1.

Orthognathic cases:
Treatment stages
PRE SURGERY (18months-2 years)
Relieve crowding
Level and align
Decompensate
Co ordinate arches
Relieve crowding
Level and align
Decompensation
(reverse dental compensations)
Co-ordinate
Width of upper and lower arches need to
match
Case 1: CT
Class III incisors, class III dental base,
increased vertical proportions
TC
Initial
appearance
SNA = 73
SNB = 85.5
ANB = -12.5
UiMx= 103.5
LiMn= 68
MMPA = 34
LFH % = 62
Treatment plan
Orthodontic maxillary expansion, aiming
for arch co-ordination
Decompensation incisors
Bimaxillary osteotomy
TC: Pre-op orthodontics
SNA = 72
SNB = 79.4
ANB = -7.2
UiMx= 116
LiMn= 94
MMPA = 33
LFH % = 58.5
Surgical plan
Maxillary adv = 8mm
Impaction 2mm
Mandible set back =
4mm
Adv genioplasty = 5mm
Simuluted prediction
shown on right
SNA = 78
SNB = 74
ANB = 4(5.5)
UiMx= 111.5
LiMn= 87
MMPA = 40
LFH % = 58
Final facial
appearance
Prediction & actual appearance
Pre-op & post op
Case 2: BG
II/I incisors, Class II skeletal base,
increased vertical proportions
AOB = -8mm
OJ = 10mm
Deep labiomental fold, active mentalis,
retroclination LLS
Aims of treatment
Align & level arches
Relieve crowding
Correct Class II skeletal pattern
Close AOB
Reduce OJ
Treatment plan
Extract lower 2
nd
premolars to relieve crowding
and allow some contraction lower arch
Expansion upper arch with quadhelix (arch co-
ordination)
Level & align, decompensate using In-ovation
brackets, Roth prescription
Bimaxillary osteotomy (maxillary posterior
impaction and advancement, mandibular
forward slide)
Overjet 11.0 mm
Overbite -9.5 mm
UI/MxP 115.0
LI/MnP 83.5
LI-APo -3.0 mm
SNA 79.5
SNB 75.5
ANB 4.0
MxP/MnP 37.0
LAFH/TAFH 58.5 %
Start
Extractions lower 5/5. L014 Sentalloy. Full engagement. SS tubing. Bend
backs ends of wire
11/09/02: 1
st
visit
1
st
visit
Upper 014 Sentalloy, Lower 19 25 SS. 7s banded
28/05/03: 6th visit, 8 months into treatment. Upper arch bonded 4 months ago.
23/10/02: 2
nd
visit: Lacebacks removed. Retie
Enough space to align UL2.
Piggy back (012 niti)
02/07/03: Visit 7.Creating more space
for UR2
Traction ligatures lower arch.
Light force to prevent
proclination of LLS during
levelling
13/02/04: Visit 10
UL 1925 SS
Rims taken: orthodontic
expansion insufficient to
address arch width
discrepancy
Quad removed to allow
uprighting upper molars
OJ = 10mm
OB = -7mm
Surgical procedure
Bimaxillary osteotomy: Posterior maxillary
impaction (3mm), maxillary advancement
3mm), mandibular forward slide 11mm
2 part maxilla with midline split (for
surgical expansion)
Reduction genioplasty (vertical & horizo
ntal)
Titanium miniplates
Overjet 3.0 mm
Overbite 0.5 mm
UI/MxP 107.0
LI/MnP 84.5
LI-APo -1.0 mm
SNA 83.5
SNB 80.0
ANB 3.5
MxP/MnP 27.0
LAFH/TAFH 56.5 %
Post-op lateral cephalogram:
12/11/04
6 weeks post-op
Seating elastics worn full time
10 weeks post-op
Debond next visit
Composite build up
UL2
4 weeks post debond
Composite restoration UL2
Summary
15 visits pre-surgery
4 visits post-surgery
Time in fixed appliances = 30 months
Case 3: SA
II/II incisors on skeletal II base with
reduced vertical proportions
Gingival trauma LLS
Full unit Class II buccal segments
Start Study models: Note gingival stripping (LR1, LL1)
Pre-op OPT: Note extensive caries LR6
Pre-op profile
Pre-op lateral ceph
Plan
Extraction lower 1
st
molars
U & L SWA (Roth)
Convert to II/I
Use full size lower 1925SS to enable good
space closure in lower. Some levelling
pre-surgery to allow for space closure and
good interdigitation post surgery.
Mandibular forward slide
Visit 1
Upper arch bonded
U 016 Sentalloy
Owing to recession 1/1, LLS left off archwire, protection with bumpa sleeve
Upper 1925 SS, lower 018SS. Retraction of buccal segments
before engagement of 2/2 to avoid proclination of lower incisors
Pre-op lateral
cephalogram
Pre-op profile
OPAL tracing pre-op
OPAL prediction: Mandibular advancement = 7mm
Post-op profile Post-op lateral ceph
Post-op OPT
Final photos
3 months post
debond
Note healthy
labial gingiva
Case 4: KB
Class III incisors on skeletal I base,
average vertical proportions
KB
Age 16
Previous loss
4/4
SNA = 80
SNB = 76.5
ANB = 3.5
UiMx= 108.5
LiMn= 101.5
MMPA = 32
LFH % = 56
Aetiology
Aims of treatment
Align upper arch
Segmental mandibular surgery
Extract lower 1
st
p/molars
intra-operatively
SNA = 80.5
SNB = 76
ANB = 5
UiMx= 110
LiMn= 97.5
MMPA = 38.5
LFH % = 59.5
Surgery: Hofer type procedure
4/4 extracted at the time of surgery
Anterior segment set back and fixed with plates
Continous archwire placed at the time of surgery
10 weeks
post surgery
SNA = 78.5
SNB = 75
ANB = 3.5
UiMx= 112.5
LiMn= 86.5
MMPA = 35
LFH % = 55.5%
Case 5
II/I incisors on class II skeletal base,
average vertical proportions
R.M.
Severe
crowding
Mandibular
retrognathia
Start Ceph: 06/07/2000
SNA = 78
SNB = 71.5
ANB = 6.5
UiMxP = 120/93.9
Li MnP = 96.5
MxMn= 23.5
Treatment plan
Lip Bumpa
Palatal arch
Extraction all first premolars
U & L standard width system-r brackets.
Roth prescription
Alignment, levelling, correction centre line,
space closure
Mandibular advancement
1st visit:
PA to de-rotate 6/6
Lip bumpa
Extraction 4/4
4/4
3
rd
visit
4
th
visit
5
th
visit: 1/ engaged
Visit 9: U&L 1925 SS
12 months into treatment
Pre-op U&L 2125 SS with ball hooks
SNA = 77.4
SNB = 71
ANB = 6.4
UiMx= 118
LiMn= 93
MxMn= 23.7
SNA = 78
SNB = 76
ANB = 2
UiMx= 116
LiMn= 93
MxMn= 23.9
Pre-op
Post-op