ORTHOGNATHIC

SURGERY

PROF DR
AHMED ABDEL-FATTAH RAMADAN
PROF OF ORTHODONTICS
BDS,MSD,PHD,FDSRCSED
SUEZ CANAL UNIVERSITY
‫بسم هللا الرحمن الرحيم‬
 Introduction

Orthognathic surgery is a process in which dentofacial deformities

and malocclusions are corrected with orthodontics and surgical
operations of the facial skeleton, sometimes combined with
various soft tissue procedures.

The term orthognathic originates from the Greek words orthos,

‘straight’, and gnathos ‘jaw’.
It is possible to correct, or straighten”, deformities separately in
either the maxilla or the mandible with many types of surgical
techniques.

“
 HISTORY OF
MANDIBULAR SURGERY
Surgical procedure to correct skeletal
mandibular deformity was described early in
1900.
Body ostectomy to shorten the mandible was
descried at 1950.
Subcondylar osteotomy (Caldwell1954) with
extra oral approach replaced body
ostectomy.
 HISTORY OF
MANDIBULAR SURGERY
Surgery to increase the mandibular length was
popularized by Obwegeser and Trauner (1957)
who described intraoarl approach for
lengthening of the mandible.
 HISTORY OF MAXILLARY
SURGERY

At 1952 In the USA, Converse (surgeon) reported

on maxillary osteotomy.

Before 1965 the dentofacial deformity was

treated with mandibular surgery alone.
 HISTORY OF MAXILLARY
SURGERY
LeFort I oseotomy with down fracture was
originated with Cheever in 1864, after a century
this technique became popular in USA.
In 1921 a German surgeon Herman Wassmund
introduced maxillary osteotomy technique.
In 1934 Auxhausen move the maxilla downward
to treat open bite.
 Indications for
Orthognathic Surgery
Severity of skeletal and dental malocclusion in one or
both jaws and in sleep apnea as well.
When growth modification can not be achieved
Esthetic and psychosocial considerations
 Timing of Surgery

Usually done when all growth is complete

Assessed by superimposition of serial lat cephs
Can be performed when growth is not yet
complete in cases of psychosocial problems or
great severity when function is compromised
(i.e. breathing, chewing)
 RULES OF ORTHOGNATHIC
SURGERY

1- Normal jaw relationship must not be changed

to compensate for abnormal tooth relationship.

2-The teeth must not be tipped beyond the limits

of their normal position to compensate for
abnormal jaw relationship.
 RULES OF ORTHOGNATHIC
SURGERY
3- Malposed teeth should first be properly
positioned on malrelated jaws, and jaws should
then be repositioned. Final dental adjustment
may be needed.

4- Correction of jaw discrepancy should be

carried out by moving of malposed jaw into
proper relation with the normally positioned
one.
The successful outcome of orthognathic surgery
depends not only on optimal tooth movement
and jaw repositioning ,but also on the
motivation and expectations of the pt.

Defining the etiologic factor for the present

abnormality is the first key to avoid relapse.
It is impossible to treat all pt problems at first by
orthodontic means ,and if it is failed, refer the pt
to orthognathis surgery.
WHY?
The treatment mechanics that would be
employed in a surgical case will often be
exactly opposite in all dimensions to that
orthodontic case alone.
MAXILLARY SURGERIES
 Orthognathic Surgery
Correction of A-P relationships in the maxilla:
Maxillary advancement
Retraction of anterior maxillary segment
Double jaw surgery
 Correction of Transverse
Relationships in the maxilla
Surgically assisted maxillary expansion
 LeFort 1 Osteotomy
is a type of surgery that involves moving the upper jaw (maxilla) to a
desired position and/or direction. After the upper jaw is removed from
the skull, it is secured in position with titanium plates and screws.
The upper jaw can be moved forward, backwards, downwards, upwards
or titled in an angle to correct a variety of conditions such as:

Gummy smile
Long face syndrome
Short face syndrome
Overbite Canting
Open bite
Off-centre jaw canting
 Le Fort II osteotomy

Le Fort II osteotomy is surgery

to move the upper jaw and nose
together to align with the
forehead and chin area; the
upper jaw and nose are held in
the desired position with screws.
 Le forte III

Le Fort III osteotomy is surgery to

move the upper jaw, nose, and
cheek bones together, usually
forward, to become aligned with the
forehead and chin area; skull (or
other) bone is used to fill in gaps
and attached to the existing bone
with screws.
 3
1 2
 Distraction osteogenesis

Distraction osteogenesis, also called callus distraction, is a surgical process used to

reconstruct skeletal deformities and lengthen the long bones of the body.

A corticotomy is used to fracture the bone into two segments, and the two bone ends of
the bone are gradually moved apart during the distraction phase, allowing new bone to
form in the gap.

When the desired or possible length is reached, a consolidation phase follows in which
the bone is allowed to keep healing. Distraction osteogenesis has the benefit of
simultaneously increasing bone length and the volume of surrounding soft tissues.
 TREATMENT OF OSA

Nasal surgery, including turbinectomy (removal or reduction of a nasal turbinate),

or straightening of the nasal septum, in patients with nasal obstruction or

congestion which reduces airway pressure and complicates OSA.

Tonsillectomy and/or adenoidectomy in an attempt to increase the size of the
airway.

Removal or reduction of parts of the soft palate and some or all of the uvula, such
as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP).
Modern variants of this procedure sometimes use radiofrequency waves to heat
and remove tissue.
 TREATMENT OF OSA

Reduction of the tongue base, either with laser excision or

radiofrequency ablation.

Genioglossus advancement, in which a small portion of the

lower jaw that attaches to the tongue is moved forward, to
pull the tongue away from the back of the airway.

Hyoid suspension, in which the hyoid bone in the neck,

another attachment point for tongue muscles, is pulled
forward in front of the larynx.
Maxillomandibular advancement
MANDIBULAR
SURGERIES
 Correction of A-P relationships
in the mandible:

Mandibular advancement
Mandibular setback
Genioplasty
 Evolution of the sagittal split ramus osteotomy of
the mandible

A. Obwegeser & Trauner

technique (1957)

B. DalPont modification
(1961)
C. Hunsuck modification
(1968)

Epker modification
(1977)
 BSSO

Mandibular ramus sagittal split osteotomy is the most

common technique used for mandibular advancement
 Correction of Vertical
Relationships in the
mandible
Mandibular ramus surgery

The vertical ramus osteotomy can be

used to set the mandible posteriorly
The inverted L-osteotomy can be used to set the mandible posteriorly. It also
allows vertical lengthening or shortening of the ramus without affecting the
major muscles of mastication .
The vertical body osteotomies can be performed in any area of the mandible
to move the anterior segment of the mandible posteriorly, or alter the vertical
and transverse position .
The anterior subapical osteotomy
The genioplasty
 IN CASES OF
MANDIBULAR DEVIATION
.
unilateral sagittal split ramus osteotomy
(USSRO)+ intra oral vertical ramus
osteotomy (IVRO) can be useful in
correcting mandibular deviation as well as
improving signs and symptoms of TMJ
disorders.
However, it also seems important to be aware
of the possibility of horizontal mandibular
relapse in patients with condylar bony
change.
 Orthognathic model
surgery procedures
Model surgery has become an essential
procedure for planning surgical outcome for
patients requiring the correction of a dentofacial
deformity.
MOCK SURGERY IS
ESSENTIAL STEP
Articulator selection

Plain line or simple hinge articulator this can be used

satisfactorily in the following applications.
1. Maxillary advancement with no height change of
the Maxilla i.e.: no impaction / no down graft.
2. Mandibular advancement as a single jaw procedure.
3. Mandibular set back as a single jaw procedure.
4. Segmental surgery with no height change.
 Semi-adjustable
articulator and face bow
this can be used satisfactorily in the following
applications.
Maxillary osteotomies with height changes i.e.:
impaction or downgraft.
Bi-Maxillary procedures.
Segmental or multi-part maxillary osteotomies.
Cases of facial asymmetry.
Condylar post set to 15° to
replicate medio-lateral
condylar angle
.
Condylar inclination set to
30 to replicate antro-
posterior condylar plane
.

Incisal pin 0° Incisal table 0°

Trimming of the casts
 Marking the casts

All markings on the casts should be scribed using a scalpel

or similar instrument.
It is also useful to use a colour coding system for the model
markings.
The example shown uses red marker for all pre-op positions.
The first line marked (A) on the articulated casts is a
horizontal line scribed 5mm from the base of the articulated
model
A second line is scribed on the white mounting
plaster (B.). The distance between the two lines
should be sufficient to allow trimming if maxillary
impaction is required.

The master casts should not be trimmed as this will

make returning the casts to the starting position .
Any plaster to be removed for a maxillary or
segmental impaction should be limited to the white
mounting plaster.
The distance between the two
horizontal lines is not critical however
it must be scribed on the cast to
ensure being able to re-measure the
model surgery at a later date
A

Model base is 5mm

The white plaster is 15mm
Vertical lines
Posterior maxilla rotation lines
scribed on the cast
Advancement measurement device.
The first stage in the planning procedure is to cut a
duplicated set of models in order to assess what
occlusion is achievable. This is not an anatomical
procedure at this stage and is only an occlusal
assessment
 On completion of this assessment the face-bow
recording is taken and the upper and lower dental
casts are articulated on the semi-adjustable
articulator as previously described.
A set of study casts are taken and must be kept
as a record of the pre-op occlusion..

A set of study casts are taken and must be kept as a record

of the pre-op occlusion.
The cast is now segmented to duplicate the cuts
made in the preliminary plan .The segments of the
maxillary cast are repositioned in optimum
occlusion using the lower cast and are sealed
together using sticky wax .
Occluded segmented cast
Maxillary cast re attached to the mounting plaster
The mandibular cast is separated from the mounting
plaster in the same way as described for the maxillary
cast. The mandible is repositioned to the prescribed
final occlusion
 ROLE OF ORTHODONTIST
PRE SURGERY
1- Formulate the treatment plan.
2- Leveling of both arches.
3- Provide space for osteotomy cut .
4- Expansion of the upper arch if needed.
5- Correction of rotation and premature contacts.
6- Closing of the spaces in the arch.
7- Decompensation of dentition.
8- Coordinated both arches.
Check List for Treatment
Planning
A-P relationships maxillary deficiency/protrusion
mand prognathism/deficiency
amount of deficiency
Vertical relationships open bite
deep bite
Transverse relationships crossbites
before surgery expansion
surgically assisted expansion
 Post Surgical Orthodontic
Treatment
1 week: check occlusion, splint and appliances
4-6 weeks: reinitiate orthodontic tx (after range of
motion and stability are achieved)
remove splint
change to light wires and light vertical elastics
treatment usually completed in 4 to 12 months
(average 6 months)
Surgical increase in posterior vertical dimension
is unstable and correlates with relapse.
Douman et al 1991

There is no relationship between pre surgical

extrusion of incisors and the stability of open
bite correction. L0 and Shapiro 1998

Limitation of any extrusive pre surgical movement

is recommended to avoid relapse. Woods 1998
Accurate splint stable result
The existing stomatognathis system is in state of
functional balance.

Surgical interference will create state of

imbalance due to change in bone positions.

Post surgery, the stomatognathic system should

be in state of balance again.
 1- FIXATION

Rigid fixation (bone plates) it is the most reliable

and stable method because the muscles of
mastication and TMJ could return to normal
function more quickly after surgery.

Smith (1985) found 45% relapse of advanced

mandible during the period of maxillo-
mandibular fixation.
 2- MUSCLE FORCE

Soft tissue tension as a general and suprahyoid

muscles in particular will play a major role in
relapse after mandibular advancement.
*Shoulder –chin brace appliance
*Cervical collar
*Myotomy
Ellis and Gallo (1986)
 3- CONDYLAR FACTOR

Avoid distalization of proximal segment during

fixation after mandibular set back.

Positional changes of the proximal segment was

found to be the most important parameter in
detrming stability after advanced mandible.
 3- CONDYLAR FACTOR

There should be bony overlap so the proximal

part should be lateral to the distal part.

Fixation is carried out while the upper and lower

jaws are in centric occlusion and the condyles
are in centric relation.
Pre existing internal derangement of the TMJ is a
major cause of relapse.
 4- DEGREE OF
ADVANCEMENT
The greater the amount of surgical advancement,
the higher the probability to do either of :
Rigid fixation
Myotomy
Bone grafting
Coronoidectomy
Petrson
(1997)
 5- SITE AND DIRECTION

After maxillary expansion, bone grafting will not

prevent the relapse.
Overcorrection may prevent the relapse.
 6- TYPE OF SURGERY

The most stable surgical procedure is the

superior repositioning of the maxilla and
mandibular advancement.
The least stable surgical one is the transverse
expansion of the maxilla.
To maximize bone contact and minimize muscle
pull, C shape, L osteotomy, inverted L are
better modifications to traditional sagittal split
type.
Relapse and Stability
 A different pattern of
stability
(1) in about 20% of the patients who had
mandibular advancement (with or without
simultaneous maxillary surgery), mandibular
length decreases between 1 and 5 years post-
treatment .
(2) after superior repositioning of the maxilla,
downward movement of the maxilla, in what
appears to be a resumption of the original
growth pattern, leads to >2 mm change in about
one-third of the patients.
(3) clinically significant changes in the position or
dimensions of the maxilla and mandible occur
in about twice as many patients as similar
changes in overjet or overbite.
(4) the Class III patients who tended to be less
stable than Class II patients in the first post-
surgical year show less change thereafter.
 7- TIMING OF SURGERY

Patients with excessive growth, the surgery

should be performed after the growth cessation.
For psychological reasons the surgical
interference could be applied early before
growth stoppage.
Patients with deficient growth, the surgery could
be considered earlier but rarely before growth
spurt.
 TIMING OF SURGERY

Early maxillary advancement remains stable if we

use bone graft.
For cleft patients the advancement will be
performed soon after puberty along with bone
grafting and fistula closure.
Condylar ankylosis are candidates for surgery at
an early age.
 RELAPSE

It should be defined as slip or fall back into a

former worse state.
Or
Return toward the pre existing condition.
It should be viewed not as an abnormal
phenomena but as an undesirable normal
phenomena that could be minimized by careful
diagnosis ,proper treatment mechanics and
satisfactory retention system.
ORTHOGNATHIC SURGICAL
SPLINTS.
 Orthognathic surgical
splints.
A guide to diagnostic model surgery and the
construction of Orthognathic wafer splints.
The technique to be shown has been used in
excess of 400 times over a ten year period.
Bi-max, single jaw and segmental Osteotomies
have been planned using it.
 Indicators for use,
Model Surgery.
Diagnostic model surgery is used to aid the
proposed surgical treatment plan.

Providing a three dimensional model

representing the anatomical structures and
helping plan the “Osteotomy” surgical cuts.
 Indicators for use,
Orthognathic wafer Splints
To provide a quick, accurate and reproducible
method to locate the Osteotomised segments
during surgery.

To stabilize the structures during bone plating.

To act as a Post Surgical Positioning .

 How is it done ?

Bi-max Osteotomy plans are split into two

phases.
The first phase is the positioning of the maxillary
model in the Intermediate position of the
operation. Resulting in the Intermediate splint.

Followed by the positioning of the mandibular

model in the Final position of the operation.
Resulting in the Final splint.
Patient Impressions
Facebow
 Model Surgery Production

Model bases are trimmed

parallel to occlusal plane.

Side angles Parallel to

dental arch.
and flat anterior aspect
Model Surgery Production.

Orbital Pin

Incisal Pin

The facebow is mounted on the articulator.

Note the Incisal and Orbital pins contacting
the guidance tables.
 Model Surgery Production.

Plaster is applied
to the model base
and the articulator
closed until the
Incisal guidance
pin touches the table.
Surplus plaster is removed and allowed to
set.
 Model Surgery Production.

The models are

occluded using the
centric registration

The pin is closed and surplus

plaster removed. Note the articulator is inverted.
Model Surgery Production.

The mounted models on the articulator

prior to calibrations.

Note the Incisal pin contacting the Incisal table.

 Model Surgery Production.

A close up of the
dentition.

Observe the wax

bite
wafer in position .
 Model Surgery Production.
Vertical and Horizontal
calibration lines are
scribed onto the plaster.

5mm spaces separate

Horizontal lines.
Vertical lines are positioned at 90 degrees to
the dental occlusal planes.
Model Surgery Production.

The model is
removed from
the base.
Model Surgery Production.

The proposed maxillary move, 4mm in

this instance is scribed onto the plaster
base and the model attached to the base
with adhesive wax.
 Model Surgery Production.

Note the position of

the adhesive wax.

Wax
Do not apply to much
wax and obscure the
calibration marks.
 Model surgery production.

The model and

base returned to
the articulator.
This shows the
Intermediate
position.
Note the pin disengaged from the table due to
occlusal contact.
 Splint Production.

Modeling wax is applied to the models to

block out unwanted undercuts.
 Splint Production

The wax must not interfere with the

occlusion.
 Splint Production

Sodium Alginate
is applied to the
occlusal and incisal
surfaces of the models.
 Splint Production

Acrylic is mixed
over a fume cabinet.
 Splint Production

And formed
into a
horseshoe.
 Splint Production.

The horseshoe
is applied to the
lower model.

Prior to closure
a few drops of
acrylic liquid are placed on the horseshoe.
This helps the acrylic flow and improves fit.
 Splint Production

The articulator is gently closed until tooth to

tooth contact is felt.
 Splint Production

While the acrylic is still soft the articulator is

carefully opened and the splint removed.
 Splint Production

Careful trimming of the splint is undertaken,

occlusal and incisal detail is preserved.
 Splint Production

The articulator is opened and closed several

times with the splint in position.
 Splint Production

When cured the splint

is carefully removed
from the articulator.
 Model Surgery Production.
The articulator
is carefully closed
until the incisal pin
contacts the incisal
guidance table.

The model base is trimmed

until this is achieved.
 Model Surgery Production.

Using the calibration

marks as a guide
determine the amount
of mandibular
setback and scribe
the movements on
the articulator base.
 Splint Production

Care is taken
when closing
the models into
occlusion not to
abrade the
occlusal surfaces
of the models.
Note the pin must contact the table.
 Splint Production

Observe the
finished splint
positioner
closely fits the
models.
 Splint Production

To identify
the Intermediate
splint from the
Final splint, the
word INTER is
scribed onto the
lingual aspect of the Intermediate splint.
The splints are
cleaned with
water,placed in
sealed plastic
bags and clearly
marked
Intermediate
and Final.
 Complications and adverse effects of orthognathic
surgery

1-NERVE INJURY
Nerve injuries in orthognathic surgery
can be caused by indirect trauma, such
as
compression by surgical edema, or
direct trauma, such as compression, tear
or cut with surgical instruments or
stretching during manipulation of the
osteotomized bone segments.
The majority of inferior alveolar nerve (IAN)
injuries following bilateral sagittal split
osteotomy of the mandible (BSSO) are
due to nerve manipulation, traction or
compression.
Normal sensation or function is usually
recovered within two months.
.
Reports on lingual nerve (LN) sensory deficits are fewer than.
reports on IAN sensory disturbances
According to most reports, the sensory deficit of LN
tends to resolve over time.

The proposed mechanism of injury to the LN appears to be

associated with the fixation methods, either bone screws or
wires.
Facial nerve injuries in orthognathic surgery are rare .
 2 Complications in TMJ
TMJ fibrous ankylosis or hypomobility following
orthognathic surgery has been
proposed to be caused by several factors:
immobilization of the TMJ by intermaxillary
fixation (IMF) ,
iatrogenic displacement of the condyle posteriorly
and intra-articular hematoma
or excessive stripping of the periosteum and muscle
attachments in the ascending ramus, resulting in scar
contraction.
 3 Vascular complications
Uncontrolled hemorrhage in the jaws may
result from either a mechanical disruption of
blood vessels or congenital or acquired
coagulation problems .
The most common cause of hemorrhage in
association with orthognathic surgery is a
lack of surgical hemostasis.

.
4 Relapse