alar base resection.

 Rhinoplasty concentrates mainly on :

Contour of the - nasal dorsum - nasal tip - width of the alar base. 2 approaches Closed technique Open Technique.

 Simultaneous / staged rhinoplasty.

22 simultaneous rhinoplasty and orthognathic surgeries Waite et al Intnl Jour of OMFS 1988 94% patents pleased with the results of orthognathic surgery. 84% pleased with the results of the rhinoplasty. 94% felt best to combine the 2 procedures. 78% would recommend combined procedure to a friend. Only 16% would have gone in for rhinoplasty if it were a separate procedure.

 Various maxillary procedures worsen the nasal

morphology. Most important among these is Le Fort I osteotomy.

Often causes widening of the alar base. To counteract the above either a nasal cinch can be done

or the Wier Procedure is performed to control unwanted widening of the nose.

 Nasal Cinching snap

 Some practitioners do not prefer a combined surgery

due to a) Edema and visualization Edema and dorsal nasal splint b) Increased Operating time. c) Increased hospital stay. d) May increase complications. e) if same surgeon Surgeon fatigue.

 Augmentation of deficient facial structures.

Midface and paranasal deficiency. High Lefort I osteotomy. Onlay bone grafting.
Soft tissue Procedures

Esthetic lip surgery

Orthognathic Surgery
Changes in the width.

Maxilla Mandible
Changes Anteroposteriorly and in vertical height.

Maxilla Mandible

 Transverse changes in the maxilla

 Changes in the width

MAXILLA Possible to both widen and narrow the maxilla with a segmental osteotomy. A 10mm (extreme limit of 15 mm ) of transverse increase/decrease is possible. More expansion at the molars than premolars. Main constrains of expasion are soft tissues. Stability of the repositioned segments must be considered.

 Relapse tendency in cases of expansion is of 2 tyopes

1. Skeletal relapse with dental occlusion being maintained. This occurs post-surgically. 2. Dental relapse after the fixation has been released. The combination of above leads to about 40% decrease in the intermolar width.

Changes in the mandible are more difficult to make than those in the maxilla because of the TMJ as well as the soft tissue constrains. Widening the mandible in the lower anterior area is impossible with conventional Orthognathic surgery procedures.

Narrowing procedures comparatively more feasible.

 When mandibular Prognathism exists with an

increased width of the mandible Mandibular body ostectomy procedure may be considered over the Ramus osteotomy procedure.

 Anteroposterior and vertical changes. MAXILLA

Total maxillary ostectomy can move the maxilla forward by 10mm or more with equally good stability. The main limitation in forward positioning is the resistance of soft tissue anterior to it. Another affect of maxillary advancement is its effect on velopharyngeal closure in cleft palate patients it may cause velopharyngeal incompetency which causes cleft palate speech.

 when the maxilla is superiorly repositioned the

mandible moves anticlockwise and the freeway space remains more or less constant.
This seems to occur due to the proprioceptive

mechanism of the natural dentition especially the maxillary posterior teeth.

 Total maxillary setback is limited to 3-5 mm.

When the objective is to retract an excessively

protrusive maxilla may be done by removing a segment across the palate.

 Moving the maxilla down is technically feasible with

an interpositional bone graft. Moving the maxilla inferiorly is not feasible since it is highly unstable. Exact cause unknown but attributed to biting force and stretch of muscles.
Additional use of miniplates and graft materials that

increase stability used when downwad displacement accomplished.

 Mandible.

Can be moved in a variety of different directions. Mandible Forward/backward Chin Up/down Moving the gonial angle upwards is easy but moving it downwards is near impossible.

 Anteroposterior repositioning of the mandible can

have 3 effects on the vertical orientation. 1. Mandibular plane angle increase, gonial angle moving up and vertical height increasing. 2. Same dimensions 3. Mandibular plane angle decreasing, gonial angle moving down vertical height decreasing.

 Mandibular surgery that rotates the mandible down

anteriorly and up posteriorly has the most stable results. { This causes opening of a deep bite if present.} However the reverse is unstable.

 Hence :

- To correct anterior open bite surgically Surgery is hence often required in both jaws to treat the problem. - To correct a short face problem better to do a mandibular surgery to increase the vertical height rather than do a downward displacement of the maxilla. - Better to treat a long face problem with superior impaction of maxilla rather than increasing th ramal length which is less stable comparatively.

 Dentoalveolar Surgery:

Can be repositioned in all three planes of space. Must not be placed in the way of lips, tongue or cheek movement as relapse is bound to occur. On the Envelope of discrepancy the amount of movement by plane tooth structure alone also denotes the amount of movement achievable by dentoalveolar segment movement.

 It can be done when

a) Anchorage considerations. b) Time. Large intrusive movements can be accomplished with dentoalveolar surgery rather than Orthodontically. Larger segments better than smaller ones due to better vascularity. Proffit,White & Sarver suggests 4 segments of 3 teeth each as optimum.

Medical Problems Related To Surgical Orthodontic Rx Significance and Rx possibilities:

Diabetes Mellitus Hyperthyroidism Adrenal Insufficiency Pregnancy Rheumatic Heart disease Bleeding disorders Allergy immune problems Rheumatoid Arthritis Osteoarthritis Behavioural Disorders. Sickle cell anaemia.

Treatment Anteroposterior movement of incisors Surgical/Orthodontic Vertical movement of incisors Mandibular advancement Maxillary advancement

Soft tissue change Soft tissue 60% to 70% of incisor movement

Minimal Soft tissue change unless jaw rotates. Soft tissue chin 1:1 with bone Lower lip 60%-70% with incisor Slight elevation of nose tip. Base of upper lip changes 20% of Pt A Upper lip 60% of incisor protraction Shortens 1 to 2 mm. Nose usually no effect. Upper lip Shortens by 1-2 mm Lower lip rotates 1:1 with mandible.

Maxillary Superior Repositioning

Mandibular setback Maxillary Setback

Chin 1:1 Lip 60% Nose: No effect Base of upper lip 20% of Point A Upper lip 60% of incisor Advancement lower lip variable, may move back. Changes similar to the combination of the two procedures separately.

Mandibular Setback Plus Maxillary Advancement.

Mandibular inferior border repositioning

Soft tissue forward 60-70% of bone. Chin up 1:1 with bone Back 50% bone Laterally 60% bone
Chin 1:1 Lower lip 70% of incisor Nose slight elevation of the tip. Shortens 1to 2 mm Upper lip shortens 1-2 mm 80% of any incisor advancement

Mandibular advancement plus maxillary superior repositioning

Maxillary Surgeries Mandibular Surgeries Adjunctive Esthetic Surgeries Mandibular Deficiencies Long Face Problems Class III Problems Dentofacial Assymetry

Class II Div 1 malocclusion

Profile view

Retruded weak chin. Deficient mandible appearance of a large nose. A short chin throat length. An obtuse chin throat angle. Everted lower lip +/- lip trap. Short upper lip Acute labiomental fold. Increased facial contour angle. In a short faced individual well developed chin button.

Dental characteristics A large overjet. Increased overbite accentuated curve of spee. Usually crowded mandibular incisor area. A tendency for maxillary incisor spacing.

 The anterior deep bite if present exhibits 2 problems:

Irritation of the gingival tissues.

Clicking within TMJ.

Growth restraining by a deep bite is also an etiologic factor.

Acc to Proffit White & Sarver

 Treatment.

Surgical Treatment: a) Align dental arches. b) Establish arch compatibility c) Place incisors in the planned incisor position.

 Alignment:

a) Mandibular arch often needs extraction of 2 first premolars. This could be due to crowding + Severe curve of spee. b) Extraction in the maxilla may or may not be required. Mild crowding : expansion If necessary second premolars extraction to i) enable freedom of lower advancement. ii) prevent increasing of NLA and loss of lip support.

 Curve Of Spee considerations:

Leveling of curve of spee increases the arch length.

Patients with a short face do not tolerate mandibular advancement. Better to level by extrusion of premolars post surgically. Large AFH better to level the curve presurgically with intrusion utilising extraction spaces or with surgical leveling.

 Arch compatibility:

1. Intercanine width. 2. Second molar banding.

3. Maxillary and mandibular arch forms compatibility to prevent cross bites.

Orthodontic Mechanics
Crowded Cases
Non- Crowded Cases

Maxillary Arch

Mandibular Arch 1. Xn of premolars 1. Class III mechanics First: if mand. Incisor retraction. for leveling. Second : If less AP space rquired 2. Maxillary and mandibular for Incisor repositioning. arches coordinated to fit 2. Sectional Arch retraction of canines. 3. Class III mechanics.

1. Second Premolar Extraction. 2. Hg use may be necessary to support the class III elastics

Surgical Treatment
Bilateral Sagittal Split Osteotomy

Treatment Of Choice. Performed intra-orally. Lengthening of the mandible. Increase in face heightwith minimal alteration in the length of elevator muscles. Compatible with RIF.
Advisable to remove the third molars: This area best for Lag.

Inverted L Osteotomy.

Soft tissue incision

 When mandibular advancement of more than 10-15

mm required an extraoral procedure combining components of the vertical ramus and sagittal osteotomy effective.

 Advancement Genioplasty may be required for final

esthetics.

POST SURGICAL ORTHODONTICS.

Light Class II elastics to override the proprioception

and guide the teeth into new occlusion. Closing of residual spaces.

Class II Div 2
A well developed chin button.
Short Anterior facial height.

Surgical Treatment: 1. BSSO 2. BSSO with reduction genioplasty.

3. BSSO with an anterior

segmental osteotomy subapical or inclusive of the lower body. Total subapical osteotomy of the mandible advancing the dentoalveolar segment of the mandible. Chin position maintained lower lip advanced.
4.

 Total subapical osteotomy

to advance the segment in this situation chin position does not change only mandible brought forward.

Class III Malocclusion

Profile view

Long chin throat angle. Protrusive chin and prominent lower lip. Reduced labiomental fold. Lip chin throat angle acute. Frontal View Lower third of the face appears flat. Chin button not prominent. Thin upper lip reduced vermilion border.

 Presurgical Orthodontics

Decompensation of incisors. Compatible archforms and inter canine widths.

Orthodontic Mechanics

MANDIBULAR ARCH
Teeth allowed to level forward. Class II elastics to advance the mandibular buccal and further procline the mandibular incisors When decompensating should be borne that the these pt have a thin gingival covering in the anterior area.

 For MAXILLARY ARCH

High pull Hg with Class II mechanics to prevent extrusion of maxillary incisors when advancing the mandibular dentition Hg anchorage should aid retraction of the maxillary incisors or merely prevent their proclination during the leveling process.

Surgical Treatment BSSO Intra-orally or Transoral Vertical Ramus Osteotomies. Medial Pterygoid and Stylomandibular m should be freed Reduction Genioplasty.

Miscellaneous Mandibular Surgeries

Body Ostectomy:

One of the first few surgeries to be performed. Now replaced. Primarily used now when there is a mandibular elongation. Space created by extraction of tooth or by orthodontically creating space.

 Mandibular Midline Osteotomy

Some cases mandible must be narrowed transversely. Midline osteotomy with bilateral surgeries.

 Inferior Body Osteotomy:

Another term for Genioplasty. Used to correct abnormalities in the vertical, transverse or anteroposterior dimensions.

 Anterior Subapical Osteotomy:

Simon Hullihen 1850s Commonly used to close Anterior Open Bite. To depress an elevated AP Segment. To retrude or advance a dentoalveolar segment. May be combined with maxillary subapical osteotomy to correct Bimaxillary protrusion.

Inferior repositioning

Superior repositioning

Posterior repositioning

Class III Maxillary Deficiency

Profile view

Sunken cheeks. Chin and lower lip in balance with nose. Sunken or flat appearance of upper lip. Upper lip length reduced and vermilion thin. Acute NLA with Columella of the nose oriented more horizontally.

 Frontal View

Flat and relatively short upper lip. Narrow alar base. Often, sclera seen inferiorly of the iris of the eye. Sunken cheeks. Possibility of defficient lip-tooth relation. Less vermilion of the Upper Lip showing. Paranasal flattening.

 Presurgical Orthodontics

1. Eliminate compensations. 2. Establish ideal incisor relation 3. Establish Arch compatibility. 4. Level & Align arches.

 Important : Transverse discrepancy can be corrected

via surgical expansion of the maxilla.

Certain cases Twin Jaw surgery unavoidable and the Two Patient Concept adopted.

 Maxillary deficiency often involves crowding of the

maxilla 1. if significant retraction required: first premolar extraction. 2. Little retraction required with mild crowding: Removal of second premolars. 3. Advancement of mandibular incisors from upright or lingually tipped position limited by lack of attached gingiva. Mandibular second premolar extraction might be required to address crowding issues.

 Orthodontic mechanics

Relieving of crowding. Incisal positioning.

Surgical Treatment

Advancement of Maxilla via LeFort I Osteotomy.

Post Surgical orthodontics

Splint.

LeFort I Osteotomy
Cheever 1864. Herman Wassmund 1921 German surgeon first

attempt maxillary osteotomy. Did not mobilize maxilla after osteotomy but applied orthopedic traction. Auxhausen 1934 mobilzed maxilla to correct open bite deformity. 1952 American surgeon Converse reported on Maxillary osteotomy.

 Prior to 1965 dentofacial deformity only treated with

mandibular surgeries .. Often not giving the desired results.

 Lefort I Osteotomy allows the mandible to be moved

in all the three planes. a) Superior impaction. b) Differential Superior impaction. c) Inferior repositioning. d) Maxillary segmentation.

 Complications:

Shortening of upper lip esp in superior/anterior repositioning. a) residual scar in the mucobuccal fold. b) Lack of suturing of transsected muscle fibres.

Nasal flaring. Maxillary sinus considerations. Nasal Airway considerations.

Class II due to Maxillary Anteroposterior Excess

According to McNamara only 10% of a group of 277

patients had a true maxillary AP excess.

Profile view
Protrusion of the middle third of the face. Long nose with dorsal hump. Prominent infraorbital rims and cheekbones. Upper lip short and everted. Deep labiomental sulcus Lip incompetence. Acute NLA

 Frontal View

Prominent middle third. Long lower facial height. Short curled upper lip. Curled lower lip under maxillary incisors.

 Surgical Technique

Wassmund 1935 Cupar 1954 Wunderer 1963 Posterior movement of the anterior maxillary segment Wassmunds technique most effective.

Segmental Surgical Techniques of the maxilla

These include:

Anterior subapical osteotomy. Posterior maxillary subapical osteotomy. In 1960s the work of Murphey and Walker and Mohnac lead to anterior maxillary subapical osteotomy.

 Anterior Subapical Osteotomy

In conjunction with mandibular anterior subapical osteotomy to correct bimaxillary protrusion. Can be used in partially edentulous maxilla before dentures to correct the profile. Range of movement possible a) Inferior. b) Posterior. c) Tipping

 Wassmund technique has a more extensive soft tissue

pedicel.

Wunderer technique is less difficult technically.

Wassmund Technique

Wunderer Technique

 Posterior maxillary Subapical Osteotomy.

Indicated when: Unilateral Mandibular crossbite. Excessive eruption of maxillary posterior teeth.

Maxillary Vertical Deficiency

Often associated with Maxillary AP deficiency as

maxilla did not grow forward and downward.

Profile view:

Middle and lower thirds reduced. NLA acute. Overclosure causes chin to appear excessive. Profile improves in rest position. Maxillary incisors not visible at rest position.

 Frontal View.

Short and square face with exaggerated masseter muscles. Edentulous appearance. Corners of the mouth turned down when lips approximated. Nasal base broad Mandible appears to be excessive.

 Treatment

Downward and forward positioning of the maxilla. This increases the Vertical Facial Height. Rotation of the mandible. The increase in the vertical height should be in the available freeway space. Cephalometric visual treatment objective considered.

 Presurgical Orthodontics

Leveling and aligning. - Severe crowding maxillary and mandibular first premolars extreacted. - mild crowding Maxillary and mandibular second premolars. Large maxillary advancement Maxillary first and mandibular second premolars extracted to create Crossbite. Transverse discrepancy can be treated by surgical expansion of the maxilla.

 Surgical Treatment.

Lefort I Downgrafting procedure. For combination of Vertical and AP defects Lefort I downsliding osteotomy design. Post Surgical Orthodontics. Occlusion evaluation Necessary elastics. Segmental wires changed to Continuous wires if transverse dimension increased. Palatal Arch.

Vertical Maxillary Excess.

According to Reyneke 30% of patients seeking Orthodontic treatment have a Long face problem.
Main complaint includes:

Gummy smile. Anterior Open Bite.

 Profile View

Increased TFH. Increased LFH Mandible rotated downward and backward. Increased maxillary incisor exposure except in Anterior open bite cases. Sunken Cheeks. Well developed curled lower lip.

 Narrow alar base width.

Excessive incisor exposure. Increase d inter labial distance

Increased vermilion exposure of the lower lip.

Increased lower third facial height. Gummy smile. Depressed paranasal areas.

 Presurgical Orthodontics.

Preferable to level the arches presurgically. Patients with VME In cases of excessive reverse curve of spee better to align in segments, gain interdental space open the bite further and do differential repositioning of the maxilla.

 Orthodontic Mechanics

Alignment of Mandibular arch. Diverging of roots in the maxillary arch.

 Surgical Treatment.

Pts with short upper lip show more teeth than pt with long upper lip. More upward movemtent possible in younger rather than older individuals. 30-40% of crown esthetically pleasing. Superior repositioning shortens Ulip Plan for 4mm tooth xposure post surgery. A few mm of lip incompetence acceptable and pleasing. Nasal cinching. No excessive superior repositioning. Excessive posterior repositioning worse.

Lip Shape.
Mandible repositions. Post Surgical orthodontics. - Short since prior leveling has been completed. - 4-6 months for stabilization of segments.

 A hierarchy of stability and predictability exists as

explained previously. Very stable: Superior impaction of maxilla, forward positioning of mandible, chin any direction. Stable: Maxilla forward/ correction of assymetry. Stable with rigid fix. : Max up, mandible forward combination or maxilla forward mandible back combination or mandible assymetry. Problemtic : Mandible back, maxilla down, maxilla wider.

 According to William Proffit Contemporary

Orthodontics 4th Ed. An isolated mandibular setback is a very unstable procedure and must be combined with a maxillary advancement with rigid fixation then the stability increases.
Surgical widening of the maxilla is the most unstable

Orthognathic surgical procedure.

 Surgical Palatal expansion causes stretching of the

palatal mucosa and the major cause for relapse tendency is the elastic rebound. Strategies to control relapse include overcorrection initially and careful retention afterward, either with heavy archwire or a palatal bar during completion of orthodontic treatment. Followed by a palatal covering retainer for minimum period of a year.

 Three principles that influence post surgical stability:

1. Stability is maximum when the soft tissues are relaxed. 2. Neuromuscular adaptation is essential for stability. 3. Neuromuscular adaptation affects muscular length not muscular orientation.

1. Stability is maximum when the soft tissues are relaxed: Moving the maxilla up relaxes the tissues. Moving the mandible forward stretches the tissues but rotating the mandible up at the gonial angle and down at the chin decreases the amount of stretch. Widening the maxilla causes a stretch. 2. Neuromuscular adaptation is essential for stability. Most orthognathic procedures lead to good neuromuscular adaptation. When the maxilla is moved up postural position of the mandible alters in concert with the new maxillary position and occlusal forces tend to increase rather than decrease. This prevents any downward relapse.

 Syndromic patients who have neuromuscular

problems (eg cerebral palsy ) are hence not good candidates for any form of Orthognathic surgery. 3. Neuromuscular adaptation affects muscular length not muscular orientation. If the orientation of a muscle group such as the mandibular elevators is changed adaptation cannot be expected. Eg. Mandibular setback procedure wherein the mandible is pushed back pushing the posterior segment and changing the orientation of muscles.

Physiologic responses to Rx
NHP: if the head tips upward the SN- true vertical

angle decreases. If the head tips downward the SN- True vertical angle increases. Acc to Proffit White and Sarver . Long Face condition pt post surgically hv a smaller angle Single Jaw Surgery pt. More or less same. Twin Jaw procedure : Flexed, chin downward.

 Jaw Posture

Edentulous patients. Dentulous patients. Key proprioceptors are the maxillary posterior teeth pdl. Too much eruption of maxillary posteriors causes downwards and backward rotation of the mandible.

Similar changes occur during surgical procedures. Freeway space remains constant. CNS said to monitor, exact cause thou unknown.

 Tongue Posture:

Early days; Tongue reduction during setback. Now postural adaptation said to occur. According to this when the mandible moves posteriorly, the tongue moves downwards and this can be seen throughthe Hyoid bone position change. Larger the posterior setback larger is the downward movement which could lead to unaesthetic appearance . Thus the airway remains unaffected. Maxillary impaction/advancement.

 Nasal vs oral Respiration:

Palate and nasal floor interconnected. Predictably nasal cavity volume would decrease. But this does not happen. Technically possible to design the surgery such that periphery moved up more than the center.

 Turvey, Hall and Warren AJO Do 1984 vol 85 entitled

Alterations in nasal airway resistance following superior repositioning of maxilla measured the nasal resistance in 52 patients designated for Lefort I Osteotomy:
1.

2. 3.

Patients with elevated nasal resistance seem to be over represented in long face population who seek and receive surgical orthodontic treatment. None of the patient with normal nasal resistance presurgically have any post surgical problems with airflow. 10 of the 12 patients who had presurgical increase resistance to nasal airflow showed a decrease to normal resistance post-surgically.

Conclusion : in approximately 80% of the long face patients who have trouble breathing presurgically will have normal respiratory resistance post surgically.

 Explanation :

Nostrils considered as the Liminal Valve Generally the problem for increased nasal resistance is supposedly more posteriorly. Narrow pinched nostril overlooked.

 Spalding PM et al : The effect of maxillary surgery on

nasal respiration , Int J Adult Orthod Orthogn Surg Vol 6 1991

The study shows total airflow in patients having Lefort

I Surgery sugges that most patients do have a greater percentage of nasal respiration after the surgery.

 Physiologic adaptation said to be another cause.

Maxillary advancement in Cleft patients has a

tendency for velopharyngeal incompetency.

 TMJ Adaptations and dysfunctions

Occurs due to rotation of condyle which is inevitable

and muscle incision and attachment at surgery. 1. Limited post surgical jaw opening. 2. May or may not regain full opening 6 months postsurgically. 3. Active physiotherapy and limiting IMF said to be helpful and aid in faster rehabilitation.

Condylar Sag
Can be defines as an immediate or late caudal

movement of the condyle in the glenoid fossa after surgical establishment of a preplanned occlusion and rigid fixation of the bone fragments, leading to change in the occlusion.

 Two types : Central

and peripheral
Central the entire

condyle inferiorly positioned and makes no contact with the glenoid fossa.

 Peripheral

Correct positioning but lateral shifts occur. BSSO mainly this is seen.

Biting Force
Relative factor.

Advancing the mandible in short or normal face height individuals changes occlusal force in considerably in either directions with equal possibilities of decreased unchanges or increased bite force.

 However in long faced individuals the biting force

tended to increase.

Tongue lip pressure.

Unchanged pressure.
Unchanged position. Large degree of adaptation of lip function post

surgery.

Neurosensory Effects
Numbness lasts for several weeks.
Hyperesthesia.

No correlation with site. All regions of the face do not recover at the same rate.

 Complications:

1. Relapse. 2. Most are stable, 5 yr follow ups show significant changes in the position of skeletal landmarks. 3. Long term condylar resorption. Although Surgical correction of Class III problems is less stable than Class II problems in short term post- surgically, the long term stability of former is higher.

Treatment Anteroposterior movement of incisors Surgical/Orthodontic Vertical movement of incisors Mandibular advancement Maxillary advancement

Soft tissue change Soft tissue 60% to 70% of incisor movement

Minimal Soft tissue change unless jaw rotates. Soft tissue chin 1:1 with bone Lower lip 60%-70% with incisor Slight elevation of nose tip. Base of upper lip changes 20% of Pt A Upper lip 60% of incisor protraction Shortens 1 to 2 mm. Nose usually no effect. Upper lip Shortens by 1-2 mm Lower lip rotates 1:1 with mandible.

Maxillary Superior Repositioning

Mandibular setback Maxillary Setback

Chin 1:1 Lip 60% Nose: No effect Base of upper lip 20% of Point A Upper lip 60% of incisor Advancement lower lip variable, may move back. Changes similar to the combination of the two procedures separately.

Mandibular Setback Plus Maxillary Advancement.

Mandibular inferior border repositioning

Soft tissue forward 60-70% of bone. Chin up 1:1 with bone Back 50% bone Laterally 60% bone
Chin 1:1 Lower lip 70% of incisor Nose slight elevation of the tip. Shortens 1to 2 mm Upper lip shortens 1-2 mm 80% of any incisor advancement

Mandibular advancement plus maxillary superior repositioning

 STO is an essential 2D tool in the surgical

Orthodontic Correction of dentofacial deformities. The STO aids in estsblishing treatment objectives and projected results.
Purpose

Establish presurgical orthodontic goals. 2. To develop an accurate surgical objective that will achieve the best functional and esthetic result. 3. To create a facial objective profile that can be used as a visual aid in consultation.
1.

 Two Stages

Initial STO Final STO

The Initial STO : It is a pretreatment evaluation to determine the orthodontic and surgical goals. The Final STO Done after dental decompensation just prior to surgery to determine the exact vertical anteroposterior skeletal and soft tissue changes.

 Initial STO

Clinical Examination. Dental model evaluation. Cephalometric Analysis.

 Cephalometric Parameters required: 1. 2. 3. 4. 5. 6. 7. 8.

Frankfurt Horizontal Plane . Facial Axis Angle. N perpendicular to point A. N perpendicular to Pogonion. Upper incisor to Point A vertical. Upper incisor to facial axis. Lower incisor to MPA. Lower incisor to A pogonion.

 Single Jaw STO

Case: Patient in a class II div 1 with end on molar relation Objective: Decomposition with mesial movement of maxillary molar by 3 mm and uprighting of lower incisors using the entire extraction space.

Anchorage considerations Moderate in maxillary arch and maximum in mandibular arch.

Draw the initial tracing with orientation reference marks including the dentition, hard tissues and soft tissues in black. Measure the mesiodistal width of the first premolar. 2. Retrace on a second sheet of paper with the permolars extracted. Mark 2 points indicating the mesiodistal width of the first premolar along the occlusal plane
1.

3. Assess the existing molar and incisal relationships. Plan for amount of molar mesialisation and anterior retraction. (This case 3 mm of molar mesialisation). 4. This case objectives get a correct Class II molar relation, Class II incisor relation and sufficient overjet for surgical advancement.

 Vertical Reference Line

drawn at the extraction space of the first premolar perpendicular to the occlusal plane at a point approximately 3mm from the second premolar in the upper arch. Total extraction space in the lower arch utilized for the incisor retraction. For this a vertical line is drawn tangential to the second premolar in the lower arch.

 On a third tracing sheet

the occlusal plane is traced along with the vertical reference line Keeping the Occlusal plane and vertical reference line as guide shift the tracing backwards in such a manner that the vertical reference line abuts the second premolar at this point the molar and premolar teeth are traced.

 To simulate the anterior

retraction, slide the tracing forward along the occlusal plane such that the vertical reference line coincides with the anterior limit of the extraction space. Trace the upper incisor changing its axial inclination as desired, depicting a controlled tipping movement.

 In the lower arch, to simulate anterior retraction the

tracing is slid along the occlusal plane such that the vertical reference line coincides with the anterior limit of the extraction space. Trace the incisors changing its axial inclination as desired , depicting a controlled tipping movement.

 Make the necessary remodelling changes in the

hard and soft tissues following dental decompentsation. This is traced on a fourth tracing paper with a coloured pencil.

Final STO
1. Structures not changed by the mandibular surgery are the cranial base, maxilla, and maxillary teeth, mandibular ramus down to the angle, and soft tissue profile down to the base of the nose.

2. Occlusal plane drawn . Distal to the second mandibular molar line drawn from the alveolar crest to the lower border of the mandible, which represents the osteotomy cut.

 The lower border of the mandibular body and the

mandibular teeh are traced in colour on a separate piece of tracing paper.

Tracing sheet is cut along the osteotomy cut so that the posterior portion has the ramus and the angle of mandible, and the anterior portion has the mandibular teeth and its associated skeletal structures.

5. The anterior portion is moved carefully along the line of occlusion, until it lies in the position desired after surgery, determined by molar and incisal relaionship. This portion is now fixed in place. 6. Measure ow far the lower incisor moved forward. The lower lip will go forward twothirds as far. Make a mark determining that distance anterior to the lip.

7. A fifth sheet of tracing paper is placed over the original and the final prediction is traced in red, with the mandible in its new position.

8. Draw the soft tissue outline and complete the lower outline through the marked point. Complete the soft tissue profile using the table of soft tissue changes.

 This is a necessary tool of Orthognathic treatment

planning.
It is an easy tool used for analyzing the dimensions of

change, and also for motivation the patient if and when required.

 Two main factors that greatly influence the accuracy

of prediction: Variable factors 2. Constant Factors.

1.

 Variable Factors:
1. 2.

3.
4. 5. 6.

Comprehension of profile planning. Accuracy of surgery. Methods of fixation. Degree of soft tissue stripping. Degree of relapse. Accuracy and reproducibility of tracing.

 Constant factors.
1. 2. 3. 4. 5. 6.

Soft tissue/hard tissue inter-relationship of movement. Reliability of cephalometrics. Reliability of photography. Profile planning limitations. Anteroposterior planning. Variation of lip morphology and posture.

Cephalometric prediction can be done manually in two ways:

Template method. 2. Tracing Overlay method.
1.

 Template method:

This method involves designing of indivudual TEMPLATES for different structures like maxilla, mandible and soft tissuesbefore you really start your prediction. It is helpful when major movements of teeth are required or in maxillary surgeries depicting rotation of mandible and chin surgeries. More time consuming and cumbersome.

 Tracing Overlay Method

Tracing overlay method simplest way to simulate the effects of surgery. Final prediction tracing is produced without any intermediate tracings. It is the most reliable and easiest method of depicting changes on an acetate sheet and is followed all over the world.

 It can be categorized into 1. Maxillary predictions

- Maxillary superior repositioning. - Maxillary inferior repositioning and advancement. - Premaxillary setback Mandibular Predictions - Mandibular setback - Mandibular advancement - Lower sub apical osteotomy 3. Chin Prediction
2.

 Cephalometric Prediction Tracing For Superior

Repositioning of the maxilla, mandibular advancement and subapical osteotomy. 1. Pre-surgical cephalogram is traced in black. Structures remaining unchanged are cranial base, frontal bone, nasal bone and the orbital rim. 2. Two +s are made on this tracing 35mm above the canine and 25mm above the molar which represents the Lefort I osteotomy cut.

3.

Three planes are constructed a) Horizontal reference line parallel to FH plane form piriform rim to zygomatic buttress area at a height of 5mm above the cuspid apex. b) A second vertical reference line in the zygomatic buttress area extending inferiorly approximately 5mm from the anterior horizontal line c) A third line is drawn parallel to the anterior horizontal line at the end of the vertical line towards the pterygoid plates.

 An additional horizontal

reference line is drawn parallel to the FH Plane at the desired vertical position of the incisor in relation to the upper lip. 4. Autorotation considerations.

5. The maxilla with the maxillary teeth is cut out and fixed superiorly.

7. For measuring the degree of autorotation 2 separate lines are drawn both originating from the center of the condyle head and extending downwards towards the pre and post surgical position of the Gnathion. . A mandibular cut out is made with a vertical osteotomy cut from distal of second molar alveolar crest to mandibular inferior border. This is advanced forward in reference to the occlusal plane the desired incisor and molar position is achieved and (rotated such that the mandibular incisors are 1 or 2 mm above the incisal edge of the maxillary incisors.)

8. A second sheet is positioned over the tracing, new maxillary and mandibular position traced and the soft tissues traced accordingly.

Subapical Osteotomy
Presurgical cephalogram traced in black. 2. Unchanged structures are: Cranial Base, maxilla, maxillary teeth, mandible lower part of symphysis, posterior mandibular teeth, functional occlusion plane and soft tissue chin.
1.

3. All structures including the lower second premolars and canines along with the functional occlusion plane are traced in black from the pre-surgical cephalometric radiograph. 4. A line is constructed parallel to the functional occlusion plane on the symphysis approximately 35 mm from the occlusal tip of the canine. This line represents the osteotomy cut

5. Repositioned according to need.

6. 7.

Fixed. Retraced.

 A Surgical relocation of the jaws is a three

dimensional movement of a geometrically complex structure.

The final treatment plan is expressed as model

surgery.

 Purpose
- To determine the magnitude and and direction of

skeletal movements. - To determine size and shape of osteotomies especially interdentally. - To provide a splint for surgical splint Corrections. - To provide a comparative to the occlusal result actually achieved as noted on release of intermaxillary fixation.

 Indications

Double jaw surgery Single Jaw Surgery

Preoperative casts are templates.

 Advantages

3D simulation. The surgeon can correlate the relevant info and arrive at the surgical predictions in three dimensions. Model surgery gives 1:1 replica of the pts dentition allowing an increased accuracy in prediction compared to 10% discrepancy seen in cephalometric distortion. Model platform and block is capable of accurately measuring articulator mounted models in three planes of space allowing the surgeon to carry out model surgery movements on a full size anatomic articulator.

 Disadvantages

Condyles are never perfectly symmetrical therefore when the model surgery is performed the mounted casts give slightly inaccurate readings. 2. There can be errors related to the actual model orientation itself. 3. There can be measurement errors related to instruments and perspective.
1.

 Can be done
1.

During the presurgical orthodontic phase, with or without diagnostic setup. After presurgical orthodontic phase.

2.

 Surgical Splints A.k.a Occlusal Wafer splints.

Used to position the teeth and add to stabilization. Advantages 1. Clear visualized goal. 2. Aids in positioning bone fragments correctly to aid

in healing . 3. Possible to put teeth in a planned position at surgery, even if they do not interdigitate perfectly without a splint.

 Precautions:

Thick Splints can cause errors if articulator mounting is not accurate. 2. Splint removal post surgically must occur simultaneously with removal of stabilizing wires. 3. Surgical expansion of maxilla requires additional anchorage. 4. Removal of splint without allowing teeth to settle can cause Convenience bite.
1.

 If maxillomandibular fixation is released due to

successful RIF, occlusal splint must NOT be removed until stabilizing archwires removed. Modifications: 1. Reduction of depth of occlusal index. 2. Adequate splint thickness thou so as to not break in function. 3. Provision for cleaning by removal by incorporation of ball end clasps.

 Used for

1. Maxillary Surgery. 2. Mandibular ramus surgery. 3. Segmental Jaw Surgery. 4. Dual Jaw Surgery

In Bi Jaw surgery 2 splints have The maxillary cast is moved first and fixed giving the first splint called the intermediate splint. The second splint created after mandibular repositioning. Always check for accuracy of fit.

 Complications:

1. Buccal expansion or contraction might induce errors of maxillary expansion. 2. Ill fit. 3. Poor Occlusal interdigitation may compromise post op control of surgical segments.

FACEBOW
Definition A calliper-like device that is used to record the relationship of the maxillae to the temporomandibular joints or opening axis of the mandible and to orient the casts in this same relationship to the opening axis of an articulator.

 If the maxillary cast is mounted using a facebow

transfer on a semi-adjustable articulator, then the mandibular cast will rotate (or arc) in exactly the same way that the mandible would move in the patient.

 A Semi-adjustable articulator is preferred. A non-adjustable articulator is contra-indicated.

 Indications for a Facebow transfer : 1. 2.

If the condyle dental relation is to be preserved.

In a two jaw surgery, the mandibular position with the condyles intact is the guide for positioning maxilla before the mandibular surgery is completed. Therefore a facebow transfer would be mandatory.

 The semi-adjustable articulator should be set up

accordingly.

Setting of the Condylar guidance :

Generally at 30 deg since this is what is found in majority of the population A spring bow type of facebow and Hanau semi-adjustable articulator is considered.

 Parts of a Facebow:

Spring bow : This flexible bow houses the earpieces that go into the external auditory meatii of the patient. It also has a bite fork clamp attached to it which can accept the bite fork.
1.

Orbitale pointer: The facebow has an Orbitale pointer attached to it. This should be kept at the level of the orbitale when recording.
2.

 Bite fork:

Horse shoe shaped plate that is used with impression compound like a tray to take maxillary teeth indentations. It has a mark in the midline that should always be kept coincident maxillary dental midline.

 Procedure for Facebow

transfer: 1. Patient made to sit in an upright position. 2. Mark the orbitale point. 3. A softened piece of baseplate wax or impression compound is wrapped around the bite fork and positioned around the maxillary teeth 4. Shallow indentations are made. 5. Indent mark on bitefork should match upper dental midline.

6. 7.

8.

9.

10.

Remove the bitefork, if wax used chill it. Reinsert and check. Ear pieces are seated. The nasal guide is locked (if present) front of the bow is raised so that the orbital pointer lines up with the orbitale reference point. The bow is checked from the front to make sure that the inter-pupillary line is parallel to the facebow horizontal plane. The entire contraption is locked.

11.

All alignments rechecked and the Facebow removed.

12. Placed or positioned over the

semi-adjustable articulator.
13. Orbitale pointer should be

level with the upper mounting ring.

14. The condylar guidance is

kept at 30 deg.

15. The maxillary cast is

mounted first.

14. Next the mandibular cast is

mounted using the bite registration taken in CR.

15. And lower jaw mounted as

well with plaster.

 Mandibular Surgery When doing an isolated mandibular surgery the

maxilla is used as a template. Facebow transfer and semi-adjustable articulator not required. Maxillary and mandibular casts held together with sticky wax in the ideal relationship and mounted on a nonadjustable articulator.

 Once the mounting plaster has set the casts are

separated from each other and the surgical splint is made.

When segmental or body osteotomies are carried out

in combination with mandibular ramus surgeries, these procedures are carried out first and once the new arch form is established the final cast placed in the desired position against the maxilla and the splint constructed.

 Maxillary Surgeries

Requires an accurate Facebow transfer to a semiadjustable articulator . Vertical reference lines placed on the maxillary cast and used to quantify the amount of anteroposterior movement during surgery.

 Same type of lines drawn on the anterior and posterior

surfaces of the maxillary cast describe the amount of arch rotation and help prevent or correct a transverse discrepancy.

 A third set of reference marks are horizontally placed at 10

to 20 mm from the articulator mounting ring.

Dental landmarks are utilized to make a series of

measurements in order to to document the pre-operative anatomic position of the maxilla.

Boley gauge used to measure the distance from the cusp

tip to the mounting ring of the maxillary cast and the incisal guide pin of the articulator, and these values are recorded on the model surgery work sheet.

 Isolated Maxillary surgery. After the initial measurements are made, the

maxillary cast is removed from the articulator and ideally positioned on the mounted mandibular arch maintaining the orientation and incisal pin relation.
The required quantity is removed from the upper

member .
Measurements retaken

 Comparative analysis done between clinical and

cephalometric records.

Splint made to transfer to transfer the AP and

horizontal changes of the maxilla.

During the surgery final vertical position is confirmed

using an external reference point.

 Segmental maxillary surgery: Additional landmarks are made to document the

surgical movement of each dentoalveolar segment in the case of segmental maxillary surgery.
After the necessary measurements are taken and the

maxillary position noted, it is de-articulated.

Split into the preplanned segments.

 Placed on the mandibular cast in required positions with

midlines matching and transverse relation constructed using the mandibular cast as template .
Stabilization done of segments with sticky wax or

mounting plaster.
Final anteroposterior placement done and all values

rechecked.
A slightly thick occlusal splint combined with an auxillary

stabilizing wire of 0.04 inches used for the transfer of vertical dimension during the surgery. The auxillary stabilizing wire made presurgically on the reconstructed maxillary cast.

 Combined maxillary and mandibular surgery. Model surgery completed in stages. Simulation surgeries performed on the maxillary and

mandibular cast and different splint fabricated to record the intermediate and and final position of the arches.

 First step determine the final desired position of the

maxilla.
And an intermediate splint is fabricated, with the

splint in its new position the maxilla is repositioned without using the mandibular cast as a template.
The fabricated splint is placed on the unoperated

mandible and this serves to reposition the mobile maxilla.

 Once the maxilla is stablized the mandible

repsitioned according to requirements in the final position using the final splint.

 Double jaw surgery including a segmentalized maxilla can

be performed with the help of a composite splint.

First an intermediate splint is made to accommodate the

final splint superiorly and the mandibular arch form inferiorly.

Thus an intermediatery splint is faricated with the final

splint in place on the maxillary cast.

The maxillary cast is then dearticulated and then split into

segments, then arranged in an ideal archform. Impressions made after stabilixzation.

 Duplicated maxillary cast mounted on a hinge

articulator in ideal archform in in ideal occlusion with the mandibular cast.

Fabrication of the final splint done first, and the

finished splint is placed on the maxilla of the intermediate model surgery. The intermediate splint is made with the final splint in place because it will not be removed intra-operatively after the fixation of the maxilla.

 Attachments
Comparison of torsional stability of 2 types of split

crimpable surgical hooks with soldered brass surgical hooks by OBannon, Dunn, Lenkc published in Am J Orthod Dentofacial Orthop 2006;130:471-5 suggest that soldered brass surgical hooks and coated split crimpable hook attachments provide more stability to torsional dislodgement from a rectangular stabilizing archwire than ribbed split crimpable hooks.

 LeFort I maxillary advancement: 3-year stability and risk factors

for relapse Ajo do 2005 Paul A. Dowling, Lisen Espeland, Leiv Sandvik, Karim A. Mobarak and Hans Erik Hogevolde Objectives of this retrospective cephalometric study were to assess the amount, direction and timing of postoperative changes after LeFort I maxillary advancement, and to identify risk factors for skeletal relapse. They concluded that Maxillary advancement with a 1-piece LeFort I osteotomy is a relatively stable procedure. Identified risk factors for horizontal relapse were degree of surgical advancement and degree of inferior repositioning of anterior maxilla.

Conclusion
A fast developing field with increased practitioner

skill requirement and a multidisciplinary approach.

wider acceptance and more demand as esthetics

becomes a primary concern for young and old alike.