Workshop

Planning Orthognathic Surgery 2010

Kamal F. Busaidy, BDS, FDSRCS, Associate Professor, Dept. Oral and Maxillofacial Surgery.

Overview of the Workshop
• • • • • • • • • • • • Setting goals Clinical evaluation Radiographic evaluation Cephalometric tracing and analysis Photographs Mounting of models Formulating the surgical plan Performing prediction tracings (The VTO) Model surgery and constructing splints The TMJ and orthognathic Surgery Planning for stability Pitfalls in planning and execution
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• Primary references:
– Modern Practice in Orthognathic Reconstructive Surgery (Edited by William H. Bell)

– Essentials of Orthognathic Surgery (Johan Reyneke)

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Goals in Orthognathic Surgery

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The Key to Successful Planning
• • • • • Find out where you are Determine your destination Plan your journey Allow for contingencies Communicate with the team

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What problem are we addressing?
• • • • Inability to incise or chew Speech impediment Oral health (dental, periodontal) Poor esthetics
• Facial soft tissue • Facial hard tissue • Dental

• • • •

OSA TMJ Primary versus secondary growth disturbance Psychological issues
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What is success?
• In the eyes of the patient success is measured by
– Addressing the original complaint – Absence of adverse outcomes – Stability of result Assuming there is no underlying psychiatric issue!

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Clinical Evaluation of the Orthognathic Surgery Patient

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The Team Approach • • • • • • • • • Orthodontist OMS General Dentist ENT Plastic surgeon Periodontist Prosthodontist Psychiatrist Pulmonologist/Sleep physician KB 2010 OMFS Evaluation • Stage 1 • Stage 2 • Stage 3 Initial evaluation/Feasibility Pre surgical evaluation Post surgical evaluation (Long term) KB 2010 5 .

Orthodontic Evaluation 6. Dental casts * Psychological Assessment KB 2010 6 . Health Status 3.Coordination of Care Referring Practitioner OMFS:1st Evaluation Ortho:1st Evaluation ENT / PRS etc OMFS: 2nd Evaluation Ortho Treatment OMFS: Surgery Ortho 2nd Evaluation Ortho Treatment Finalization OMFS: 3rd Evaluation Ortho 3rd Evaluation Perio / Pros etc KB 2010 Patient Evaluation 1. Cephalometric Evaluation 7. Complaint + History 2. Photos 8. Assessment of Facial Esthetics 4. Routine Dental Examination 5.

Facial Esthetics KB 2010 Facial Esthetics 1/3 1/3 1/3 KB 2010 7 .

4 mm Note lip-tooth relationships at rest and when active! 1/3 2/3 KB 2010 Facial Esthetics • Nasofacial Angle 30 . New York.110 Powell and Humphreys: Proportions of the Aesthetic Face.Facial Esthetics ULL 21mm (+/. Thieme-Stratton.2 mm) Men ULL 19 mm (+/-2 mm) Women Incisor Show at Rest 2 .40 o o • Nasomental Angle 120 -132 o o • Mentocervical Line 80 – 95 to Vertical o o • Mentocervical Line 110 – 120 to Nasomental Line o o • Nasolabial Angle 100 . 1984 KB 2010 o o 100 8 .

Dental Esthetics Tooth Location (Midline) Tooth Size Tooth Shape Tooth Number Tooth Orientation Emergence Tooth Color KB 2010 Dental Esthetics Arch Form Occlusal Plane Occlusal Level Overbite Overjet Buccal Corridor Surrounding Tissues KB 2010 9 .

KB 2010 Case Example KB 2010 10 .

Case Example SMILE REST 12 mm 9 mm KB 2010 Case Example KB 2010 11 .

Poor bridges (shape/color) KB 2010 12 .Case Example KB 2010 Case Example Class II Skeletal Pattern (*mandible) Increased incisal show No increased LFH! Close bite (?traumatic) Maxillary cant Ocular dystopia Unstable occlusion.

Radiographic Evaluation of the Orthognathic Surgery Patient KB 2010 Radiographs • Lateral Cephalogram • Panoramic Dental Xray • • • • Periapicals SMV PA Cephalogram Others (MRI/CT/Bone scan/Wrist Films) KB 2010 13 .

symphysis) • Position of proximal segment post op • Position of internal fixation post op KB 2010 14 .MRI/CT/Bone scan/Wrist Films • • • • • TMJ meniscus position OSA Complex craniofacial deformities Local growth disturbance (Condylar Hyperplasia) Systemic growth disturbance (Excess growth hormone) • Autoimmune arthritis • Assessment of completion of growth KB 2010 PA Cephalogram • Symmetry (particularly gonial angles.

SMV • • • • Thickness of mandible (Superseded by CBCT!) Flaring of rami (vertical ramus osteotomy) Position of proximal segment post op Position of internal fixation post op KB 2010 Periapicals • Periodontal bone loss • Proximity of apices (multi-piece segments) • Periodontal bone loss post op KB 2010 15 .

Panoramic Radiograph • Third Molars • Inferior alveolar nerve position • Intraosseus pathology (best screening tool) • Position of fixation post op • Position of condylar head post op KB 2010 Lateral Cephalogram • • • • • Skeletal proportions Growth prediction Cessation of growth Soft tissue measurements Planning (primary tool) • Position of fixation post op • Baseline post op status*** KB 2010 16 .

Cone Beam CT Dolphin Imaging KB 2010 Lateral Cephalogram What is wrong with this Lateral Ceph? KB 2010 17 .

the point at about 11 0’clock on the outline of the pterygomaxillary fissure adjacent to the foramen rotundum Or-Orbitale: the lowest point on the inferior margin of the orbit ANS-anterior nasal spine: the tip of the anterior nasal spine Point A: the innermost point on the contour of the premaxilla between the anterior nasal spine and the incisor tooth Pog-Pogonion: the most anterior point on the contour of the chin Pm-Suprapogonion: the point where the anterior curvature of the mandible changes from concave to convex Me.The point in the middle of the ramus. at the base of the clivus Po-Porion: the midpoint of the upper contour of the external auditory canal (anatomic porion). or.Menton: the most inferior point on the mandibular symphysis Na-Nasion: the anterior point of the intersection between the nasal and frontal bones Go.Lateral Cephalogram Nasion Pt point Porion Basion Xi Point Gonion Pm Point Pogonion Menton Gnathion PNS Orbitale ANS A Point KB 2010 • • • • • • • • • • • • • • • Ba. approximately in line with the occlusal plane FH-Frankfort Plane: the horizontal reference plane in the heads natural position extending from the porion to orbitale KB 2010 18 . the midpoint of the upper contour of the metal ear rod of the cephalometer (machine porion) Pt.Gonion: the midpoint of the contour connecting the ramus to the body of the mandible Gn-Gnathion: the most outward and everted point on the mandibular symphysis PNS-Posterior nasal spine: the tip of the posterior nasal spine of the palatine bone. at the junction of the hard and soft palate Xi.Basion: the lowest point on the anterior margin of the foramen magnum.

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KB 2010 Lateral Cephalogram MARK THESE POINTS ON YOUR CEPHALOGRAM Porion Basion Xi Point Pt point Orbitale PNS ANS A Point Nasion Gonion Pm Point Pogonion Gnathion Menton KB 2010 19 . and start measuring the pertinent angles using Rickett’s analysis.Hands-on Exercise •Lateral Ceph •Pencil •Protractor/Ruler Identify the points marked in the previous slides. (then trace the outlines of the skeleton as described).

Facial Depth (Angle) 87 +/.4 o 26 o Mandibular Plane Gonion Pogonion Menton KB 2010 20 .3 Nasion o Frankfort Horizontal Porion 87 Orbitale o Pogonion KB 2010 Mandibular Plane Angle: 26 +/.

Facial Axis: 90 +/.3 o 90 o A point KB 2010 21 .3 o 90 Basion o Skull Base KB 2010 Maxillary Depth: 90 +/.

Convexity at point A: 2mm +/.2 mm A point Pogonion KB 2010 22 .2 mm A point KB 2010 Lower incisor to APog: 1mm +/.

4 o ANS Xi 47 o Pm Point KB 2010 23 .Xi Point and Functional Occlusal Plane Xi KB 2010 Lower Face Height : 47 +/.

Interincisal Angle: 130 o 130 +/-6 o KB 2010 Other Analyses 32 +/-5 o Approximately Parallel 112 +/-6 112 +/-6 130 +/-6 o o o 90 +/-7 o KB 2010 24 .

KB 2010 WHICH THIS PATIENT IS NOT Clinical Photography KB 2010 25 .Evaluation of Soft Tissue on Lateral Ceph 30-40 o UFH: 130 o 100-110 o LFH: 120-132 o o 85-95 CHECK THAT THE PATIENT IS IN REPOSE.

Clinical Photographs KB 2010 Clinical Photographs KB 2010 26 .

Mounting the Case KB 2010 • • • • • Take the impressions Interocclusal records Face bow record Mount the casts Measuring in 3 planes of space KB 2010 27 .

Impressions • 2 sets of upper impressions • 2 sets of lower impressions • Block out brackets with wax to prevent distortion of the impression • Avoid bubbles/voids in pour-up KB 2010 KB 2010 28 .

Interocclusal Record • Record occlusion in centric relation (Potential disparity with centric relation when asleep) • Avoid displacement from premature contacts (Wax is not ideal for occlusal records) • Alternatives: • Record occlusal relationship supine • Deprogramming • Short general anesthetic! KB 2010 Facebow Recording • Find Frankfort Horizontal (Easier said than done!) KB 2010 29 .

A Common Reference Plane The Frankfort plane identified clinically should correlate with the Frankfort plane on the articulator AND the lateral Ceph KB 2010 True Frankfort versus Clinical KB 2010 30 .

2001 Jun. KB 2010 31 . discussion 640-1.59(6):635-40.Radiographic Frankfort Projected Frankfort Clinical Frankfort KB 2010 Identifying True Frankfort J Oral Maxillofac Surg.

Identifying True Frankfort KB 2010 A Common Reference Plane KB 2010 32 .

Facebow Recording • Find Frankfort Horizontal (Easier said than done!) • Ensure the facebow is centered on the face • Lock down the hinges to prevent distortion of record KB 2010 Midlines and occlusal angulations/cants are consistent with clinical picture KB 2010 33 .

Mount Two Sets of Casts A B KB 2010 Erickson Model Block and Platform KB 2010 34 .

KB 2010 3 Planes of Measurement KB 2010 35 .

3 Planes of Measurement

RIGHT SIDE DOWN!

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3 Planes of Measurement

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3 Planes of Measurement

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Formulating the Surgical Plan and the VTO

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When I hand articulate the models can I get a good occlusion? Segmental maxilla / (Segmental mandible) / More Ortho
No Yes

Proceed to Next

Is the position of the anterior maxilla acceptable?
No Yes

Proceed to Next

Maxillary osteotomy

Mandible acceptable?
No No. There is an AOB Yes

Mandibular osteotomy

Maxillary osteotomy +/Mandibular osteotomy

No

Is the position and form of the chin acceptable?

Yes

Genioplasty

Finished

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Prediction Tracing: Exercise One
Visualized Treatment Objective (VTO) for Mandibular Sagittal Split Osteotomy

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Exercise 1: VTO for BSSO Setback

Trace the cephalogram and indicate in the mandible where the osteotomy will be placed KB 2010 Take a new piece of tracing paper and trace over the original: only trace structures in the maxilla and above. Trace the soft tissues of the nose and upper lip. KB 2010 39 .

Reposition the prediction tracing on the original such that the maxillary teeth of the prediction tracing meet the mandibular teeth on the original tracing in class 1 Trace the mandible ANTERIOR to the osteotomy line. Rotate the prediction tracing around the axis of rotation in the condylar head until the inferior border of the proximal mandibular segment seems aligned with the inferior border of the distal segment. Note the degree of overlap. KB 2010 40 . including the teeth. Trace the soft tissues of the lower lip and chin. This corresponds to the amount of mandibular setback. KB 2010 Reposition the prediction tracing such that the skull bases and orbits coincide. Trace the proximal mandibular segment.

Exercise 2: VTO for Le Fort 1 .

Prediction Tracing: Exercise Two Visualized Treatment Objective (VTO) for Maxillary Le Fort 1 Osteotomy KB 2010 Trace the cephalogram and indicate in the maxilla where the osteotomy will be placed KB 2010 41 .

This represents the overbite.e. Trace the entire mandible and the soft tissue of the neck and chin up to the labiomental fold. Mark a horizontal line that corresponds to the level of desired maxillary incisal vertical height KB 2010 Rotate the top sheet around the axis of rotation in the condylar head until the tip of the lower incisors protrude above the horizontal line by 2 to 3 mm. above the osteotomy cut). Stop tracing the soft tissue of the nose at the supra-tip break. KB 2010 42 .Take a second piece of tracing paper and trace again all the structures that will NOT move during the osteotomy (i.

Reposition the top tracing over the original such that the maxillary dentition occludes with the new mandibular dentition in class 1. Pay particular attention to the incisal relationship. KB 2010 Reorient the prediction tracing on the original such that the skull bases and orbits coincide. Trace the remainder of the nose and upper lip. Make a note of these measurements. KB 2010 43 . Examine also the effect on the chin prominence and assess whether a genioplasty is required. then complete the tracing of the lower lip. Examine the degree of movement of the maxilla in 2 planes. Trace the maxilla and the maxillary teeth. Examine the degree of autorotation of the mandible.

Exercise 3: VTO for 2-Jaw Surgery .

Prediction Tracing: Exercise Three Visualized Treatment Objective (VTO) for Bimaxillary Osteotomy (Le Fort 1 and BSSO) KB 2010 Trace the cephalogram and indicate in the maxilla AND mandible where the osteotomies will be placed KB 2010 44 .

Indicate with a vertical line the desired AP position of the incisal edge of the maxillary incisors KB 2010 Rotate the top sheet around the axis of rotation in the condylar head until the tip of the lower incisors protrude above the horizontal line by 2 to 3 mm.Take a new sheet of tracing paper and trace over the original: only trace structures that will NOT move in either the maxillary or mandibular osteotomies. Stop tracing the soft tissue of the nose at the supra-tip break Indicate the desired vertical height of the incisal edges of the maxillary teeth with a horizontal line. KB 2010 45 . Trace the mandible. This represents the overbite.

Align the maxillary occlusal plane with the occlusal plane of the mandibular teeth on the prediction tracing.The degree of reverse overjet indicates the amount the mandible must be set back. Label this tracing “IPT” (Intermediate Prediction Tracing) KB 2010 46 . KB 2010 Your prediction tracing should look like this now. Reposition the prediction tracing such that the maxillary incisal edge rests in the indicated ideal position. (Note that the maxillary teeth NEED NOT be in class 1 occlusion with the mandibular teeth at this point!) Trace the maxilla and the maxillary teeth. Trace the remainder of the nose and the upper lip.

Trace the mandibular teeth.Take a new sheet of tracing paper and trace over all hard structures on the first prediction tracing except the mandible. Label this tracing “FPT” (Final Prediction Tracing) KB 2010 Place the Final prediction tracing (FPT) over the Intermediate Prediction Tracing (IPT) in such a way that the maxillary teeth on the FPT meet the mandibular teeth on the IPT in class 1. Trace soft tissues down to and including the upper lip. KB 2010 47 . Trace the mandible ANTERIOR to the mandibular osteotomy line. It is recommended that you use a different color pencil.

KB 2010 48 . KB 2010 Place the FPT on the original tracing of the cephalogram such that the lower incisor and symphysis of both coincide. Rotate the FPT around an axis of rotation on the condylar head until the inferior border of the proximal mandibular segment aligns with the inferior border of the distal mandibular segment. Estimate the predicted chin and lower lip shape.Reposition the FPT on the IPT such that the skull bases and orbits coincide. Trace the proximal mandibular segment. The overlap indicates the amount of mandibular setback.

Note that the post-surgical occlusal plane in this example was determined by the occlusal plane of the mandible after rotation. KB 2010 Soft Tissue Predictions Mandible • Advancement – Chin 100% – Lower Lip 70% • Setback – Chin 90% – Lower Lip 90% – Upper Lip 20% KB 2010 49 . however the occlusal plane can be adjusted (within limits) to fit the needs of the individual case.Your FPT should now look like this. Measure the vertical and AP predicted movement of the maxilla and mandible and record the measurements.

Soft Tissue Predictions Maxilla • Advancement – Nasal Tip 30% – Upper Lip 50% at incisor level (70% .60% (Less with VY) – Subnasale 30% (Less with VY) – Upper Lip 10% KB 2010 Soft Tissue Predictions Maxilla • Inferior – Lip length increases 10-15% • Superior – Subnasale 20% up – Nasal Tip 20% up – Lip 10% up (Less if VY) KB 2010 50 .90% with VY closure) – Upper lip shortens 1-2 mm • Setback – Upper Vermillion 50% .

10 o Z Line: Tangent to most protrusive lip and soft tissue chin KB 2010 51 .Predicting Chin Position Horizontal distance to 0-Meridian 0-Meridian 0-Meridian: Perpendicular to FH from soft tissue forehead. Chin should be 0-3mm ahead of this line KB 2010 Predicting Chin Position FH to Z Line Z Line 78 +/.

3. position of maxilla form lateral ceph Predict ideal superior/inferior position of anterior maxilla from clinical incisal show Set occlusal plane: Use Xi point. 2. 4. 5.Predicting Chin Position H Line to NB H Line H Line: Tangent to most protrusive lip and soft tissue chin 8 +/. Frankfort Horizontal and mandibular occlusal plane as primary guides Find required lateral repositioning of maxilla from clinical assessment of midlines Assess cant from clinical measurement and mounted casts Assess maxillary arch width from models KB 2010 52 . Predict ideal A. 6.2 o KB 2010 Review of Process in Planning.P. Start with the Maxilla 1.

Detailed Process in Planning (continued) 7. Are the movement planned so far reasonable. 8. AP and arch width dimensions of the posterior and anterior maxilla and the intended amount of set back/push forward at the mandibular osteotomy. 9. Re-analyze using Ricketts to compare the VTO to cephalometric norms. or change the plan entirely. transverse. Trace the new maxilla and mandible positions (VTO) as we did in the exercises. If not start again and redistribute the movements between the maxilla and mandible. KB 2010 Detailed Process in Planning (Step Back) 10. Record the intended changes in vertical. (SARPE or more orthodontics) KB 2010 53 .

12.Detailed Process in Planning (Chin and Profile) 11. 13. particularly the chin Proceed to model surgery Verify on the models that the movements are surgically feasible KB 2010 Model Surgery and Splint Construction KB 2010 54 . Assess the projected soft tissue profile.

Vertical and Transverse). 6. 8. 7. 3. KB 2010 Adjust Occlusal Surfaces Segment maxillary cast at this stage to achieve best occlusion if performing multipiece Le Fort 1 Record where occlusal adjustments are made so that they can be duplicated intraoperatively KB 2010 55 . 4.Model Surgery 1. Segmentalize the upper segment if necessary and make occlusal adjustments to give best intercuspation Mount maxillary model to new position using the Erickson model block and platform Mount mandibular model to new position (in occlusion with upper model) on the articulator Verify movements correlate with intention Note magnitude of movements in all planes Verify movements are surgically feasible Construct splints 2. Calculate the new measurements that would give the desired new maxillary cast position (AP. 5.

Remount Upper Cast to Desired Position in Space KB 2010 Maxillary Post op cast with Mandibular Post op cast Final splint ONLY CONSTRUCT FINAL SPLINT FIRST KB 2010 56 .

Maxillary Post op cast with Mandibular Pre op cast Final splint AND Intermediate splint CONSTRUCT INTERMEDIATE SPLINT SECOND KB 2010 Final Splint Final Splint capable of being wired into maxillary dentition to support maxillary fixation KB 2010 57 .

KB 2010 58 .Intermediate Splint Intermediate Splint should locate positively in Final Splint KB 2010 Summary • Take the records meticulously • Verify that the “A” casts match the “B” casts • Verify that the mounted casts match the clinical picture • Perform the model surgery on one set of casts • Construct the splints in correct sequence for the planned surgery.

TMJ Considerations in Orthognathic Surgery KB 2010 The “Normal” TMJ • What does a normal TMJ look like and how do we identify it? – Clinically – Radiographically – MRI KB 2010 59 .

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KB 2010 Goals of Orthognathic Surgery as Relate to the TMJ • Restore/maintain “normal” range of opening • Eliminate/avoid joint pain and noises • Achieve stable condyle and meniscus position in fossa when teeth are in centric occlusion • Where is the ideal location for the condyle? KB 2010 61 .

Condylar Malposition • Condylar sag: Inferior displacement of the condylar head within the glenoid fossa KB 2010 Central Condylar Sag • Condyle is positioned inferiorly in the fossa • No contact between condylar head and articular fossa in centric occlusion • Immediate malocclusion on release of fixation (assuming no hemarthrosis or joint edema is present) KB 2010 62 .

Central Condylar Sag KB 2010 Peripheral Condylar Sag • Contact between condylar head and articular fossa may support the inferiorly positioned condylar head • Immediate or late relapse • Late relapse associated with condylar resorption KB 2010 63 .

Peripheral Condylar Sag KB 2010 Condylar Resorption KB 2010 64 .

Other Causes of Condylar Malposition • Posterior positioning of condyle is associated with increased risk of post-operative symptoms of popping and locking. paralyzed state – Improper surgical technique – Condylar sag KB 2010 Other Causes of Condylar Malposition • Uneven contacts between the proximal and distal segments may cause the condyle to become laterally or medially displaced when fixation is applied KB 2010 65 . • Limit that the condyle may be posteriorly positioned increased by – Supine.

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Minimizing Condylar Malposition • Avoid creating intrarticular edema or hemarthrosis – Support during split – Support during mobilization – Avoid rotating the condyle around its long axis KB 2010 Minimizing Condylar Malposition • Avoid bad splits. they complicate condylar positioning! KB 2010 67 .

Minimizing Condylar Malposition • Ensure adequate stripping of medial pterygoid to eliminate interference to distal movement of distal segment. • Reduce bony interferences. KB 2010 Minimizing Condylar Malposition • Eliminate uneven contact between osteotomized segments that prevent passive. even and stable apposition KB 2010 68 . especially on mandibular setback.

Minimizing Condylar Malposition • Gentle use of clamps to hold segments whilst placing fixation KB 2010 Minimizing Condylar Malposition • Use shims of bone to eliminate intersegmental gaps KB 2010 69 .

KB 2010 70 . More difficult to achieve with positional screws.Minimizing Condylar Malposition • Avoid lag screw fixation • Positional screws are fine KB 2010 Minimizing Condylar Malposition • Plates can be adapted in order to provide passive fixation.

Minimizing Condylar Malposition • Positioning the condyle prior to fixation – Direction of force – Magnitude of force KB 2010 KB 2010 71 .

Minimizing Condylar Malposition • Ensure adequate bone removal at posterior of maxilla in Le Fort 1 osteotomy KB 2010 KB 2010 72 .

Minimizing Condylar Malposition • Avoid heavy post-op elastics as the effect on the occlusion may be more temporary than you think! KB 2010 Idiopathic Condylar Resorption • Progressive alteration of the condylar shape with decreased mass bilaterally. in temporomandibular joints that previously exhibited normal growth patterns • AICR (Adolescent Internal Condylar Resorption) KB 2010 73 .

Risk Factors for ICR • • • • • • • Female Age 15-30 Pre-op TMJ disease Mandibular hypoplasia High mandibular plane angle Small posterior face height Posterior inclination of condylar neck • Large mandibular advancement • Counterclockwise rotation • IMF • Posterior repositioning of condylar head in fossa • Increase in ramus length KB 2010 Idiopathic Condylar Resorption KB 2010 74 .

Idiopathic Condylar Resorption KB 2010 Treatment and Prognosis • Re-osteotomy alone has 50-100% failure rate • Stabilization of occlusion with occlusal splint prior to re-osteotomy has similar failure rate • Orthodontic occlusal compensation and stabilization achievable in some • Advanced cases require condylectomy and joint reconstruction (alloplastic or costochondral) KB 2010 75 .

Effect of Orthognathic Surgery on the Symptomatic TMJ Patient • Lack of consistency in terminology used to categorize TMJ disease • Populations are often poorly described • Outcomes are poorly defined • Lack of information on the post-op condylar position in patients studied KB 2010 Concomitant TMJ and Orthognathic Surgery for Symptomatic TMJ Patients • Pts without symptoms from TMJ pathology can become symptomatic after orthognathic surgery • Pts with anterior disc displacement prior to BSSO will most likely not improve. and may get worse • IVRO in a pt with ADD improves disc-condyle relationships and pain KB 2010 76 .

looking at 51 pts with pre-op TMJ symptoms and compared concomitant TMJ + orthognathic surgery to orthognathic surgery alone.Concomitant TMJ and Orthognathic Surgery for Symptomatic TMJ Patients • Goncalves et al (JOMS April 2008). Retrospective cohort study. Demonstrated improved stability and relief of symptoms in the former group after 31 months follow up KB 2010 Summary • Perform a baseline TMJ exam on every patient • Avoid intra-operative trauma to the TMJ that might cause intra-articular edema • Take care with positioning and fixation of the segments • Orthognathic surgery may induce symptoms from the TMJ • Consider treating the TMJ first if disease is present KB 2010 77 .

Stability Issues KB 2010 Instability • Early: From the time of surgery up to week 8 After 8 weeks • Late: KB 2010 78 .

Long Term Stability in Maxillary Osteotomies MORE STABLE • • • • Impaction Setback Advancement Downgraft Expansion (**SARPE) Advancement with downgraft KB 2010 LESS STABLE • • Long Term Stability in Mandibular Osteotomies MORE STABLE • Advancement*** (Proportional to advancement) • LESS STABLE Setback ***Idiopathic Condylar Resorption KB 2010 79 .

(*Cleft cases) • Overcorrection especially when doing a mandibular setback (easier to correct a relapsing class II with ortho than a relapsing class III) • ? Rigid fixation versus IMF.Limiting Long Term Instability • Bone grafting especially when downgrafting a maxilla by 5mm or more • Conservative moves. ? Positional Screws versus miniplates KB 2010 Pitfalls in Planning and Execution • Leaving appliance activated at time of surgery • Inadequate strength of arch wire at surgery • Inadequate incisor decompensation (leads to inappropriate incisal relationship) • Inaccurate pre-op occlusal record (condylar position) • Inadequate root divergence before segmentalizing • Hasty split (fracture or nerve damage) • Occlusal splint too thick • Poor condylar position during application of fixation • Excessive torque on proximal segment during fixation KB 2010 80 . not ambitious.

Pitfalls in Planning and Execution (continued) • Compromising blood supply – Gingivae during flap for segmental osteotomy – Over-ambitious advancement Le Fort 1 level • • • • • • Tear of palatal mucosa during segmentalization Condylar sag (very difficult to plan for) Failure to check condylar position post-op Setback of mandible in presence of a flat chin-throat angle Planning for >6mm posterior maxillary impaction Weak brackets/hooks at time of surgery KB 2010 81 .