ORTHODONTIC ASPECTS OF

ORTHOGNATHIC SURGERY

V.SHIVA SANKAR

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 CONTENTS

1. INTRODUCTION

2. ENVELOPE OF DISCREPANCY

3. GROWTH MODIFICATION AND CAMOUFLAGE TREATMENT

4. SYSTEMATIC PATIENT EVALUATION

5. EXPANDED FACIAL AND DENTAL ANALYSIS

6. NASAL CONSIDERATIONS IN ORTHOGNATHIC SURGERY

7. COMPENSATION VS DECOMPENSATION

8. PRE SURGICAL& POST SURGICAL OBJECTIVES

9. PREDICTION TRACING& MOUNTING MODELS

10. SURGICAL PROCEDURES AND TREATMENT POSSIBILITIES

11. BIOMECHANCICAL FACTORS IN SURGICAL ORTHODONTICS

12. CONCLUSION

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 ORTHODONTIC ASPECTS OF ORTHOGNATHIC SURGERY

o rthognathic surgery refers to the surgical repositioning of

the maxilla,mandible, and the dentoalveolar segments to achieve facial and occlusal
balance. One or more segments of the jaw(s) can be simultaneously repositioned to treat
various types of malocclusions and jaw deformities.

Correction of dentofacial deformities involves a complex series of orthodontic and

surgical procedures . As orthodontists, look at both the occlusion and
the esthetics when evaluating the success of a surgery. However, the best occlusion will
not satisfy a patient who is unhappy with the esthetic outcome.

The amount of esthetic change desired by a patient can dramatically alter the treatment
plan. It can determine the need for bimaxillary versus single-jaw procedures and whether
adjunctive procedures such as genioplasty, rhinoplasty, or liposuction are necessary

History of the Procedure:

Historically, the ability to reposition the mandible in a stable manner long

preceded the ability to reposition the maxilla. As a consequence, many patients
underwent only mandibular surgery to correct a primary maxillary deformity. The
specialty of orthognathic surgery did not fully develop until Obwegeser demonstrated the
possibility of repositioning the maxilla in a stable consistent manner in 1965 and reported
simultaneous repositioning of the maxilla and mandible in 1970.

Before 1960"s the surgical correction of dentofacial deformities was done either without
patient ever having orthodontic treatment, after orthodontic appliances had been
removed, or, occasionally before any orthodontics was begun.

Orthodontics is an essential part of modern orthognathic surgery. This was stressed by

the surgeon Converse and the orthodontist Horowitz in 1969. It is important that the
dental arches are properly aligned before the operation. At that time, rigid arch bar
constructions, familiar from trauma surgery, were used perioperatively when needed.
Technical development of orthodontic brackets and steel rectangular wires, edgewise
technique, could give excellent and sufficiently rigid control of occlusion to be utilized
also in surgery. The more precise tooth movements allowed finishing of the occlusion
postoperatively.

The introduction of occlusal wafer splint was an important step in allowing surgery to
occur before orthodontic detailing of the occlusion was completed. Consequently, the
total treatment time reduced significantly, when some type of tooth movements could be
more efficiently accomplished postoperatively. (Proffit & White 1991).

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 Severity as an indication for orthognathic surgery:

The envelope of Discrepancy

In 1985, Proffit and Ackerman presented the concept of 3

envelopes of discrepancy.. The “ Envelope of discrepancy” graphically illustrates the
current concepts of how much change can be produced by the various treatment
modalities. The inner circle indicates the limits to orthodontic tooth movement alone; the
middle circle, orthodontic tooth movement combined with growth modification and the
outer circle, surgical correction.
Envelope of discrepancy outlines the limits of hard tissue change
toward ideal occlusion,if other limits due to the major goals of treatment do not apply.
Infact ,soft tissue limitations not reflected in the envelope of Discrepancy often are a
major factor in the decision for orthodontic or surgical – orthodontic treatment.

Facial skeletal growth patterns in the adolescent that often are improved through
orthodontics and growth modification:

1. Mandibular deficiency-Redirection of skeletal growth vectors with headgear is the

most commonly used method. and Functional appliances have the potential to improve
mandibular projection
2. Maxillary horizontal deficiency-Maxillary protraction and nonsurgical advancement
of the maxilla in moderate cases.
3. Vertical maxillary excess—Superiorly directed headgear ,Other therapies,such as
biteblock functional appliances and vertically directed chin cups
4. Horizontal maxillary excess—Retardation of anteroposterior growth with headgear
or through camouflage via premolar extraction and retraction of the anterior teeth.

Areas of skeletal deformity that are not easily improved or corrected by

orthodontics or growth modification:

1. Mandibular Prognathism- In the past, attempts to retard excessive growth of the

mandible have been made through extraoral forces applied via chin cup. Because the
mandible grows by apposition of bone at the condyle and along its free posterior border,
this method is not as successful as the use of extraoral forces to the maxilla. Although the
treatment results from most chin cup cases are often disappointing, they can be quite
effective in cases in which a short-lower facial height is present, because application of
chin cup force can result in a down-and-back rotation of the mandible. Of course, this
means chin cup therapy is contraindicated in the long-face class III patient.

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2. Vertical Maxillary Growth Deficiency-Any control or influence of this growth pattern
is difficult.
3. Chin Deficiency-Relative improvement in chin projection may occur with treatment
designed to increase anteroposterior projection of the mandible, but growth of the chin
point itself is not affected by orthodontic or orthopedic treatment.

Indications for camouflage treatment

.
Craniofacial characteristics only make up part of several important considerations
in determining the effectiveness of camouflage treatment.
Other important considerations include the following:
1. Moderate basal bone discrepancy as determined by conventional cephalometric
standards
2. Double jaw involvement in the discrepancy; that is, 50 % of the skeletal
problem is due to maxillary antero-posterior excess, and the remaining 50% of
the anteroposterior problem is related to mandibular deficiency.
3. Adequate alveolar bone and gingiva for incisor reangulation. Sometimes
gingival grafting procedures are indicated to allow for the compensatory
movements, and this is statistially acceptable to achieve proper incisor
guidance.

Contraindications to camouflage treatment

1. When single jaw imbalances are severe; that is, a patient demonstrates on template
evaluation a skeletal class II malocclusion restulting from l00 % mandibular deficiency .
Although an incisal relationship may be achieved with camoufiage treatment, the
resulting profile would be imbalanced, and upper incisors would be excessively
retroinclined to achieve incisal contact.
2.Skeletal Class II cases with maxillary and mandibular deficiencies (relative to nasal
superimposition)

Proffit et al have provided some guidelines for predicting successful outcome when the
choice between surgical versus orthodontic correction exists for an adolescent beyond the
adolescent growth spurt The conclusion was a satisfactory orthodontic outcome is
unlikely, and therefore surgery is likely to be needed for Class II adolescents beyond the
growth spurt when there is overjet greater than 10 mm. Successful orthodontic treatment
is less likely when excessive overjet is accompanied by any of these findings: (1) the
pogonion to nasion-perpendicular distance is greater than 18 mm, (2) mandibular body
length is less than 70 mm, or (3) face height is greater than 125 mm.
-Profitt ,Seminars in ortho 99

Treatment planning is a vital but often neglected area in surgical orthodontics. This is due
to many reasons which include a lack of understanding of the various modalities of
planning available, paucity of communication between the surgeon and the orthodontist.

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To achieve the objective of restoration of normal jaw function,optimal facial
esthetics,and long term stability,the treatment plan should be,proper,adequate and
feasible.

The major steps involved in treating a case with orthognathic surgery.

Pre treatment records.

Multidisciplinary Diagnosis and Treatment planning.
Presurgical decompensation.
Presurgical records.
Cephalometric prediction tracing.
Model surgery and construction of the surgical splint.
Surgery.
Post surgical orthodontics.

Orthognathic surgery planning starts with step by step method of evaluating a patient
with a dento facial deformity.soft tissue, skeletal,dental components are sequentially
examined to determine the contribution of each patient ‘s esthetic and functional anomaly

PRE SURGICAL DATA BASE

The primary components of the pre surgical database are the

Clinical examination, lateral and anteroposterior cephalometric radiographs, and the
articulator-mounded models.

Important secondary components are panoramic and periapical radiographs (for

interdental osteotomies) and facial and intraoral photographs.

Functional problems related to the patients Temperomandibular joints and

malocclusion are recorded. The orthodontist must note not only the symmetry of the jaws
but also the symmetry of other important structures, such as the eyes and ears.
In examining the profile, the clinician will assess the anteroposterior position of the
maxilla and mandible. In the frontal plane, the clinician establishes, a clinical midline and
integrates diagnostic information in relation to that reference line.
Upper lip support is an important clinical feature. An assessment of upper lip
support will provide the clinician with information regarding the proper antero posterior
position of maxilla relative to facial soft tissues.
Pre surgical radiographs and photographs are also important parts of the presurgical
data base. Facial photographs and cephalograms are taken with the patient holding his or
her head in the same position. Teeth are in light contact and in centric relation.
Information from the three primary components of the presurgical data base, the
clinical examination, the cephalometric radiographs and the anatomically mounted
models - can be integrated, with FM serving as a common reference plane.

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SYSTEMATIC PATIENT EVALUATION

1. General patient evaluation

-Medical history
-Dental evaluation
a)Dental history
b)Dental health
2.Social –Psychologic evaluation
3.Esthetic facial evaluation
-Front face analysis
-Profile analysis
4.Cephalometric evaluation
-Soft tissue
-Skeletal relations
-Dental relations
5. Panoramic or full mouth peri apical evaluations
6.Occlusal evaluation
-Functional
-Static
7.Masticatory muscle and TMJ evaluation
-Masticatory muscles
-Mandibular movements
-TMJ signs& symptoms

Dental health
All indicated restorations are done before orthodontic-surgical
treatment except inlays, crowns, bridges,or partial dentures,which are deffered until the
completion of the orthodontic-surgical treatment.
Osseo integrated dental implants may be employed to restore missing
teeth and /or provide anchorage for orthodontic purposes.
If orthodontic anchorage is lacking from existing natural dentition,it
may be prudent to place implants early in treatment. Conversely if adequate anchorage
exists,but a tooth is missing,implants may be placed at the time of orthognathic surgery or
they may be placed following completion of the surgery.
All acute and chronic endodontic lesions should be dealt with at least three months prior
to surgery and preferably before any treatment starts. The presence of a periapical
infection close to an osteotomy site poses the distinct potential for infection of the wound
and a resultant bony nonunion.
Extracting any impacted third molars adjacent to future osteotomy sites at least six
months prior to the orthognathic procedure to allow adequate time for bony healing and
repair. In some cases, surgeons are comfortable removing the third molars at the time of
the orthognathic surgery. The decision should be based on the degree of impaction, size
of the mandible, and position of the future surgical cuts. However, third molars left in situ
or extracted at the time of surgery have the potential for becoming sources of wound
infection and for interfering with the position and angulation of the surgical bony cuts.
- Peter Sinclair JCO1983 nov

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 Periodontal status
Acute periodontal disease and inadequate attached gingival must be
managed before surgery..
Gingivectomy,Gingivo plasty or bone recontouring is usually best
defeered until completion of orthognathic surgery because the orthodontics and surgery
alter the existing anatomy and the appropriate periodontal procedures can not be
determined until the final anatomy has been produced.

Social –psychologic evaluation

The pychologic make up of the patient is important because,despite
an objectively favourable treatment results,certain patients express dissatisfaction with
their results.this can occur for 2 basic reasons
1. unrealistic patient expectations regarding the results of treatment
2. failure of the clinician to inform the patient realistically of the probable
treatment result.

THE IMPORTANCE OF ESTHETICS IN ORTHODONTIC AND

ORTHOGNATHIC TREATMENT
Treatment decision making may be determined by what is most esthetically appealing
rather than by what the cephalometric norms may be. The expanded facial and dental
analysis is done directly on patient,with the patient maintaining a head posture with the
Frankfort horizontal and inter papillary lines parallel to the floor,because patients with
facial deformities commonly exhibit compensatory head posturing that masks their
deformity and may result in erroneous esthetic measurements.

Facial analysis: the comprehensive systematic assessment of the frontal view

Symmetry,balance and morphology are the 3 major elements that are important in the
production of good front face esthetics.
The proportional relationship of height and width is more important than absolute values
in establishing the overall facial type.

Attractive faces tend to have common proportions and relationships that generally differ
from normative values. The ideal face is vertically divided into equal thirds by horizontal
lines adjacent to the hairline, the nasal base, and menton - Farkas et al

Arnett and Bergman cite a more quantitative evaluation of the vertical thirds of the face,
with the thirds to be between 55 to 65 mm height. The disproportion of the facial vertical
this may be a result of many dental and skeletal factors, and these linear measurements
may help us define the contributing factors of vertical dentoskeletal dysplasia.-Ajo 93

One of the most important measurements guiding the surgical orthodontics is lower face
height to maxillary face height. LAHRMAN 1977 JCO

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Excessive vertical facial proportions -Problems and treatment possibilities
1. Excessive nasal height
• Increase in lower facial height to camouflage nasal proportions
• Rhinoplastic modification of the alar width to affect proportions
2. Excessive lower facial height
a. Vertical maxillary excess –
Orthognathic maxillary impaction to shorten facial height
Clinical keys that may be associated with VME-Long face
Gummy smile, Open bite, Lip incompetence,Steep mandibular plane

b.Excessive chin height

Excessive chin height from lower vermilion to menton Vertical wedge reduction
of the inferior border of the anterior mandible (vertical reduction genioplasty) to shorten
the chin

Clinical keys that may be associated with excessive chin height

Lower facial third disproportionate from the 1/3 upper lip to 2/3 lower lip and chin
ratio with the ratio being closer to 1/4 to 3/4.

Short lower facial height

1.Vertical maxillary deficiency
Orthognathic maxillary downgraft to increase lower facial height.

Clinical keys that may be associated with VMD-short face

Short lower third face height,Inadequate maxillary incisor show at rest and on smile.
Soft-tissue redundancy with labiomental sulcus

2.Short chin height

Short chin height measured from lower vermilion to menton.Normal upper incisor
to lip relations at rest and smile.

The chin may be lenghtened via surgical downgraft of the inferior border osteotomy of
the anterior mandible or with alloplastic augmentation of the inferior border.

Clinical keys that may be associated with short chin height

Disproportionality of the lower facial third from the 1/3 upper lip to the 2/3 lower lip and
chin ratio with the ratio closer to 1:1.

Transverse facial and dental proportions

Facial Widths in the Overall Assessment the Face

The rule of fifths is a method used to describe the ideal transverse relationships of the
face. The face is divided sagittally into five equal parts from helix to helix of the outer

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ears. Each of the segments should be one eye distance in width.The orthodontist should
be familiar with the rule of fifths because it emphasizes more of the total dentofacial
picture than do just the mouth and teeth.

Transverse discrepancies generally fall into two categories, laterognathy and

laterocclusion depending on the facial midline.

Laterognathy is the situation where the dental midlines do not coincide both
in the rest position and in Occlusion.
This usually is due to basal skeletal abnormalities such as unilateral condylar hyperplasia.

Laterocclusion on the other hand, is where the midlines coincide at rest but the
mandible deviates during closure to one side or the other. This situation usually develops
when the maxillary arch is severely constricted.

In Laterognathy cases, a predominantly surgical approach is required. In latero occlusion

patients expansion of the constricted maxilla will usually take care of the mandibular
deviation.

Orthdontic treatment primarily affects the prominence of the teeth and contours of the
lips.Changes in the position of the chin and nose are likely to have a greater impact on
facial esthetics than changes limited to the lips,and the effect of orthognathic surgery on
the lower face extends the esthetic impact of treatment considerably.

Vertical Nasal Problems

Ideal nasal width should be approximately 70% of nasal height (nasion to nasal tip).
According to Baum, nasal length in the mature face should equal the distance from
stomion to menton.

Problems and Treatment Possibilities

Radix deformities
• Deep radix
Augmentation with cartilage from nasal septum, ear concha, or alloplastic
augmentation
• Shallow radix
Difficult to change because of thick bone and thin dermis. (Care in dorsal-hump
removal must be recognized)

Nasal dorsum deformities

• Dorsal hump
Removal of bone and cartilage, often with lateral nasal fractures to narrow
dorsum from frontal view
• Lack of nasal projection
Augmentation with cartilage taken from nasal septum or ear concha, bone grafts
with corti cal bone, or alloplastic augmentation

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 Nasal-tip deformities
• Amorphous tip
Tip alar modification via “Goldman tip” procedure
Refinement of the supratip

NASOLABIAL ANGLE
Acute nasolabial angle:
Options for improvement
1. Maxillary procumbency & Maxillary dental protrusion

Adolescent
Retardation of anteroposterior maxillary growth via headgear, or extraction of
premolars with anterior dental retraction with orthodontic therapy
Adult
Extraction of premolars and anterior dental retraction with orthodontics or
orthognathic retraction.

2.Low nasal-tip position

Rhinoplasty for vertical nasal tip positioning
3.Thick maxillary lip
Reduction cheiloplasty

Obtuse nasolabial angle

1. Maxillary retrusion& Maxillary dental retrusion

Maxillary protraction or incisor advancement if possible.

Maxillary advancement, as in the case in which the nasolabial angle has been flattened
due to orthodontic extraction and retraction .

If the incisors are upright, reverse headgear may be used to protract incisors.
2. Elevated nasal tip
Rhinoplasty is an effective treatment option

3.Thin maxillary vermilion

Lip “plumping,”

Lip-Chin- Throat Angle

The angle between the lower lip, chin, and R point should be approximately 90
degrees. An obtuse angle often reflects
• Chin deficiency-. Chin augmentation via inferior border osteotomy
• Lower lip procumbency- Orthodontic/ Surgical retraction of lower incisors
• Excessive submental fat -Submental liposuction, Platysmal lift
• Retropositioned mandible- Advance mandible surgically or through growth
modification

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 Lip-chin-throat length
Short lip-chin-throat length
Mandibular advancement via growth moditication or surgical mandibular
advancement
Chin advancement via inferior border ostcotomy
Chin advancement with alloplastic augmeuntation

Chin-neck angle
Obtuse angle: anything that advances the genial tubercles
• Mandibular advancement • Chin advancement • Submental liposuction
• Hyoid suspension • Subplatysmal resection

Lip projection
Full lips
• Bidental protrusion& Maxillomandibular protrusion
Orthodontic/surical retraction of anterior teeth (camouflage)
Advancement genioplasty to balance profile (camouflage)
• Thick lips
Reduction cheiloplasty

Labiomental sulcus
Deep labiomental sulcus
Protrusive and/or proclined lower incisors
Orthodontic retraction of lower incisors
Excessive chin projection
Surgical chin reduction via interior border osteotomy
Orthodontic treatment designed to produce down-and-back rotation of the
mandible to deemphasize chin projection and increase lower facial-height
Reduced vertical facial-height relations
Increase in lower facial height (orthodontically in the growing patient or
surgically in the adult surgical increase in chin height.
Over jet
Orthodontic reduction in overjet via extraction and retraction or nonextraction
growth modification& surgical mandibular advancement or maxillary retraction

Shallow Labiomental sulcus

• Retrusive and/or retroclined lower incisors
Orthodontic advancement of lower incisors
• Insufficient chin projection
Surgical chin advancement via inferior border osteotomy
Orthodontic up-and-forward rotation of mandible to emphasize chin projection
and decrease lower facial height
Alloplastic chin projection augmentation
Chin augmentation via inferior border osteotomy
• Vertical facial-height relations

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 Decrease in lower facial height (orthodontically in the growing patient or
surgically in the adult)
Decrease in chin height a surgical solution by wedge reduction via interior
border osteotomy

Nasal considerations in orthognathic Surgery

Stephen A. Schendel, and Albert E. Carlotti, Ajo 91 sep

The specific nasal evaluation begins with the identification of external

landmarks.From the frontal view, the root or radix of the nose should have a smooth,
uninterrupted curve along the lateral aspect of the nose into the eyebrow . Inferiorly, this
curve connects the dorsum of the nose with projections of the alar cartilages. Any
interruption of this smooth, gentle curve is readily identified.
The domes of the alar cartilages should be both symmetric and of equal distance from
the midline. Their width and angle of divergence determine the broadness or narrowness
of the tip of the nose. Nasal dorsal width is determined by the nasal bones and upper
lateral cartilages and should balance with the tip and total facial width generally
measured at the zygomas.
The columella protrudes slightly downward beyond a horizontal line drawn through the
nasal bases in the facial view . A retracted columella, one that does not protrude beneath
the base of the ala, is evaluated by this method. The base of the nose normally has a
classic "gull wing" shape in the frontal view

MAXILLARY SURGERY AND THE NOSE

Maxillary surgery— more specifically, the LeFort I osteotomy— results in significant
nasal and labial changes. Typically, there is widening of the base of the nose and
associated flattening and thinning of the upper lip, especially noticeable in loss of the
visible vermilion border. Nasal changes most often associated with maxillary osteotomy
include increased nasal-tip projection, increased nasal-tip rotation, increased nasolabial
angle, and increased alar-base width

Nasal widening that is almost universally found after maxillary osteotomies is only
partially dependent on the amount of skeletal movement. Most important is the amount of
subperiosteal dissection and elevation accomplished, which with most surgical techniques
involves the total face of the maxilla. This disinserts the facial muscles from the
nasolabial area and the anterior nasal spine. They are thus free to retract laterally, since
muscles normally shorten when elevated. This lateral retraction then results in flaring,
widening, and elevation of the base of the nose, which is frequently asymmetric .

Subsequent to this, there is also thinning of the upper lip with lateral movement of the
tissues and the loss of vermilion show because of inrolling of the lip. These are similar to
some of the changes seen in the aging face and may cause patients to appear much older
after surgery. After maxillary impactions there is also a tendency for the tip to rise. Any
humping of the nose or dorsal kyphosis is lessened and frequently disappears in minor
cases because of elevation of the nasal tip and base.

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 Maxillary surgical retraction usually results again in widening of the alar bases with a
tendency for the tip of the nose to rotate downward and back, the nasolabial angle usually
opening . This may result in an appearance similar to a parrot's beak nasal deformity,
where the tip of the nose lacks any supratip break or a break at the junction of the lobule
and columella.
Maxillary downgrafting may have similar associated changes and also may demonstrate
inferior retraction of the alar bases followed by a secondary appearance of a retracted
columella. Although lip length may remain unchanged, it frequently shortens or
occasionally lengthens with all these procedures.

There are two basic approaches to rhinoplasty: the closed rhinoplasty and the open
rhinoplasty. The closed rhino plasty is characterized by an intranasal approach.

The open rhino plasty is characterized by a transcolumellar incision that provides

superior access of the nasal structures and anatomy..

Rhinoplasty cannot be performed until nasal maturation is complete, which is generally

age 15 in females and even later in males.
Treatment decisions on class III malocclusions may have to be delayed until the severity
of the growth pattern has been determined. This conclusion is often made after periodic
cephalometric observation to decide whether the patient represents a surgical problem or
not

Indications for simultaneous orthognathic surgery and rhino plasty

- Functional nasal septal deviations .

- Minor defects of the nasal tip and or alar base morphology can appear.
- Major abnormalities of the nose can arise, particularly in cases of excessive nasal
dorsal projection.
-Surgical maxillary movements may worsen the appearance of the nose. The most
common problem encountered includes widening of the alar base. The LeFort I
osteotomy often produces an increase in alar width, and in most cases this produces an
unesthetic change in the nose.
-The saddle-nose deformity

Contraindication for simultaneous surgery

- Minor correction of tip position—Fine detail and exact tip position are difficult to
predict even in isolated rhinoplasty. Treatment for overprojected, overrotated, and ptotic
nasal tips is difficult when maxillary movements alter the nasal base.

Indications for staged rhinoplasty and orthognathic surgery

Detailed correction of minor nasal deformities

Nasal deformities that are only slightly beyond normal or defects that are slightly
noticed or only de tected by critical analysis are best treated by a staged procedure that
permits the finest detailing possible.

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Effects of orthognathic procedures on neck esthetics in presence of fullness or
lipomatosis
Improve
Mandibular advancement,Genioplasty,Maxillary superior repositioning
Worsen
Mandibular set back,Reduction Genioplasty,Maxillary inferior repositining
Noeffect
Maxillary advancement ,Mandibular total sub apical osteotomy.

Pre surgical Orthodontics

Pre surgical orthodontics is required in almost all patients awaiting orthognathic
surgery. The aim of this phase of orthodontics is to;
1. Correct dental interferences
2. Dental de compensation - to bring the teeth into proper axial relationship to
the supporting basal bone.

On mandibular corrections, majority of orthodontics will be done before surgery due to

the excessive amount of dental compensations present.
On the maxillary surgery, eliminate gross dental interferences.
On segmental maxillary osteotomies, the majority of the orthodontics will be done
postsurgically
RUTKOWSKI 1979 june jco

Surgery
After completion of pre surgical orthodontics, surgery can be undertaken.
The Orthodontist contributes to the surgical procedure by:
1. Fabrication of surgical positioning splints (intermediary & final splints in
two jaw surgery)
2. Provision of fixation points on the orthodontic appliances to facilitate intra
operative and / or post-operative maxillo-mandibular fixation
3. Reviewing the patient during the Immediate post-operative phase for elastic
guidance of the occlusion if so indicated

Post — Surgical Treatment

The final phase of treatment aims at:
1. Stabilization of the occlusion
2. Retention
3. Assessing relapse.

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Compensation vs Decompensation

In many cases of severe jaw imbalances and the resulting malocclusion, the
teeth are inclined in such a manner as to partially offset the discrepancies.

In a mandibular prognathism case, for e.g. the lower incisors may be upright or
tipped lingually to compensate for the protrusion of the mandible, and vice versa in a case
of mandibular retrognathism.

Thus, the nature tends to compensate for the deficient jaws by proclining or
retroclining the antcrior teeth. This is called as compensation.
Pre surgical orthodontics should be aimed at removing this natural
compensation or to decompensate.
In a mandibular prognathisrn case for e g. presurgical orthodontics should bring
the retroclined lower incisors into the ideal axial inclination by proclining them. Like
wise, when the mandible is relatively small natural compcnsation should be
decompensatcd by retroclining the lower antcriors often with removal and retrusive,
the of one or more teeth.
The decompcnsation makes the maxillomandibular dental relation temporarily worse, that
is why, it is called “Reverse orthodontics”.

Rationale For Decompensation

To position the teeth in an ideal axial inclination with respect to the jaws.
To optimise the magnitude of surgical advancement or repositioning.
For better aesthetics, stability and function.
If malpositioned anterior teeth are not corrected, they may hinder the repositioning
of the jaws at the time of surgery..

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ORTHODONTIC CONSIDERATIONS.

Appliance system:
In surgical orthodontic treatment, the fixed orthodontic appliance is used to
stabilise the teeth and basal bone at the time of surgery and during healing.
For this reason, the appliance system should permit the use of rectangular wires
for strength and stability. Any of the variations of the edgewise appliance and the
combination Begg edgewise appliance are acceptable.
The standard Begg appliance does not provide the control needed, even though
a ribbon archwire and special retaining pins can provide some additional stability. The
other problem of using the Begg appliance is anterior and molar torque control is not
possible which is very important in surgical cases because it may alter the amount of
surgical corrections both anteroposteriorly and transversely.

Orthodontic treatment objectives.

The orthodontic treatment objectives for an orthognathic case in the vast

majority of cases are entirely opposite to those that might be employed if the case where
to be treated by conventional orthodontic methods alone .In addition it is often found that
the extraction pattern demanded in an orthognathic case is the reverse that is seen in a
comparable orthodontic case. For instance the classic pattern of extracting the upper first
premolar and lower second premolar in a conventional class II case might be replaced by
a pattern that requires extraction of upper second premolar and lower first premolar if the
case where to be treated orthognathically.

PRE SURGICAL OBJECTIVES. JCO 1989 Jun MICHAEL G. WOODS, ,

JAMES Q. SWIFT

This is further subdivided into a) lntra-arch objectives, b) Anteroposterior

objectives, c) Transverse objectives, and d) Vertical objectives.

Intra-arch objectives.

In the initial phase of treatment, orthognathic and conventional orthodontic

mechanics have some similar objectives. Correction of arch length deficiencies,
elimination of rotation and overall arch alignment are all common features. However
levelling and coordination of the arches, common features of conventional therapy are
not automatically carried out in every orthognathic cases.
Intra-arch mechanics in orthognathic cases should designed to achieve the
ultimately desired postsurgical interdigitation and allow for class I canine and molar
relationships after surgical treatment. Acheivement of these objectives will require that
the maxillary and mandibular teeth to be positioned in an ideal relationship 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 revealed.

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 If extraction are necessary to accomplish the desired objectives, then the
extraction sites should closed, unless segmentized surgical closure is planned. In
orthognathic cases it is necessary to establish the correct incisor and molar torque prior to
surgery because if delayed until after surgery, it may tend to cause relapse, such as the
return of openbite. Tooth size discrepancies should be identified and eliminated.
Anteroposterior objectives.
In most malocclusions these dental compensation are manifested in all three
planes of space but 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 class III
cases the mandibular incisors are commonly seen to be retroclined while the maxillary
incisors are flared forward. Since the presurgical objectives in orthognathic cases include
positioning. the incisors in axial relationships that are as ideal as possible, it will often be
necessary to decompensate the incisors with orthodontic mechanics. Thus when the
surgical procedure is carried out the jaws can be correctly positioned with minimal
interferences from the occlusion.

Achievement of these objectives will often necessities the use of class III elastics in
class II patients to upright the mandibular incisors and reciprocally advance the maxillary
molars. Conversely in a class III patient class II elastics might be used to retract the
maxillary incisors and to bring the mandibular molars forward.

Similar principles apply to anchorage requirements. In class II cases the greatest

anchorage requirement is in the mandibular arch for the retraction of the usually
proclined incisors. Conversely the class III cases often require maximum anchorage in
maxilla and minimal anchorage in the mandible in association with pattern of
extractionof maxillary first premolars and mandibular second premolars.

18
Transverse objectives.

First, it is essential to determine whether the problem is skeletal or dental in

nature. This determination cannot be based on the patients diagnostic cast in their original
centric occlusion relationship. The study models should be hand articulated into the
anticipated postsurgical class I canine relationship in order that transverse dimension
problems may be accurately diagnosed.

Most patients with skeletal class II malocclusion will not exhibit transverse
problems in their pretreatment centric relationship. When the casts are manipulated to a
class I canine relationship however there may be an absolute transverse maxillary
deficiency (i.e. bilateral palatal cross bite) which must be corrected. Conversely many
patients with skeletal class III malocclusion exhibit a pretreatment bilateral crossbite.
This relative transverse maxillary deficiency is corrected when the study models are
repositioned into a class I canine relationship.

Skeletal discrepancy should not be masked by compensatory dental movements. Such

procedures like expansion through headgear, arch wire or elastic therapy are not
recommended because these procedures have high relapse potential and compensations
such as tipped molars and premolars should be corrected and the correct buccal segment
torque should be established prior to surgery.

19
In cases in which there is an isolated skeletal transverse discrepancy and no other
maxillary surgery is anticipated, a lateral maxillary osteotomy followed by rapid palatal
expansion may be the procedure of choice.
Where a skeletal maxillary discrepancy is combined with other maxillary problems,
multiple segmental maxillary procedures are indicated. To avoid building, in adverse
relapse potential, the application of segmental arch orthodontic mechanics is advisable
prior to segmental maxillary surgery. The individual archwire segments should
correspond to the anticipated surgical segments as determined by the patients
malocclusion and archform.

Vertical objectives.

The two principal objectives of orthognathic mechanics in the vertical plane

prior to surgery are 1) the avoidance adverse relapse potential 2)the maximizing the
speed and efficiency of treatment.

In cases in which anterior facial height is to be reduced surgically, the major

portion of orthodontic tooth movement should be accomplished prior to surgery. When
the open bite has resulted in only minimal to moderate curves in either arch the use of
continuous arch wire and presurgical leveling is indicated.

To avoid excessive extrusion or intrusion of teeth and potential adverse relapse

tendencies careful considerations should be given to surgical rather than orthodontic
correction of severely accentuated or reversed curve of spee.
Segmental orthodontic therapy should be carried out when necessary, possibly in
both maxilla and the mandible, prior to corresponding segmental surgery.

In those patients who exhibit a deep bite tendency and short anterior facial
height, the major portion of the orthodontic mechanics, especially relative to the leveling
of the mandibular occlusion plane, should be postponed until after 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 bite.

20
 This treatment sequence tends to enhance the stability of mandibular advancement
procedure since the presence of deepbite presurgically will facilitate the introduction of
an open in a component of rotation of the mandible during the advancement which is
more stable than straight forward or closing rotation.

Objectives during surgery, fixation and immediately post fixation

Immediately prior to surgery, the orthodontist should take a complete set of

presurgical records. These records should include accurate models for stimulating model
surgery and for splint fabrication, a centric relation recording, face bow transfer and
mounting where indicated, a cephalometric head film in centric relation with lips relaxed
and facial as well as intraoral photographs.

The face bow transfer and mounting on an adjustable articulator are advisable in
cases exhibiting significant asymmetries as well as in cases requiring maxillary and/or
combined maxillary and mandibular procedures. Only in this way can model surgery
adequately stimulate the necessary surgical moves and resulting mandibular anatomic
response.

Following model surgery and approval of the anticipated post operative

occlusion a surgical splint is fabricated.

It is essential that the orthodontist have placed his surgical arch wires atleast 4-6
weeks prior to taking the presurgical records. Heavy rectangular arch wire filling as much
of the slot as possible with full engangement are most often used in the maxilla, either as
an continuous arch wire or in segments where this is indicated. In the mandible a similar
wire is use,’where anterior face height is to be decreased so as to provide maximum
stability since little post operative mechanotherapy should be required.

Immediately after the removal of the fixation and the splint, the patient should be
seen by the orthodontist. At this appointment he should superimpose the cephalometric
head films taken before surgery, immediately after surgery and at the release of fixation.
Analysis of the changes seen will enable the clinician to identify precisely what surgical
changes occurred and also the nature and extent of relapse during fixation. This
knowledge is vital in planning the post surgical phase of treatment.

In most cases after the removal of the fixation the patient should be placed on
full time elastic therapy, until healing allows the use of normal orthodontic mechanics to
be resumed. Light elastics should be placed in triangular or box formation with only a
slight, if any, class II or class III vector.
The use of these short elastics will minimize the tendency to cause molar extrusion
and hence open the bite or cause a CO-CR discrepancy, while effecting, maximum
occlusal interdigitation.
A continuous arch wire should be placed in the maxilla if segmental surgery has
been performed. In addition teeth can be ligated across the osteotomy site, particularly if
any mobility remains in the segments. Where cross arch stability is required following.,

21
expansion, an expanded transpalatal arch which exerts a force of 3-4 ounce in maxilla
and a lingual arch in the mandible have proved effective.

Post surgical 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.
An ideal overjet and overbite with a mutually protected occlusion where CO equals CR
should be obtained. Establishment of correct parallelism is important, particularly in
segmental cases where the roots of the teeth adjacent to the osteotomy sites should be
kept divergent so as to provide an additional interdental space for the surgical cuts. Once
the orthodontist feels that finishing is complete, the patient is placed in passive arch wires
without any elastics for one appointment.

PREDICTION TRACINGS AND MODEL SURGERY

Presurgical predictions are important tools to demonstrate possible postsurgical results.

They serve as an instrument for patient communication and provide a goal for operative
treatment planning.Whatever the method for establishing these predictions—acetate
layouts, landmark digitizations and line drawings, digital imaging, and soft tissue
morphing—the accuracy of the prediction ultimately depends on the algorithms used to
define the response of the soft tissue to the bony change, not on the technology used to
project the possible result.

Prediction tracings are limited to two dimensions and are inherently distorted.
Conventional cephalometric x-ray equipment produces images that are generally 10 per
cent enlarged.

Surgical-Orthodontic Cephalometric Prediction Tracing Epker and fish JCO 1980

Why do prediction tracings for mandibular surgery?
1 ) to accurately assess the profile esthetic results which will result from the proposed
surgery
2) to consider the desirability of simultaneous adjunctive procedures such as genioplasty,
suprahyoid myotomy, etc.,
3) to help determine the sequencing of surgery and orthodontics
4) to help decide what type of orthodontics might best be employed (i.e., extraction
versus non-extraction)
5) to determine the anchorage requirements should extraction treatment be chosen.

I. Cephalometric Prediction Tracing for Mandibular Advancements

Step 1 - Trace the Stable Structures.
Step 2- Add skeletal structures changed by surgery.
Step 3- New A-Po line.
Step 4- Placing the teeth.

22
Step 5- Tracing the new lip contours.

II. Cephalometric Prediction for Maxillary Superior Repositioning.

Step 1-Trace the stable structures
Step 2-Determination of ideal vertical position of upper incisors
Step 3-Auto rotation of the mandible
Step 4-Genioplasty determination
Step 5-Placement of teeth in ideal position
Step6-Nasal outline
Step7-Upper lip
Step 8-Lower lip
Step 9-Chin

III. Cephalometric prediction tracing for combined maxillary and mandibular cases.

Step 1 - Trace the Stable Structures .

Step 2 - Determine the Ideal Vertical Position for the Upper Incisor.
Step 3 - Autorotation of the Occlusal Plane.
Step 4 - Mandibular Movement.
Steps 5-10 - Completing the Tracing..

When making a prediction tracing, the planning surgeon and orthodontist will manipulate
two-dimensional drawings, or “cut outs”, of the maxilla or mandible or, both. Prediction
tracings allow the surgeon to perform trial surgery and test the potential benefits of a
particular surgical plan. In the case of isolated mandibular surgery, the distal mandible is
positioned in its estimated post surgical position with the maxilla.

In isolated maxillary surgery, the estimated occlusal relationship between the maxilla and
mandible is established, and the maxilla is auto rotated on mandibular tracings, around
the hinge axis of the mandible, to its planned vertical position. In two-jaw surgery, the
surgeon first places the maxilla in its new position and then trings the mandible to it,
Prediction tracings allow the clinicians to estimate both dental and bone
changes.ln the case of twojaw surgery, the surgeon may wish to change the vertical and
anteropostecicr positions of the incisor teeth. By manipulating the predictior~-tracing
cutout, the clinician can change both the tooth-to-lip relationship and the upper lip
support. Vertical changes of the second molars in combination with vertical changes of
the incisors will determine the occlusal plane.

Predicting soft tissue changes in maxillary impaction surgery: A comparison of

two video imaging systems Angle 1997
Glenn T. Samishema.& sinclair evaluated the accuracy of two video imaging systems,
Orthognathic Treatment Planner (OTP) and Prescription Portrait (Portrait), in predicting
soft tissue profile changes after maxillary impaction surgery. Computer-generated line
drawing predictions were compared with actual postsurgical profiles.
Neither program was very accurate with vertical measures and lower lip contour.

23
Portrait was more accurate at pronasale, inferior labial sulcus, and pogonion in the y-
axis direction . Video image predictions produced from the presurgical photographs were
rated by orthodontists, surgeons, and lay people, who compared the predictions with the
actual postsurgical photographs using a visual analog scale.
Portrait’s prediction images were scored higher than OTP’s for five of eight areas.
Orthodontists were most critical of the lips and the overall appearance. Lay people were
most critical of the chin and submental areas.

Predicting lower lip and chin response to mandibular advancement and genioplasty
Trevor &Peter H. Buschang, Ajo dec 02

This retrospective study were to examine the soft tissue changes associated with
mandibular advancement and genioplasty and to develop predictive models. Longitudinal
lateral cephalograms of 62 nongrowing patients (27 men and 35 women) were taken in
centric relation with the lips in repose within 4 weeks before surgery and at least 6
months postoperatively. The mandibular incisor and pogonion were advanced surgically
approximately 6 mm and 11 mm, respectively. The lower lip lengthened slightly (2.5 -
3.8 mm), and its surface contour straightened because of thinning at labrale inferior (2.8 -
2.0 mm); there was a slight thickening at the labiomental fold (1.0 - 2.3 mm) and a slight
thinning at soft tissue pogonion (0.8 - 2.2 mm). Multiple regression models showed that
soft tissue response to advancement surgery depended on pretreatment tissue thickness,
horizontal skeletal movement, vertical skeletal movement, and the position of the
maxillary incisors.

Lines and Steinhauser, who were among the first to attempt prediction in this area,
concluded that the lower lip advanced at a 0.66:1 ratio to the mandibular incisor
advancement, and soft tissue pogonion advanced at a simple 1:1 ratio to hard tissue
pogonion advancement. Other studies have confirmed the 1:1 ratio for soft tissue
pogonion,but predictive ratios for the lower lip have been highly variable,
ranging from 0.26:1 to 0.85: 1

Computer assisted orthognathic surgical treatment planning:

John Eastman . Angle 1992
In 1972, McNeill was the first to describe the use of surgical cephalometric prediction
tracings.

Bell, Profitt, and White proposed the use of cephalometric prediction using templates to
complement model surgery changes, to predict changes in bony relationships not seen on
the dental casts, and to predict soft tissue changes.

Ricketts and Walker were among the first to publish their experiences using computers
for cephalometric analysis. Their efforts were directed at clarifying facial changes in the
growing individual.
Schendal, et. al. looked at soft tissue changes of the orthognathic surgery patients and
reported mean values based on data from digitized pre and postoperative lateral
headfilms.

24
Bhatia and Lowery described an interactive on-line computer analysis program that
collected, stored, and analyzed data from cephalometric radiographs. Their program
diagnosed dental and skeletal deformities and predicted posttreatment soft tissue profile
changes.

Harradine and Birnie, and Walters and Walters reviewed free-hand and photographic
cutting techniques and compared them to computer-based methods of predicting the
results of orthognathic treatment.

Video imaging represents a major addition to the role of computers in orthognathic

surgery. Sarver, et. al described his experiences with a video imaging system that
permitted the manipulation of photographic images to coincide with proposed hard tissue
movement of orthodontic treatment and surgery. He noted favorable patient acceptance.
Thomas, et. al. also noted the favorable response by patients to video imaging

Simple hinge and semiadjustable articulators – Marko AJO-DO 1986 Jul

Advantages of face-bow:
1. It registers the anteroposterior position of the maxillary cast with respect to the hinge
axis of the mandible.
2. It aids in the vertical positioning of the casts with respect to a chosen horizontal plane
of reference.
3. It permits a more accurate simulation of excursive movements of the mandible when
combined with condylar guidance wax check-bites.
INDICATIONS FOR THE USE OF A SIMPLE HINGE ARTICULATOR
1. The anteroposterior and vertical orientation of the anterior maxilla is determined first
by cephalometric measurements.
2. The feasibility of autorotation of the mandible is studied first by cephalometric
measurements.
3. The maxillary occlusal plane is not canted significantly.
4. Tripod occlusal stability exists between the maxillary and mandibular models (that is,
no large edentulous spaces are present that prevent proper model orientation).
Having noted the constraints under which a hinge articulator must be used, the
indications for its use are as follows
1. Mandibular advancement, setback, or subapical surgery
2. Maxillary subapical surgery (when no changes in the vertical plane of space are
proposed)
3. Maxillary transverse expansion or contraction.

INDICATIONS FOR THE USE OF A FACE-BOW AND SEMIADJUSTABLE

ARTICULATOR
1. When the case fails to satisfy the constraints listed under indications for hinge
articulators
2. Maxillary impaction and mandibular autorotation (including feasibility studies)
3. Fabrication of an intermediate splint
4. To ensure coincidence of dental and facial midlines

25
5. Mandibulofacial asymmetries
6. When excursions of the proposed occlusion are to be studied
It can be seen that canted occlusal planes and edentulous spaces require full three-
dimensional control during planning and surgery— hence the need for a facebow and
semiadjustable articulator with models oriented to the. Frankfort plane or true postural
horizontal plane.
Asymmetries often demonstrate canted maxillary occlusal planes. However, growing
asymmetry patients can occasionally be treated with unilateral ramus surgery,which can
easily be simulated on a modified semiadjustable articulator.

MOUNTING DENTAL MODELS FOR SURGERY

The use of anatomic articulator in treatment planning allows the
manipulation of the maxillary and mandibular models in three planes of space within the
articulator. When the models are correctly mounted, this manipulation will be analogous
to surgical movements of the jaws within the facial skeleton. The functional and esthetic
implications of this procedure are clear.
An anatomic articulator is the 3 dimensional analogue of the 2 dimensional
cephalometric radiograph. Currently, work is being done on correlating model surgery
movements with computerized cephalometric analysis and prediction tracing programs.
In mounting dental models on an anatomic articulator, the purpose of any face
bow transfer procedure is to reproduce accurately the functional and spatial relationship
of the jaws. All transfer techniques attempt to obtain a hinge-axis mounting.
With a hinge-axis face bow transfer, special techniques are used to ensure that
the intercondylar axis of the patient coincides with the intercondylar axis of the
articulator. The “arc of closure” of the mandibular model on the articulator will very
closely simulate the real mandibular arc of closure over a given range .

Some clinicians would argue that a hinge-axis transfer should be done in all cases of total
maxillary surgery, whether isolated or in combination with mandibular surgery. The
greater vertical change (vertical maxillary change and increased mandibular
autorotation), the more important a hinge-axis mounting becomes.

In isolated mandibular surgery, a hinge-axis transfer will have no advantage over an

arbitrary face bow mounting. When used in conjunction with the Model Platform and
Model Block, an anatomic mounting for isolated mandibular surgery will allow an
accurate correlation between jaw movements on the prediction tracing and those on the
mandibular.model.

The SAM face bow is best suited for surgical cases. The modifications
of the surgical face bow include an adjustable nasal rest and infra orbital pointer. The
vertical position of the nasal rest is adjustable.
Care should be taken to mount the maxillary model as close as possible
to true natural horizontal plane (HP; HP = FH). This practice will allow a common
reference plane for interrelating the mounted models with the cephalometric prediction
tracing. The degree to which the HP of the prediction tracing and the (HP = FH) of the
mounting correspond will affect the accuracy of the final model surgery and ultimately

26
will transfer the planned movements to the surgical site.

The mandibular cast must always be mounted to (related to) the maxillary cast, with
attention paid to the position of the mandibular condyles.
A centric occlusion position - a solely tooth-dictated position - is frequentlyhabitual
rather than anatomic and is insufficient. When mounting the mandibular model, a wax-
bite registration is taken that relates the mandible to the maxilla independent of the
occlusion

MODEL SURGERY

The primary goal of model surgery is to accurately simulate the patient’s facial structures
both functionally and spatially. Mounted models can be used to predict hard tissue
changes in much the same way, as do prediction tracings.

THE MODEL PLATFORM AND THE MODEL BLOCK

The model platform and the model block are capable of accurately measuring
articulator-mounted models in three planes of spaces. This feature allows the clinician
planning to carry out accurate model surgery movements on a full-sized anatomic
articulator.

The Model Platform is a measuring instrument

The Model Block is an orientation block that is used with the Model Platform. Models
are mounted on the Model block in the same way they are mounted on a full sized
articulator .

The Model Block will accurately transfer the orientatiton of the model to the measuring
platform. With the Model Block of its base, reproducible vertical measurements can be
made. With the Model Block on end, reproducible anteroposterior measurements can, be
made. By manually changing the Model Block cn the platform, the surgeon can quickly
measure and re measure any point of interest, either dental or bone, on the case. The
electronic caliper inserted into the base of the platform is able to obtain an appropriate
level of precision .

Innovations in Orthognathic Splint Construction - BRIAN W. WONG, D JCO 1985

OCT

A true hinge facebow recording is taken with a SAM Axiograph. Because orthognathic
splint construction relies on a highly accurate "jaw hinging" or autorotation effect, an
inaccurate or arbitrary axis location will yield an unpredictable splint .

27
One set of models is mounted on a SAM II Articulator, using the Axiograph facebow axis
recording, and referenced to the patient's centric relation by using an accurate centric
relation interocclusal registration. The mounted models become the permanent record of
the patient's occlusal relationship, jaw relationship, and true hinge-axis location.

Centric relation is recorded with the "Roth Power Centric Technique" , which relies on
the patient's own jaw-seating musculature to help seat and center the condyle-disc
assemblies in their respective fossae. This reproducible technique is based on the concept
of applying resistance to the closing muscles at the level of the anterior teeth, .

Delar blue wax strips are used for bite registration..

Orthognathic Occlusal Relator System

A new instrumentation system for mock-surgical repositioning is based on an

Orthognathic Occlusal Relator— consisting of micro-adjustable plates, fossa extensions,
and a long incisal guide pin— which is mounted on a SAM II articulator . The patient's
centric relation is captured with the wax bite registration on the original mounted models
and duplicated on the Orthognathic Occlusal Relator, using the Reference Split Cast
technique.

The Reference Split Cast is used to align the Orthognathic Occlusal Relator so that its
axis location is identical to that of the original models.

The Reference Split Cast is mounted on the articulator . Once the Reference Split Cast is
properly mounted, the alignment pins are removed. The Orthognathic Occlusal Relator is
aligned by attaching it to the upper member of the articulator. The lower section of the
Reference Split Cast is attached to the lower member of the articulator as before, and the
upper section is attached to the Orthognathic Occlusal Relator. When the Orthognathic
Occlusal Relator is aligned with the Reference Split Cast, it duplicates the original
alignment and axis location of the articulator.Interim Splint Construction Red
Orthognathic Surgery Hard Acrylic is used to construct the interim splint.

28
 Maxillo facial deformities Craniofacial.orthognathic surgery
eMedicine-july 2004
Sagittal problems

Vertical problems

29
Mandibular deformities

Surgical procedures and treatment possibilities

Correction of Anteroposterior relationships

Maxillary surgery
Lefort I down fracture,is used to reposition the maxilla.
If maxilla is advanced,a graft in retromolar area or at a step created in the lateral wall
usually is required. Posterior movement of the entire maxilla is difficult.,other skeletal
components supporting the maxilla interfere with moving it back
In maxillary advancements the possibility of relapse and speech alteration from
nasopharyngeal incompetence increases with larger movements

Mandibular Advancement

The sagittal mandibular osteotomy under local anesthesia and intravenous sedation:
Four years of multicenter experience -Raffani et al Int J Adult Orthod Orthognath Surg 02;

Raffini et al designed a protocol to be followed in a multicenter study (Milan and

Barcelona) and applied it in 35 clinical cases with Class II malocclusion. The surgical
procedure was performed with the Monitored Anesthesia Care technique, a combination
of regional anesthesia and intravenous sedation.
This initial sedation is achieved with a combination of a benzodiazepine, short-lasting
narcotics, and ultrashort-acting hypnotics .
Soon after the initial sedation, the surgeon injects the local anesthetic (Marcaine plus
epinephrine 1:50,000, ) at the level of the lingula and the buccal and lingual side of the
ascending ramus and the buccal side of the body of the mandible. Since this is done

30
bilaterally, both regional block of the inferior alveolar, buccal, and lingual nerves, as well
as infiltrative anesthesia, are achieved.
The major advantage of this technique is the functional control of the
temporomandibular joint, which avoids displacements caused by gravity and the
muscular relaxation commonly seen under general anesthesia

BSSO Advantages:
The osteotomy design provides a broad interface of medullary bone for
rapid healing.The overlapping of the two segments allows easy rigid internal fixation
with screws and problems with postoperative instability are rare.

The greatest drawback of the sagittal split is altered sensation post operatively.Some
stretching and retraction of the inferior alveolar nerve are necessary to place the
osteotomy cut, and as a result ,Paresthesia is almost present.Usually it disappears in 2-6
months.
Anterior movements of the mandible greater than 10-12 mm create considerable tension
in the investing soft tissues and tend to be unstable.

Tridimensional planning for surgical/orthodontic treatment of mandibular excess –

Bell and Jacobs Ajo 81 sep

Schulhof, Nakamura, and Williamson have identified four cephalometric "predictor

measurements" to distinguish between normal growth and abnormal growth manifest by
persons with true mandibular prognathism. The aberrant measurements included
decreased cranial deflection (decreased growth from basion to nasion), anterior ramus
position, anterior porion location, and a Class III molar relationship. When such findings
are revealed by sequential cephalometric monitoring, extractions for orthodontic purposes
and surgical intervention are usually deferred until completion of the pubertal growth
spurt. Ajo 77

Presurgical orthodontic objectives

Sagittal dimension
In the sagittal dimension, eliminate all dental compensations preoperatively and thus
obtain proper incisor position in both the mandible and the maxilla prior to surgery.
Class II mechanics and worsening of the anterior cross-bite proportionately to the amount
of existing skeletal discrepancy., that in most cases the mandibular arch should be treated
on a nonextraction basis if possible.
Also, the amount of the skeletal discrepancy in combination with the pretreatment
position of the upper lip may indicate maxillary premolar extraction to enhance even
further the amount of mandibular reduction possible as well as reduce the prominence of
the upper lip.
A third possibility is that of maxillary first premolar extraction and mandibular second
premolar extraction in those cases in which a severe arch-length discrepancy

Vertically, presurgical orthodontic objectives

31
If, there is a component of vertical maxillary excess with accompanying open-bite in
combination with the mandibular prognathism, then presurgical orthodontic treatment
should be designed to maximize the open-bite (extrude posterior teeth and intrude
incisors) and coordinate the arches as closely as possible in order to minimize the amount
of orthodontic treatment necessary postsurgically.
The opposite would hold true for vertical maxillary deficiency patients with
accompanying deep-bite deformity; orthodontic treatment designed to open the bite
should be withheld as much as possible until after surgical skeletal repositioning has been
completed.

Tansverse problems with the mandibular excess

-Avoid any significant dental expansion or constriction of the posterior teeth prior to the
surgical repositioning of the affected skeletal units. Therefore, in most of these cases
segmentalized orthodontic treatment is recommended presurgically, with definitive
finalization of occlusal interdigitation and arch coordination postponed and accomplished
post-surgically.

Asymmetric mandibular excess.

Careful diagnosis and treatment planning and execution of maxillary, mandibular, and
chin surgery are the keys to successful correction of asymmetric mandibular excess .
If there is an associated anteroposterior, vertical, or horizontal maxillary dysplasia
surgery is programmed to reposition the maxilla to achieve three-dimensional facial
balance. The plan to level the maxillary occlusal plane and correct the canted occlusal
plane is based upon the following considerations:
-In the anterior region the lip-to-tooth relationship and the asymmetric smile line are the
principal factors used to plan for differentially raising or lowering the anterior maxilla.
-In the posterior region, the smile line, the mandibular plane angle, and the occlusal plane
angle are all relative diagnostic parameters to determine whether the posterior occlusion
will be leveled by raising one side of the maxilla or lowering the contralateral "short'' side
of the maxilla by interpositional bone grafting

Mandibular setback
Reduction in mandibular prognathism can be accomplished by
1. BSSO setback
It is widely used for setbacks because of excellent control of
the condylar segments aand because osteosynthesis screws can be
employed for fixation.
2. Transoral vertical oblique ramus osteotomy (TOVRO)
It is limited to mandibular setback and requires full
thickness overlapping of the segments.
Advantage:
- This procedure requires less time than the sagittal split
osteotomy .
- Less likely to produce neuro sensory changes.

32
 Problem
Control of condylar fragment can be difficult.
Jaw immobilization after surgery is necessary

Correction of vertical relationships

General guideline
Long face problems- are treated best by superior
repositioning of the maxilla.This allows the mandible to rotate around the
condyle,thereby reducing the mandibular plane angle and shortening the face.
Short face problems,are treated most predictably and
successfully by mandibular ramus surgery that allows the mandible to move downward
only at the chin,increasing the mandibular plane angle by shortening the ramus and
opening the gonial angle rather than by rotating at the condyle.
Maxillary surgery
Skeletal openbite – Lefort I down fracture of the
maxilla,with superior repositiong of the maxilla after removal of bone from the lateral
walls of the nose,sinus,and nasal septum.the overall facial height is shortened as the
mandible responds by rotating upward and forward.
When the maxilla is moved downward to increase the face height ,it tends to
relapse back up post surgically,so that 20% or more of the vertical change often is lost
even when rigid fixation is used.
Mandibular surgery
Mandibular advancement with rotation of the mandible to
move the chin upward and decrease the mandibular plane angle is
contraindicated,because of high potential for relapse.Because the fulcrum for rotation is
the posterior teeth,this rotation lengthens the ramus and stretches the muscles of the
pterygomandibular sling. Long face patients often have excessive eruption of mandibular
anterior teeth.This vertical tooth chin problem can be corrected by orthodontic intrusion
or by anterior segmental surgery to depress the elongated incisor segment.Often the
preferred treatment is an inferior border osteotomy of themandible to reduce the vertical
height of the chin .
Patients with a short face(skeletal deep bite) problem are characterized by
A long mandibular ramus.
Square gonial angle.
Short nose-chin distance.
often the maxillary incisors are tipped lingually in angles class II,division 2
pattern.These patients often have an associated mandibular deficiency,could be described
as”classII rotated to classI”because of short anterior face height.They are treated by
sagittal split mandibular ramus surgery to rotate the mandible slightly forward and down
and the gonial angle area up.Orthodontic leveling of the lower arch is required and
usually is done after rather than before the surgery.

Correction of transverse problems

Transverse problems may be
-due to Symmetrical narrowing / widening of one dental arch
-due to jaw asymmetry

33
Maxillary expansion for lingual cross bite
Expansion is done with parasagittal osteotomies in the
lateral floor of the nose or medial floor of the sinus that are connected by a transvers cut
anteriorly.
Surgically assisted palatal expansion using bone cuts to
reduce the resistance without totally freeing the maxillary segments,followed by rapid
expansion of the jackscrew is the treatment approach for adults with skeletal maxillary
constriction

Mandible
Expansion anteriorlyand movements in posterior region are
limited by the need to cover the surgical site with soft tissue.
Asymmetry.
A review of large data base at the university of north Carolina
showed that one of the mandibular deficient patients were asymmetric,and 40% of class
III and longface patients had some degree of asymmetry.
The aymmetry primarily involved the chin,(Midface-nose was affected)
In patients with deficient or excessive mandibular growth,when the chin was off to one
side,therewas a 90% chance that the deviation was to left.
Mandibular asymmetry often leads to a secondary maxillary deformity.More
vertical mandibular growth on one side produces compensatory changes in maxillary
growth and a pronounced tilt in oclussal plane is likely to occur.when the mandible
deviates compensatory changes in mandibular alveolar process are likely.the teeth shift
backward toward the midline as growth continues,and the chin deviates more than the
dental midline.
Surgical correction of asymmetry
Lefort I osteotomy - to reposition the maxilla,moving it more vertically than transversly.
A lower border osteotomy of the mandible to reposition thechin transversly and vertically
also indicated.

Genioplasty technique
The clincian be sectioned anterior to the mental foramen and
repositioned in all three planes of space.The lingual surface remains attached tomuscles
in the floor of the mouth,which provide blood supply.
Moving the chin anteriorly,upward or laterally produces highly favourable esthetic
results.
Moving it back or down may produce a boxy appearance.
Genioplasty as an adjunct to non extraction treatment
Prominence of lower incisors relative to the chin has been
treated by retracting the incisors to establish a proper tooth-chin balance.But when the
lower incisors are retracted,the upper incisors also must be retracted.For some
patients,this creates the risk of an unesthetic flattening of the lips and can make a large
Nose appear even more prominent.For such patients,a lower border osteotomy to
augment the chin provides an alternative to premolar extraction and retraction of
prominent lower incisors.

34
Integration of orthognathic and other facial surgery
Nasal prominence and elevation of nasal bridge often accompanies severe class
II malocclusion. A typical clinical presentation includes an increased tooth-to-lip relation,
increased gingival display,increased interlabial gap, and a relative mandibular
deficiency,The patient will often have an anterior open bite, but this is not always present
due to dentoalveolar compensations and hypereruption of the teeth occlusion.With out
changes in the nose retracting protruding maxillary incisors makes the nose even more
prominent.

Simultaneous mandidular advancement and rhinoplasty usually can be accomplished.

Combining maxillary surgery and rhinoplasty and nasal and two jaw surgery is more
difficult.
Asymmetry patients:2 nd stage rhinoplasty 12-15 weeks after the jaw surgery.

Maxillary Orthognathic Surgery

Level of Osteotomy

The level of osteotomy is classified based on LeFort's trauma studies from the 19th
century.
I. LeFort I level osteotomies involve movement of only the dentoalveolar portion of the
maxilla. Occasionally, patients will require anteroposterior augmentation of the malar
area in addition to the maxilla. An intermediate surgical procedure is the "high" LeFort I
osteotomy which goes slightly superior to the typical LeFort I and includes a portion of
the zygomatic process of the maxilla and a small portion of the inferior aspect
of the zygoma.
2. LeFort II osteotomies include the maxilla and nasal bones. One approach for the
LeFort II level surgery is a subconjunctival approach. Another more extensive
surgical approach involves use of a bicoronal flap.
3. LeFort III osteotomies include the maxilla, zygoma, and nasal bones, extending
superiorly to the zygomaticofrontal suture as well as the frontomaxillary suture. The
typical surgical approach for the LeFort III level surgery involves a bicoronal flap.

The higher the levelof osteotomy (highLeFortI,LeFortII,or LeFortIII),the higher the

center of resistance

Osteotomy vs ostectomy Jco 77 may David Bojrab

In an osteotomy cut through bone and rearrange it, but do not remove any.
An ostectomy involves removal of a segment of bone. Most of the time, all orthognathic
surgery is referred to as an osteotomy, even if a segment of bone is removed
.

35
Impaction
Indication - vertical maxillary excess.
Some of the cephalometric indicators within the cephalometries for orthognathic surgery
(COGS)analysis,include: an increased upper and lower facialheight (N-ANS and ANS-
Gn); increased mandibular plane angle (MP-HP); increased posterior facial height (N-
PNS); increased gonial angle (Ar-Go-Gn); increased facial height ratio (N-ANS/ANS-
Gn); and divergent occlusal planes.
clinical features : an increased tooth-to-lip relation, increased gingival display,increased
interlabial gap, and a relative mandibular deficiency,The patient will often have an
anterior open bite, but this is not always present due to dentoalveolar compensationsand
hypereruption of the teeth

Of special consideration with vertical maxillary excess is minimizing the orthodontic

extrusion that can occur quite rapidly with mechanics,such as the placement of low
modulus continuous archwires.
Segmented arch mechanics are an excellent way to predictably control the point of force
application and magnitude of force applied, and to produce an operator-determined, not
appliance determined, force system. The segmented arch technique has the additional
advantage of being able to level each arch without requiring additional arch length.

When divergent occlusal planes exist, a treatment occlusal plane must be selected first
and then the appropriate force system designed. Typically, a functional occlusal plane
(perpendicular to the maxillary posterior teeth) is drawn. Once selected, the anterior teeth
may be on, significantly above, or significantly below the treatment occlusal plane.

If the maxillary anterior teeth have erupted significantly beyond the treatment occlusal
plane, an extremely efficient orthodontic mechanism for leveling the arch is the intrusive
base arch.

0.017 x 0.025 beta-titanium or a 0.017 x 0.025 stainless steel base arch

Two stainless steel posterior segments containing the second molar to the first premolar
and an anterior stainless steel segment from the lateral incisor to the lateral
incisor are fabricated.
Force level -20-25 gm intrusive force per maxillary incisors
The extrusive forces in the posterior segment and the moment of the force created by the
base arch are balanced by using a high-pull headgear oriented through a point above and
in front of the center of resistance of the maxilla.
Without the high-pull headgear setup to balance the adverse effects of the intrusive base
arch, a significant steepening of the maxillary posterior occlusal plane can be observed,
In addition, no true anterior intrusion at the level of the center of resistance may occur.

Once the anterior and posterior segments are oriented along the same plane (the treatment
occlusal plane), a continuous archwire is placed to maintain the arch leveling.

36
In other vertical maxillary excess patients, the maxillary anterior segment may be more
superiorly positioned than the posterior occlusal plane. In this situation, an extrusive
force of approximately 50 g per tooth is applied to extrude the anterior teeth to the level
of the posterior occlusal plane.

Advancement

Kerr et al tried to establish some cephalometric yardsticks in adult Class III patients to
allocate them to treatment more objectively. The pretreatment lateral cephalograms of
patients who had either surgical or orthodontic correction of their Class III malocclusion
were compared by means of univariate statistical methods.
The most significant differences between both groups were found in ANB angle,
maxillary/mandibular (M/M) ratio (ratio between the maxillary and mandibular lengths),
mandibular incisor inclination, and Holdaway’s angle. Ajo 02

Some of the COGS analysis indicators of maxillary anteroposterior deficiency and

normal mandibular position include glabella-subnasale (G-Sn), nasion-A point (N-A) ,
nasion-B point (N-B), nasion-pogonion (N-Pg), and glabella-soft tissue pogonion (G-
Pg').

clinical indicatior s for performing a maxillary advancement rather than a mandibular

setback include decreased pharyngeal airway, excessive submental adipose tissue,
decreased malar convexity, and increased nasolabial grooves upon smiling.

One way to clinically evaluate the patient involves using an object, to "block out" the mid
face and then examining the projection of the lower face relative to the clinically
determined glabella vertical. If the chin position is acceptable, it is most likely the patient
has a maxillary anteroposterior deficiency.

Many patients with maxillary anteroposterior deficiency also exhibit varying degrees of
transverse and vertical deficiency. Typically, a crossbite exists as part of the presenting
Class III malocclusion.

A posteroanterior cephalograph in addition to the clinical examination can assist in the

diagnosis of transverse deficiency.

Relative crossbite -not need to be corrected

Absolute crossbite- Skeletal/ Dental
Skeletal crossbites are best corrected skeletally
(rapid palatal expansion [RPE], transverse maxillary distraction osteogenesis, or
segmented maxillary surgery),
Dental crossbites may be corrected skeletally or dentally (RPE, palatal arch, cross arch
elastics, or expansion of the maxillary archwire).

37
Occlusogram analysis,in addition to model analysis, can assist in the differential
diagnosis of the transverse dimension. First, the occlusal aspect of the teeth is traced
on a piece of acetate and articulated in the current anteroposterior occlusion. The
maxillary member of the occlusogram is then brought forward the anticipated
amount of the maxillary advancement surgery. Then, using the mandible as the template
arch, the appropriate arch form, arch width, and arch length analysis is performed.
The difference between the current and predicted arch width represents the required
amount of maxillary expansion or mandibular constriction.

Dental cross bite – TPA is a method of dental arch expansion

To activate the TPA, the appliance should not only be expanded but also have buccal root
torque placed. Because the expansive force is being applied occlusal to the center of
resistance of the tooth, a significant buccal tip can be observed. To reduce the tipping
tendency, buccal root torque is applied.
If the TPA is left in place long enough, an iatrogenic occlusal plane cant can be created
by extruding the side that has greater buccal root torque. Often the iatrogenic cant can
only be resolved by differential vertical positioning of the maxilla as it is brought
forward.

Skeletal maxillary transverse deficiency is typically larger in magnitude and can be

measured from the posteroanterior cephalograph by comparing the J point measurement
to the midsagittal reference plane and the axial inclination of the posterior teeth. In a
skeletally mature patient, the most stable method of correction is maxillary transverse
distraction osteogenesis (also referred to as surgically assisted RPE), or segmentalization
of the maxilla.

Extractions are performed in surgical orthodontic cases primarily for two reasons; to
ideally position the teeth within the basal bone and to resolve significant arch length
deficiency.The extraction mechanics typically should not be directed toward orthodontic
correction of the molar classification or obtaining an ideal buccal segment relationship.
Instead, the extractions should be directed toward making the occlusion reflect the
magnitude of the skeletal discrepancy.

Cases with significant maxillary anterior crowding where undesirable proclination of the
anterior teeth will occur with placement of a continuous archwire are best managed by
early extraction of the first bicuspids.
The posterior segments are aligned and coordinated with the maxillary canines using a
0.017 x 0.025 stainless steel track.
Once aligned, a segmental precalibrated 0.017 x 0.025 beta-titanium "A" anchorage "T"
loop is placed from the first molar to the canine to perform initial canine retraction. "A"
anchorage is achieved by placing four 30-400 moment activations in the posterior leg of
the ''T' loop and three moment activation bends in the anterior leg. The differential
moments produce a moment/force ratio of 10:1 (translation) at the canine versus a
moment/force ratio of 13:1 (root movement) at the posterior segment.

38
Inferior Repositioning (Down graft)
Cephalometric indicators within the COGS analysis :
decreased lower facial height (ANS-Gn); decreased mandibular plane angle (MP-HP);
decreased gonial angle (Ar-Go-Gn); increased facial height ratio (N-ANS/ ANS-Gn); and
deep overbite.
clinical features - a decreased tooth-to-lip relation, decreased gingival display, no
interlabial gap, and a relative mandibular prognathism and/or prominent chin button.

Instead of intruding maxillary and mandibular anterior teeth, posterior extrusion is the
primary goal of the orthodontic biomechanics. Continuous low modulus archwires may
be used to facilitate orthodontic eruption; however, in many of these short-face, low
angle or convergent patients pre or non-surgical orthodontic extrusion is extremely
difficult to achieve. Extrusive force systems may be placed with continuous low modulus
archwires, but often the heavy occlusal bite force of the patient will exceed the eruptive
force delivered by the archwire.

Two solutions are available. Extrusive base arch and post surgical leveling

Extrusive base arches are designed to produce an extremely efficient eruptive force to
the posterior maxillary and/or posterior mandibular segments.
For intrusion, typically 15-25 g of force is used to intrude each anterior tooth. For
extrusion of the posterior segments, a much higher force is applied, typically a minimum
of 200 g. The force produces hyalinization of the anterior teeth, minimal to no anterior
intrusion over the short term, and very efficient orthodontic eruption of the posterior
segments.

Additional benefits derived from the extrusive base arch force system include the
possible arch length increase obtained as well as an uprighting force that can be applied
to the maxillary anterior teeth. With an extrusive base arch, not only is a significant
extrusive force present on the posterior segments, but also a crown distal or
counterclockwise moment.

An alternative method that can be utilized involves performing the orthodontic leveling
postsurgically. A significant mandibular curve of Spee is an excellent indication
for postsurgical leveling. Postsurgically, the deepest part of the curve of Spee, the mid
arch, is still present. Immediate postsurgical leveling is extremely effective
because the teeth can be erupted into air rather than into heavy occlusal forces.

Postsurgically, due to a change in muscle fiber orientation, the mechanical advantage and
thus the bite force may also decrease.
Due to the healing and increased vascularization, there is a regional accelerative
phenomenon. This combination of factors can cause extremely rapid and efficient
orthodontic tooth movement. To assist eruption of the teeth, either a continuous light

39
stainless steel archwire with vertical box elastics in the mid arch, segmented arch
mechanics with an extrusive base arch, or an overlay extrusive base arch can be placed
with a light continuous main archwire.

Segmentalization

Main reason
Multiple maxillary occlusal planes.
Maxillary transverse problems

Segmentalization allows for differing amounts of superior or inferior repositioning of the

segments surgically. When surgical closure of an anterior open bite is planned,
orthodontic eruption of the maxillary anterior teeth is undesirable because this will build
potential instability into the case and reduce the amount of vertical surgical repositioning.

As a result, segmentalization of the maxilla for differing occlusal planes typically

requires that segmental, not continuous, archwire mechanics be used. Placement of light
continuous archwires will generally lead to unwanted extrusion of the maxillary anterior
teeth, posterior teeth, or both. Instead, the teeth should be aligned in segments based on
the location of the occlusal plane divergence.

Typically, the maxillary arch is segmented either between the lateral incisor and the
canine or between the canine and first premolar .
One advantage that a four-tooth incisor segment has over a six-tooth anterior segment is
that the former can be set deeper surgically without the presence of the maxillary canine.
Generally, there is also a natural root divergence between the maxillary canine and the
lateral incisor. To augment the divergence, a segmental root spring can be placed from
the molar to the canine to obtain the necessary root divergence for the osteotomy

One common mistake with continuous arch mechanotherapy is the placement of an open
coil-spring to create an osteotomy space. The open coil-spring is effective in opening
space at the level of the crown, but actually will bring the roots of the adjacent teeth into
closer proximity and increase rather than decrease the risk of damage during the
interdental osteotomy.

Another method for root divergence in the continuous arch method is to place a "V" bend
with the apex of the "V" pointing apically instead of in the typical occlusal direction. If
the "V" is centered between the teeth adjacent to the osteotomy, equal and opposite
moments are generated that produce root divergence.

Segmenting the maxilla for maxillary transverseproblems

Skeletal crossbites that are more moderate in magnitude (no more than
5-7 mm) can be adequately addressed with segmental LeFort I osteotomy.

The location of the segmental osteotomy depends on the location of the desired arch
expansion .

40
Canine expansion - when a three-piece maxillary osteotomy is planned, the canine must
be in the posterior segment.
Molar and premolar expansion - the canine may be included in the anterior segment.
When differing amounts of canine and molar expansion are treatment planned, a four-
piece maxillary segmental osteotomy can be performed to increase not only the maxillary
canine width, but also the maxillary molar width differentially.

A twopiece maxillary osteotomy with a sagittal cut separating the maxilla into right and
left segments may also be used when the cuspids as well as the buccal segments need to
be expanded.
Presurgically, it is important not to make any attempts to increase the arch width with the
TPA, archwires or cross arch elastics because this will introduce the possibility of
orthodontic relapse into the surgical procedure, or the surgeon may underestimate the
necessary amount of expansion. Intermaxillary fixation still takes 10-14 days, but
postsurgically these patients are typically left in a "horseshoe" type splint with a palatal
strut that is wired to the maxillary arch for approximately 6-8 weeks. As
close to the day of splint removal as possible, a continuous stainless steel maxillary
archwire and either a TPA or labial overlay wire should be placed.

Mandibular Surgery
MandibularAdvancement
HighAngle
cephalometric indicators: mandibular length (Go-Gn); facial height (N-ANS and ANS-
Gn); gonial angle (Ar-Go-Gn);mandibular projection (N-B); chin projection (N-Pg); and
angle of skeletal convexity (N-A-Pg).
In the high-angle (steep mandibularplane, backwardrotator,etc.) patient,often
the effective chin projection is minimal and the mandibular incisors are extruded (lower
incisor to mandibular plane distance measured perpendicular to the mandibular plane).

A true mandibular deficient patient with a normal face height but steep mandibular plane
can often be treated with isolated mandibular surgery.
Patient with increased facial height as well as a steep mandibular plane will often require
two-jaw surgery with a maxillary impaction and mandibular advancement.

Leveling the arch by posterior extrusion, produces backward rotation of the mandible
further reducing chin projection. If any mild extrusion is anticipated, it is important to do
so prior to surgery. Any postsurgical extrusion would have the undesirable tendency to
open the bite again.
A better approach focuses on intrusion of the mandibular anterior teeth. In addition,
leveling with a continuous archwire tends to produce incisor proclination. If the
proclination is significant,the mandible may not be able to be advanced into a Class I
relationship because the incisors take up a greater arc than they should. True intrusion of
the anterior teeth will require segmentalization of the mandibular arch and use of an
intrusive base arch.
A 0.017 x 0.025 stainless steel intrusive base arch is inserted into the auxiliary tube of the
molar and tied either gingival to or just labial to the mandibular incisor brackets. It is

41
important not to insert the wire directly into the incisor brackets as torque might be
present which would produce an indeterminateforce system.The torque could be additive,
creating a larger intrusive effect, or negative, producing a smaller and clinically
ineffective intrusive effect. Once the arch is level, a rigid stainless steel continuous
archwire shouldbe placed to maintain the overbite correction.

If the arch length deficiency is more significant or the lower incisors are proclined, - a
split intrusive base can be fabricated.The same posterior segments are used, but this time
the anterior segment is stepped approximately 5 mm gingivally as the wire exits the
mandibular lateral incisor. The wire is then contoured to the arch and extended distally
with a stop at the distal extent of the segment.Then, a cantilever spring can be made (one
on each side to deliver approximately 15 g of force per tooth to be intruded) and placed
behind the center of resistance of the anterior segment of teeth. The applied force system
produces simultaneous intrusion and uprighting of the anteriorteeth. By intruding the
anterior teeth, not only can the mandible be advanced, but also rotated counterclockwise
to increase the chin projection.

Low Angle
The low-angle (low mandibular plane, forward rotator, etc.) patient typically possesses a
deep curve of Spee and decreased facial height. With short-face patients, the facial
musculature (masseter, lateral, and medial pterygoids) is typically stronger, and posterior
dental extrusion can be difficult to achieve and maintain due to high posterior bite
force.While the mandible may be deficient, the chin projection may be quite acceptable
due to a large chin button. Class II, Division 2 patients often display these characteristics.

One goal of treatment focuses upon increasing the facial height.Lengthening the facial
height is extrusion of the teeth and advancing the mandible "downhill" along the occlusal
plane. This can be extremely easy with a steep maxillary occlusal plane, as the occlusal
plane will dictate the relative amount of vertical and horizontal mandibular change in
isolated mandibular advancement surgery. But many low-angle patients have a normal-
to-flat occlusal plane,

An extremely efficient way to obtain leveling is to perform the mandibular advancement

surgery early in treatment prior to leveling the curve of Spee. Historically, prior to rigid
fixation, the mandible was advanced to an edge-to-edge incisor relationship and
occlusion on the second molars. The patient was fixated with an anterior and/or superior
border wire and an interocclusal splint. After adequate healing time, the splint
was removed and intermaxillary elastics in the mid arch were used. The maxilla would
have a rigid archwire, with a relatively nonrigid mandibular wire, such as a 0.018
stainless steel wire. Once the elastics had leveled the mandibular arch, a more rigid
mandibular wire was placed.

Now, with rigid fixation, less immediate postsurgical relapse occurs, and the mandible
does not need to be placed in an edge-to-edge "tripod" occlusion, but merely into Class I
with a mid arch open bite. The fixation allows for elastic use almost immediately
postsurgically, unlike with wire fixation.
Mandibular Setback.

42
Cephalometric measurements that will assist in the diagnosis of mandibular hyperplasia
include increased mandibular projection (N-B); chin projection (N-Pg), and a normal
maxillary projection (N-A, and G'-Sn).
Careful evaluation the soft tissue drape of the lower face and neck, especially the lower
face throat angle and lower face throat height/depth ratiois important . Both
measurements can prevent inappropriate setback of the mandibular arch and avoid
creating potential airway problems.
One of the most common findings with mandibular hyperplastic patients includes the
dentally compensated, retroclined mandibular incisors. The lower incisor to mandibular
plane angle can often be in the mid 70° range. In addition, the labial mucosa is often thin.

An efficient mechanism for lower incisor torque correction is the high alpha root spring .
The root spring is an auxiliary full size archwire that is placed directly into the lower
incisor brackets. The wire exits the brackets, is stepped gingivally, helices are placed
bilaterally, and the activated distal archwire extension is then clipped over the main
archwire as far posteriorly as possible.
longer the wire - greater the moment, more efficient.
With shorter root springs, significantly higher forces are required to generate the same
moment, which has the tendency to cause unwanted mandibular incisor extrusion. To
minimize the extrusive component, the main archwire is placed in the posterior brackets
and then stepped incisally to rest in top of the tie wings of the mandibular incisor
brackets.
The extrusive force that is generated by the root spring will erupt the anterior teeth until
the main archwire is contacted. Then the extrusion will cease.
If labial crown torque of the incisors is desired, the high alpha root spring must be tied
back to prevent the crowns of the lower anterior teeth from coming forward.
If incisor proclination is desired, the root spring does not need to be tied back as tightly,
but the force level should be reduced to prevent over proclination of the incisors.

The orthodontic treatment to remove the dental compensations should be the same
whether a bilateral sagittal split ramus osteotomy (BSSRO) or an intraoral vertical ramus
osteotomy (IVRO) is performed..
A critical error that occasionally occurs involves improper positioning of the condyle in
the fossa and rigidly fixating the proximal and distal segment together.
If the proximal segment has been surgically displaced posteriorly, when the patient is
released from intermaxillary fixation, the mandible will rotate forward producing a more
Class III relationship.
If the proximal segment was not fully seated with the condyle in the fossa, but the
condyle was distracted anteriorly, the patient will exhibit a Class II open bite
malocclusion upon release from the intermaxillary fixation.
Many surgeons prefer to perform the IVRO procedure with mandibular setback,
involving longer intermaxillary fixation but without proximal and distal segment fixation.
The result is that the proximal segment is allowed to assume a "physiologic" position that
is determined by the musculature and not the surgeon.

OCCLUSAL PLANE CHANGES

43
Limited changes in the cant of the treatment occlusal plane can be performed with
isolated maxillary or isolated mandibular surgery.
High mandibular plane angle patients benefit facially from flattening of the occlusal
plane. To accomplish this change, the mandible needs to be leveled with anteriorintrusion
rather than extrusion of theposterior teeth. The mandible can then be rotated
counterclockwise, closing the gonial angle and flattening the mandibular occlusal plane.
With maxillary advancement patients, the occlusal plane can be flattened or steepened,.
The maxillary occlusal plane may be flattened if the anterior aspect of the maxilla is
elevated, but it is unwise to inferiorly position the posterior maxilla. Such lengthening
produces pterygomasseteric muscle stretch which is inherently unstable. The maxillary
occlusal plane change is limited because it must still articulate with the unchanged
mandible. Typically, when the maxillary occlusal plane is changed and no mandibular
surgery is performed, a complete LeFort I (with or without segmentalization) is
performed, the maxilla is placed in intermaxillary fixation and the entire complex is
rotated to the desired position. In a Class I vertical maxillary excess patient, this requires
a slight maxillary advancement along with the occlusal plane change.

For maximal occlusal plane change, two-jaw surgery is required.

maxilla, mandible, and occlusal plane can be moved in all three planes of space.

As a general geometric rule, steepening the occlusal plane will take a patient who is
dentally Class II and make him/her more Class I However, steepening the occlusal plane
will tend to make the facial profile more convex (i.e. more Class II).

Flattening the cant of the occlusal plane will have a tendency to take a Class III
malocclusion and make the apical base discrepancy more Class I. However, flattening
the occlusal plane with two-jaw surgery will make the facial profile less convex ( flatter
and more Class III).
In nongrowing individuals, changing the occlusal plane nonsurgically is usually unstable
and will tend to revert to the original position. On the other hand, surgery, particularly to
steepen the occlusal plane, can allow for significant occlusal plane changes that can be
quite stable.

The most common two-jaw surgical patient displays vertical maxillary excess . The goal
of treatment typically focuses on steepening the occlusal plane by impacting the maxilla
(usually more posteriorly than anteriorly as in an open bite patient) and allowing the
mandible to autorotate. Then, either a mandibular advancement or setback is performed
based on the occlusal result after maxillary impaction. Several practitioners have focused
on flattening the occlusal plane in the same type of patient to produce greater gonial
angle definition and chin augmentation.

Other patients that benefit from occlusal plane changes include some of the Class III
maxillary hypoplastic syndromic patients. Typical patients present with Apert or Crouzon
syndrome, achondroplasia, or cleft lip and palate. All these patients to some degree would
benefit from a clockwise rotation of the maxilla and mandible, and in some cases the
frontal bone. The occlusion may be near Class I dentally, but skeletally presents as Class
III. By rotating the entire complex clockwise, the relative mandibular projection is

44
minimized, allowing greater projection of the frontal bone and maxilla. The initial dental
malocclusion can be corrected orthodontically, and the occlusal change then maintained
throughout.

CLEFT LIP &CLEFT PALATE

After comparing maxillary dental arch morphology in 97 untreated cleft lip and palate
patients and 51 patients with normal occlusion, Omar Gabriel concluded that:
1) Maxillary dental arch dimensions and morphology are distorted by the presence
of a cleft.
2) The maxillary dental arch is characterized by a constriction that is more severe in
the medial and anterior regions as a consequence of medial displacement of the palatal
segments, primarily the minor segment. Simonart’s band was present in 15.4% of the
unilateral cleft lip and palate patients in this study.
3) Simonart’s band affects the maxillary dental arch size and shape, redirecting the
anterior extremity of the major segment towards the minor segment
- The influence of unilateral cleft lip and palate on maxillary dental arch
morphology Omar Gabriel . Angle Orthodontist 1992
DENTOFACIAL FINDINGS IN CLEFT LIP AND PALATE
Bishara and Jacobson AJO 1985 studied the dental and cephalometric parameters of 30
with unoperated unilateral cleft lip and alveolus, unilateral cleft lip and palate, and
bilateral cleft lip and palate were evaluated.
Cephalometric parameters
The major significant cephalometric finding in the comparisons between the three cleft
groups was that the UCLP and BCLP subjects had a relatively steeper mandibular
plane associated with a relatively shorter posterior face height and a relatively longer
anterior face height when compared with UCLA.
Persons with isolated clefts of the palate have retrusion of the maxilla and mandible but
the maxillomandibular relationship remains normal due to the backward rotation of the
mandible.
Persons with bilateral cleft lip and palate showed varying degree of protrusion of the
premaxilla
Dental arch parameters
The maxillary intercanine width in the BCLP was smaller than in either the UCLA or
the UCLP subjects.
Correction of jaw deformities in patients with cleft lip and palate
Larry M. Wolford, DMD 2002, Baylor University Medical Center

Cleft lip repair. Commonly performed within the first 3 months of life, this procedure can
adversely affect the anterior maxillary alveolar morphology, which is probably related to
the discontinuity defect in the alveolar cleft and the extent of soft-tissue undermining and
subsequent fibrosis.

45
Cleft palate repair. These procedures can affect the vertical, anteroposterior, and
transverse development of the maxilla and alveolar processes . Periosteal stripping at the
time of surgery and the resulting fibrosis are the most likely reasons for this response.

Alveolar cleft repair. Bone grafting of alveolar cleft defects, when performed in early
childhood, can severely inhibit maxillary growth.. Bone grafting usually adversely affects
vertical and horizontal growth of the maxilla. Ideally, alveolar cleft bone grafting should
be delayed as long as possible, until just before the permanent cuspid teeth erupt into the
cleft area (age 9 to 12 years), thus allowing more maxillary growth before surgical
intervention .

Pharyngeal flap. With posterior pharyngeal flaps, a surgical procedure used to correct
hypernasal speech problems, a tissue flap from the posterior pharyngeal wall is attached
to the soft palate. This flap can have a profound effect on facial growth and development,
decreasing the anteroposterior and transverse growth of the maxilla and, in many cases,
increasing the vertical component of maxillary growth . The increased vertical maxillary
growth may be the result of altered breathing patterns, since the pharyngeal flap can
result in a mouth-open breathing posture

In adolescents and adults who have undergone cleft defect repair, common consequences
include anterior and posterior crossbites; midface hypoplasia; anteroposterior, vertical,
and transverse maxillary deficiency; residual lip and nasal deformities; and speech
problems.

Cleft lip and cleft palate management

The present concept in the orthodontic management of cleft lip and palate patient is of
minimal intervention during various phases of development of dentition and occlusion.

1. Neonatal maxillary orthopedics as an infant.

2. Orthodontic-orthopedic treatment during the deciduous dentition.
3. Orthodontic treatment during the mixed dentition.
4. Orthodontic treatment alone or in conjunction with orthognathic surgery in the
permanent dentition.

Neonatal Maxillary Orthopedics

46
The rationale behind this method involves orthopedic realignment of the "collapsed"
segments using various mechanisms ranging from simple passive appliances to more
active orthopedic appliances to extraorally activated pin-retained appliances.

The aims of presurgical treatment are not the same for unilateral and bilateral clefts because
of the different segment displacement that occurs. In the unilateral, complete cleft of the
lip and palate, the greater and lesser segments tend to rotate away from each other about
axes in the tuberosity regions or the lesser segment can be rotated inwards towards the cleft
Both active and passive appliances have been described and either can be used in
combination with lip strapping, if this is indicated. It is important that the initial appliance
is fitted-within seven days of birth otherwise, acceptance may prove to be a problem.
Presurgical orthopedics treatment – Is it necessary ?
Proponents of presurgical orthopedics like Lubit 1976 proposes
the following claims
The cleft reduces in size which simplifies the primary surgery and by implication,
affects the quality of the repair.,Partial obdurate of the cleft helps in feeding
Tongue behaviour is modified which may lead to improved speech in the long term,
Decrease in the number of ear infection , Expansion of the collapsed maxillary
segment Constriction of the expanded anterior part of the maxillae, Repositioning the
premaxillary segment
Opponents of presurgical orthopedics put forth the following claims

Cleft always reduces in size without presurgical treatment

VIG , clinical plastic surgery 1985

Orthodontic-Orthopedic Treatment in the Deciduous Dentition

Vig and Turvey believe that orthodontic treatment in the deciduous dentition, although
possible, is contraindicated.
Growth modification at this stage has been proposed by Rygh and Tindlund.They
recommend utilization of a quad-helix appliance soldered to bands on the primary second
molar teeth and canines to expand the upper arch.

Mixed Dentition
Some authors advocate bone grafting at the age of 5 to 6 years to give the lateral incisor
the possibility to migrate into and erupt through the bone graft. Others raise concerns that
such an early intervention may interfere with maxillary growth and recommend that the
graft be placed after the 8 th or 9th year of age.
Orthodontics, when carried out in conjunction with bonegrafting, is commenced at least 6
months before graft placement and includes fixed appliances in the maxillary arch.

Comprehensive orthodontics
2-3 years after the secondary bone grafting, when the permanent canines have
erupted,comprehensive orthodontic treatment is started.Twin edge wise or preadjusted
appliance system provides better 3 dimensional control on the teeth.

47
Orthodontics Combined With Orthognathic Surgery

Because the size and position of maxilla is often a problem, maxillary advancement and
occasionally down-grafting needs to be performed to address the anteroposterior and
vertical deficiency of the maxilla. The transverse problem may be resolved by merely
positioning the maxilla forward relative to the mandible.
Three-piece maxillary surgery -Bilateral cleft lip and palate,
Two-piece or three-piece maxillary osteotomy -unilateral cleft lip and palate.

A two-piece maxillary surgical procedure may address the transverse problem in a

unilateral cleft lip and palate case but a three-piece option may also allow rotation of the
individual segments thereby permitting a more favorable occlusal plane thus reducing the
amount of postsurgical orthodontic treatment needed .

The decision to section the maxilla in more than one piece implies that leveling and
alignment of the maxillary dentition will be performed independently for each segment.
Bracket placement may require modifications for the teeth adjacent to planned osteotomy
sites. If the cut is to be made between the maxillary canine and first premolar, it is
required that a nonangulated bracket or a contralateral canine bracket is bonded on the
canine to cause divergence of the canine and premolar roots.

However, if the incision is to be made between the lateral incisor and canine, the lateral
incisor should be bonded with a standard, nonangulated bracket or an opposite-side
lateral incisor bracket, whereas the canine should have bonded the customary
preangulated bracket.

Such a bracket placement method may save time compared with the alternative of using
secondorder arch wire bends to diverge roots adjacent to the osteotomy site.
Presurgical orthodontic treatment usually extends for a period of 12 months. Removal of
"dental compensation," especially in the lower arch and the alleviation of crowding is one
of the objectives during this stage of treatment.
If the anteroposterior jaw discrepancy exceeds 8 mm, maxillary "over advancement"
could lead to a very unstable result, in addition to further compromising speech. In this
situation, mandibular surgery should be considered even though the mandible may be of
normal size and position.

48
Mandibular bilateral sagittal split osteotomy is often indicated when there is a severe cant
of the occlusal plane and/or when a mandibular asymmetry exists.
Postsurgical orthodontics usually extends for a period of approximately 4 to 6 months.
Objectives of the postsurgical phase of orthodontic therapy include detailing of the
occlusion and closure of any residual spaces while maintaining the transverse correction.
- Christos C. Vlachos ,Seminars in ortho 96

Orthodontic-surgical interaction in the management of cleft lip and palate.

Vig KW, clinical plastic surgery 1985

The aims of presurgical orthodontic treatment are as follows

• To improve arch alignment with the extraction of teeth, if necessary, for the relief
of crowding
• The adjustment of maxillary arch width to enable a satisfactory occlusion to be
obtained at the time of surgery.
• Decompensation of the maxillary and mandibular incisors to enable the optimum
surgical movements to be achieved.
• . The correction of the maxillary center line, if necessary.
• The redistribution of space if the prosthetic replacement of teeth

The adjustment of maxillary arch width.

In the repaired unilateral cleft, some arch expansion is generally needed and this can be
achieved with a quad helix appliance.
In bilateral cleft the posterior arch width is increased and in this situation, a contraction
quad helix is the appliance of choice. This is constructed in a conventional way but the
palatal arms are omitted and replaced with buccal arms which will initially move the
premolars palatally as well. The quad helix appliance is ideal for this purpose as it can be
adjusted differentially, has a long range of action and can produce changes in the segment

Decompensation of lower incisior

In a severe class III malocclusion there is marked compensatory retroclination of the

mandibular incisors together with some proclination of the maxillary incisors which may
disguise the skeletal discrepancy, to some extent. The lower incisor retroclination
especially may produce arch irregularity which can be falsely interpreted as crowding. In
such cases the decision to extract the lower premolars are not done until it is certain that
orthognathic surgery is not required

49
Correction of the maxillary centre line.
Very often the maxillary incisors tip towards the cleft with loss of centre line. An extraction
may need to be considered in the non-cleft quadrant if correction of the maxillary centre
line is one of the treatment aims.

Redistribution of space prior to the prosthetic replacement of teeth

In cases where bone grafting has not been carried out or the closure of the space is
recommended a prosthesis is constructed in the lateral incisor region. Osseo intergrated
implants is another choice

Surgical treatment plan

Most common procedure is Maxillary advancement( Le Fort I) , mandibular may be
required but isolated mandibular set back is rarely indicated. In case where nasomaxillary
hypolasia is present then Le Fort II is done

Distraction osteogesis

Transverse discrepancies >6-7 mm in the skeletally mature patient are best managed with
transverse maxillary distraction osteogenesis.

Maxillary and mandibular distraction have an advantage over orthognathic surgery in that
not only is there a skeletal expansion, but potentially also a concomitant distraction
histiogenesis that may produce an enhanced soft tissue response.

Distraction osteogenesis, a biologic process designed to separate and manipulate two

osteogenic fronts to extend or expand the jaws, is being applied to both the maxilla and
mandible.

Maxillary Distraction Osteogenesis

Martin Wassmund - first maxillary distraction osteogenesis. In the 1920s he reported on
a total LeFort I osteotomy to which he later applied orthopedic traction in order to obtain
the necessary movement.
Father of modern-day distraction osteogenesis" is Gavril Ilizarov, a Russian orthopedic
surgeon who developed the contemporary distraction protocol. His protocol, developed
and refined in the 1950s and 1960s, requires a latency period of 1 week, with a specific
rate (1 mm per day) and rhythm (0.25 mm four times per day).

Maxillary Anterior Distraction

The orthodontic biomechanics for maxillary anteroposterior distraction osteogenesis are
very similar to maxillary advancement surgery.

The first aspect that must be considered is the transverse relationship to assure that when
the maxilla is distracted forward, it will be wide enough to accommodate the mandible.

50
The second factor is the verticalrelationship of the maxillary anterior and posterior
teeth. It is difficult to fit the maxilla to the mandible untilboth arches are level.

A major difference in distraction versus surgical advancement of the maxilla is vector

control. Whereas in orthognathic surgery, the maxilla undergoes a single acute
movement from its current to its final position all during one procedure, in distraction, the
process is much more gradual. Precise and controlled movement of the maxilla is
required to maximize occlusal contact and facial esthetics.To accomplish these precise
movements, the location of the center of resistance of the maxilla is essential.

Patient with maxillary anteroposterior hypoplasia with an anterior open bite will be
distracted using a vector through a point anterior to and above the center of resistance.
This will produce both a protraction force as well as a clockwise moment that will act to
bring the anterior maxilla downwardand forward, increasing the amount of overbite and
anteroposterior projection of the maxilla.
A patient with maxillary anteroposterior deficiency but increased overbitewill be
distracted using a vector below the center of resistance of the maxilla to produce
maxillary advancement, and posterior inferior positioning to decrease the amount of
overbite.
Multiple maxillary distraction appliances are currently available.
The rigid external distractor (RED) appliance.
Maxillary protraction face mask assembly .
.
Maxillary Transverse Distraction
Osteogenesis
In the mid 1970s, Bell developed a technique for maxillary expansion of the skeletally
mature patient.. At that time, a subtotal LeFort I osteotomy was performed. The same
cuts were made as a standard LeFort I, including pterygoid plate disjunction; however,
the inferior maxilla was not down fractured and separated from the superior aspect of the
maxilla. In addition, a midsagittal cut was added to simulate the suture in a growing
patient. Once the cuts were completed, the appliance was activated approximately 2 mm
to ensure complete mobilization of the maxilla. Then, the patient was instructed to
activate the appliance two turns in the morning and two turns in the evening until the
desired expansion was achieved.

The current protocol for maxillary transverse distraction osteogenesis utilizes a similar
protocol as Bell's, but incorporates a latency period of approximately 1 week.
In healthy, skeletally mature individuals, 1 week will allow for the formation of a
fibrocartilaginous callus in the osteotomy sites. This callus can then be gradually
separated, molded, and later stabilized to significantly augment the innate maxillary
alveolus and basal bone . Once the maxillary transverse distraction osteogenesis is
completed, it is important to stabilize the teeth until there is radiographic evidence of
bone formation. Premature movement of the teeth into the distraction gap can lead to a
periodontal defect and possible loss of attachment.

It is especially important to evaluate the torque of the maxillary anterior segment after
significant transverse expansion. There is a tendency for the incisors to become much

51
more upright which can cause difficulty in obtaining ideal overbite and overjet. If the
maxillary incisors are too upright, they occupy a smaller arc and may not occlude
correctly with the mandibular anterior segment. An efficient way to apply torque to the
four incisors utilizes a high alpha torquing spring

A full-dimension, rectangular stainless steel archwire is placed, filling the incisor bracket
slots. The wire is then stepped gingivally and two helices are placed to deliver a crown
labial/root palatal torque. The torquing spring must be tied back to prevent incisor
proclination and ensure root movement. Care must be taken to minimize the force level
to minimize the extrusive force anteriorly. If the spring extends posteriorly to
approximately the first molar region and is brought up and hooked over the main
archwire, a long moment arm is created, reducing the magnitude of the vertical forces. It
is possible to obtain approximately a 2000-2500 g-mm moment with only 100 g of force.
An incisal step is made in the main archwire distal to the lateral incisors so that the wire
can be placed on the underside of the incisal wings of the maxillary anterior brackets to
further minimize the possible extrusive effect.

Asymmetric Advancement/Inferior
Distraction
Patients with both skeletal and soft tissue deficiencies (such as hemifacial microsomia)
are ideal candidates for distraction osteogenesis. Particular attention should focus on the
presence, location, and magnitude of any occlusal plane cant. The cant may be a frontal
occlusal plane cant, posterior cant, or both.
With only an isolated frontal occlusal plane cant, intrusive or extrusive base arches are
excellent appliances to obtain the necessary correction.
A rigid anterior segment can be placed, with the base arch tied only to the tooth or teeth
that require intrusion.. Once level, a continuous archwire can be placed to obtain
coordinated maxillary and mandibular arches. Then, with level and coordinated arches,
maxillary distraction can be initiated.
When the same amount of cant is present posteriorly and anteriorly, it is best addressed
during the distraction phase.

Mandibular distraction osteogenesis

Mandibular Symphyseal Widening
One recent paper describes incomplete
resolution of the arch length by symphyseal distraction. As a result, critics have
suggested that distraction in the symphysis to widen the mandible and resolve arch length
deficiencies has unnecessarily proclined the mandibular incisors. Others have suggested
that extraction therapy is a more suitable treatment. Conceptually, distraction is the only
mandibular expansion alternative that increases the ,mandibular basal and alveolar bone.
The increase in bone can provide a suitable base for the dentition.

To summarize, the classic patient requiring mandibular widening presents with a

buccal crossbite that completely encompasses a narrow mandible. Other individuals who
would benefit from expansion include those with both a narrow maxilla and mandible.
Expansion in the maxilla was previously limited by the mandibular arch width; now, both

52
the maxilla and mandible can be widened simultaneously, producing additional basal and
alveolar bone allowing for true skeletal bimaxillary expansion.

Presurgically, root divergence of the mandibular anterior teeth is required. Much like the
interdental osteotomy in the maxilla, the midsagittal mandibular osteotomy requires
adequate interradicular space.

One way to obtain the necessary root divergence preoperatively is by exaggerating the
second-order bracket position. If this is done for all the mandibular incisors, care must be
taken to avoid extrusion of the mandibular central incisors due to the excessive tip placed
in the lateral brackets. In addition, a superelastic wire should not be used, because it
cannot be stepped to minimize the incisor extrusion.

A second way to obtain the root divergence requires a vertical tube/slot in the incisor
brackets and fabricating a modified root spring . The spring should exit the vertical slot,
have a helix, and then extend posteriorly and clip over the archwire. This root
spring will produce extrusion but also lateral root movement of the incisors. The force
should be kept as low as possible to minimize the extrusive effects. Due to the long
momentarm, the root spring will still be extremely efficient.

Postsurgically, a short (approximately I week) latency period is observed to allow for soft
callus formation. Then the applianceis activated no more than I mm each day until the
desired expansion has been obtained. The teeth are prevented from drifting toward the
midline for approximately 30-60 days. After approximately 3 months or until
radiographic evidence of new symphyseal bone is observed, the appliance can be
removed and a passive 0.036" stainless steel lower lingual arch placed to maintain the
expansion.
An important consideration during distraction relates to the magnitude and direction of
movement that occurs at the mandibularcondyle.A recent clinical study has shown that
there appears to be translation at the condyle with no clinically significant effects or
development of any joint symptom

Codivilla first used distraction in 1924, but the process did not become popular until the
early 1990s. Grayson and McCormick, Molina, and others have described distraction as
an excellent mechanism for craniofacial anomalies such as hemifacial microsomia,
Goldenharsyndrome, and Pierre-Robin sequence.

Whenconsidering distraction, the principles of preparing the dentitionare the same as

those for standard orthognathic surgery.The main difference is that the mandibular
skeletal change will be accomplished over a longer period of time using small
incremental movements as opposed to an acute positional change in orthognathic surgery.
Prior to orthognathic surgery,model surgery is performed, a custom splint is fabricated,
and the amount and direction of the acute movement are determined. The interocclusal
splint is then used intraoperatively to determine the final position of the mandible.

The center of resistance will depend on the age of the patient, geometry of the osteotomy,
size and shape of the distal and proximal segments, bone density, and muscle strength

53
and pull, among many other factors. It is likely impossible to describe one center of
resistance for the mandibles of all distraction patients.

The simplest distraction procedure is the uniplaner mandibular distraction where only
anteroposterior distraction is needed. The appliance should most often be oriented to
distract the proximal and distal segments parallel to the occlusal plane. Any distraction
force applied in a direction other than parallel to the occlusal plane will produce rotation
of the distal segment. The rotation could be counterclockwise or clockwise, either of
which must be managed to avoid creating an iatrogenic malocclusion. With a deep bite
patient, it may be possible to orient the distractor above the level of the center of
resistance in the distal segment. A moment will be generated that should produce a
clockwise or biteopening rotation. Too steep an angulation, however, could
result in creating an open bite. Open bite patients may be able to have the same distractor
placed, but below the level of the center of resistance of the distal segment. That way,
a counterclockwise or bite closing rotation can be created.

Biplanar distraction is much more difficult to assess and obtain . Fabrication of a plastic
skull constructed from a three-dimensional CT can be a useful aid prior to surgery to
determinethe locationof the applianceThen,the relativeamountof vertical and horizontal
distractioncan be calculatedwith a predetermined activation schedule and sequence.

Temporo mandibular joint

Validated numerical modeling of the effects of combined orthodontic and orthognathic

surgical treatment on TMJ loads and muscle forces
Jeffrey C. Nickel, AJO JAN 02

Studied the combined effect of orthodontic and orthognathic surgical treatments on 10

completed cases . Three-dimensional anatomical data from each subject were used in
computer models to predict the sagittal TMJ eminence morphology and
joint and muscle forces for each subject, consistent with the neuromuscular objectives of
minimizing joint loads and muscle effort. The actual shape of the eminence in each
subject was measured with jaw tracking. Surface electromyographic recordings were a
measure of the muscle forces involved in static molar biting.
Model predictions were compared with measured data from the subjects for eminence
shape and for muscle activity ratios . The results suggested that the mechanics of the
masticatory system are affected by the combined treatments. The TMJ loads increased in
8 subjects. The average increases in condylar and muscle forces were 4% relative to the
applied bite force, but in 1 case the increases were up to 20%.

Efficacy of high condylectomy for management of condylar hyperplasia

Larry M.Wolford, , Pushkar Mehra, AJO FEB 02

Compare the treatment outcome and long-term stability of 2 groups of young

adult patients diagnosed with active condylar hyperplasia and treated with 2 different
surgical methods. Group 1 (n = 12;) was treated with orthognathic surgery only, while

54
group 2 (n = 25) had high condylectomy, articular disc repositioning, and orthognathic
surgery. Lateral cephalometric radiographs were evaluated for presurgical and
postsurgical mandibular growth. There were no statistically significant differences
(P > .05) between the 2 groups for maximal incisal opening, lateral excursions, or
subjective jaw function before surgery. At the long-term follow-up, no differences were
found in lateral excursions or subjective jaw function. There was a statistically significant
difference in maximum incisal opening , with a greater increase in group 2, as
well as a statistically significant difference (P < .05) in cephalometric stability, with
group 2 being much more stable at long-term follow-up. All patients in group 1 grew
back into skeletal and occlusal Class III relationships and required secondary
intervention. Only 1 patient in group 2 required secondary surgery, involving maxillary
surgery to correct postsurgical transverse maxillary relapse; the mandible was stable at
long-term follow-up.
The results of this study showed that patients with active condylar hyperplasia treated
with high condylectomy, articular disc repositioning, and orthognathic surgery have
stable, predictable outcomes compared with those treated with orthognathic surgery
alone.

Rigid versus wire fixation for mandibular advancement: Skeletal and dental changes
after 5 years
Calogero Dolce, DDS, PhD,a John P. Hatch, PhD, AJO june 02
. To compare long-term (5 years) skeletal and dental changes between wire and rigid
fixation after BSSO. Skeletal and dental movements occurred in both groups throughout
the study period. Five years after surgery, the wire group had 2.2 mm of sagittal skeletal
relapse, while the rigid group remained unchanged from immediately postsurgery.
Surprisingly, at 5 years, both groups had similar changes in overbite and overjet. This
was attributed to dental changes in the maxillary and mandibular incisors. Although rigid
fixation is more stable than wire fixation for maintaining the skeletal advancement after a
BSSO, the incisor changes made the resultant occlusions of the 2 groups
indistinguishable.
In the wire fixation group, flaring of the mandibular incisors compensated for the
continued skeletal relapse (42%) of mandibular symphysis.
In the rigid fixation group, there was a transient anterior movement of the mandibular
symphysis and a posterior movement of the mandibular incisors.

There are advantages and disadvantages with both fixation techniques. Among the often-
cited advantages of rigid fixation is patient convenience. Because rigid
fixation requires little or no jaw immobilization, patients can resume their activities
sooner. Disadvantages of rigid fixation include undesirable palpability of
screws or plates and distortion of future magnetic resonance images or computed
tomograms. Irreversible nerve damage was a concern in early reports .some authors have
noted condylar resorption 6 months or longer after surgery when rigid fixation has been
used..

55
Surgically Assisted Rapid Palatal Expansion

Surgical relief of the zygomatic buttresses can facilitate the action of rapid palatal
expansion devices in non-growing patients. After the RPE phase, make a wax setup to
coordinate the expanded upper arch to the lower, which will also have been affected by
the expansion. This setup dictates the presurgical archform. The major advantage of the
buttress-relief procedure, therefore, is that the upper and lower arches can be precisely
coordinated and effective third-order control gained before surgery. The expansion will
also facilitate the placement of rigid plates following a LeFort I osteotomy, because the
lateral steps between the surgical fragments will be less severe than if the palate had been
split surgically.

Successful RPE will allow the upperteeth to be aligned and placed in the desired
presurgical positions without space-gaining extractions . However, it should be noted that
the mandible's tendency to rotate backward in conventional RPE also applies to the
surgically assisted procedure.

Orthognathic and Craniofacial Surgical Diagnosis and Treatment Planning: A Visual

Approach JCO 1982 Jan

It is necessary to consider the relationship of SN to the Frankfort Horizontal whenever

measurements based on SN are used. The measurements SNO (degrees) and O-NA (mm),
where O is orbitale and O-NA is the perpendicular distance from Point O to NA line, are
based on the work of Leonard and Walker and are useful in assessing midface dysplasia
when contemplating a High LeFort I, a LeFort II or, in severe cases, a LeFort III
procedure. If a patient has an SNO of less than 50° and an O-NA distance of more than
16mm, an unusual degree of malar and orbital retrusion is to be expected

Dentofacial Deformities Related to Midface Deficiencies Integrated Orthodontic-

Surgical Correction - LEWARD C. FISH JCO 1987 Sep
LeFort I Midfacial Advancement
This patient has essentially normal relations of the forehead, supraorbital rims, lateral
orbital rims, infraorbital rims, and nasal bridge relative to the globe. The nose appears

56
relatively prominent, yet is lacking in supratip projection. These features all indicate
maxillary retrusion or deficiency. Neck-chin length is normal. Therefore, if this patient
were to have a mandibular setback, chin definition would be lost and the nose would
appear even more prominent. facial features can best be improved by a LeFort I maxillary
advancement
Modified LeFort III Midfacial Advancement
This patient has infraorbital areas that are deficient or recessive relative to the globes.
Individuals with Class III malocclusions and these esthetic facial features would benefit
from a modified LeFort III midfacial advancement in which the malar bones and maxilla
are brought forward as a unit .
LeFort II Midfacial Advancement
The infraorbital rims can be either normal or, in some instances, recessive relative to the
globe., the nasal bridge— indeed the entire nose- is recessive relative to the rest of the
face..
LeFort III Subcranial Midfacial Advancement
Lateral and infraorbital rim deficiencies, retrusion of the nasal dorsum, a small or
retrusive-looking nose, paranasal convexity, and a normal nasal tip-subnasale-alar base
ratio

Conclusion
Dento facial deformities of the jaws have both functional and
esthetic component and only a coordinated approach by the orthodontist and surgeon will
establish an excellent occlusion with the condyles optimally seated within the glenoid
fossa.The first step in striving for an excellent results is correct diagnosis and meticulous
treatment planning.

57