ORTHOGNATHIC

SUGRERY
ENVELOPE OF DISCREPANCY
 DIAGNOSIS

• MOTIVATION
• EXPECTATION
• WHY NOW
• MEDICAL PROBLEMS
 MEDICAL PROBLEMS
• SICKLE CELL
DIABETES MELLITUS
ANEMIA
• HYPERTHYROIDISM
ALLERGY IMMUNE PROBLEMS
• ADRENAL INSUFFICIENCY
RHEUMATOID ARTHRITIS
• PREGANACY
OSTEOARTHROSIS
• RHEUMATIC HEART
BEHAVIORAL DISORDERS
DISEASE
• BLEEDING DISORDERS
 SOFT TISSUE CHANGES
TREATMENT SOFT TISSUE
CHANGES
• 60 -70 %
• A-P INCISOR
• VERTICAL INCISOR • MINIMAL unless jaw rotates
• MANDIBULAR • CHIN 1:1 OF BONE
ADVANCEMENT LL 60 -70 % OF INCIS
• MAXILLARY • NOSE slight elevation of tip
ADVANCEMENT BASE OF UL 20% of point A
UL 60% of incisor
shortens 1-2 mm
• MANDIBULAR SETBACK • CHIN 1:1
LIP 60 %
 SOFT TISSUE CHANGES
TREATMENT SOFT TISSUE
CHANGES
• MAXILLARY SETBACK • NOSE no effect
BASE OF UL 20% of point A
UL 60% of incisor
• MANDIBULAR SETBACK
• COMBINATION
+
MAXILLARY ADVANCEMENT
• MAXILLARY SUPERIOR • NOSE no effect
REPOSITIONING UL shorten 1-2 mm
LL 1:1 rotation with mandible
 SOFT TISSUE CHANGES
TREATMENT SOFT TISSUE
CHANGES
• MANDIBULAR ADVANCEMENT • CHIN 1:1
LL 70% of incisor
+ UL shorten 1-2 mm
MAXILLARY SUPERIOR 80% of incisor
REPOSITIONING NOSE slight elevation
of tip

• MANDIBULAR INFERIOR • SOFT TISSUE FORWARD

BORDER REPOSITIONING 60-70% of bone
CHIN: UP 1:1 of bone
BACK 50%
LATERAL 60%
TREATMENT POSSIBILITIES

• MAXILLA

• MANDIBLE
 MAXILLA
• WIDTH
• 10 mm
• 40% reduction in intermolar width medland
• Surgically assisted expansion vs
 MAXILLA
• SAGITTAL
• FORWARD
– 10 mm
– RESISTANCE OF UPPER LIP
– VELOPHARYNGEAL SEAL
• BACK
– 3 - 5 mm
– SEGMENTAL OSTEOTOMY
 MAXILLA
• VERTICAL
• 10 -15 mm
• MANDIBULAR POSTURE ADAPT
• FREEWAY SPACE REMAIN THE SAME
 MANDIBLE

• WIDTH
• LIMITATIONS
– SOFT TISSUE
– TMJ
• SYMPHYSEAL OSTECTOMY
when mandible is narrowed, condylar width is maintained and
condyles rotate on their vertical axis
• BODY OSTECTOMY
 MANDIBLE
• SAGITTAL & VERTICAL
• SAGITTAL CHANGES IN MANDIBLE -- 3
POSSIBILITIES FOR VERTICAL ORIENTATION
– MP STEEP
– MP CONSTANT
– MP FLAT
• MANDIBULAR ADVANCEMENT VS SETBACK
• TYPE OF FIXATION AND RELAPSE IN AP PLANE
 USEFUL TIPS

• SHORT FACE
MANDIBULAR SURGERY

• LONG FACE
MAXILLARY SURGERY
 DENTOALVEOLAR SURGERY
• 3 PLANES OF SPACE
• ADVANTAGES
NO NEED OF ANCHORAGE
LESS TIME
• LIMITATIONS
DISTANCE
SAME LIMITS AS FOR ORTHO TOOTH MOVEMENT,
BECAUSE OF THE SOFT TISSUE CONSTRAINTS
SIZE
MAXIMUM OF FOUR SEGMENTS PER ARCH
3- TOOTHED SEGMENT IF MORE THAN
2 SEGMENTS ARE NEEDED
• COMPLICATIONS
• TEMPORARY LOSS OF NERVE SUPPLY (6 MONTHS)
• RARELY BLOOD SUPPLY IS LOST
• VITAL TOOTH NOT RESPONDING TO
ELECTRICAL PULP TESTING
CHIN SURGERY
 GENERAL GUIDELINES
• APPLIANCE SELECTION
PREADJUSTED EDGEWISE
S/S TWIN BRACKET, HALF THEWIDTH OF TOOTH
• AESTHETIC APPLIANCES
LABIAL SURFACE OF UPPER
• 18 VS 22 SLOT
• BANDS VS BONDS
• APPLIANCE MODIFICATION
PREADJUSTED APPLIANCES
SECOND MOLAR
LOWER 7 INCLUDE PRESURGICALLY
UPPER 7 POSTSURGICALLY, IF PRESURGICALLY THEY B
DEPRESSED ABOVE THE OCCLUSAL PLANE
AUXILLARY ATTACHMENT
MD WIDTH
INTEGRAL HOOKS
POSTSURGICAL INTRA ARCH ELASTICS
NOT FOR MMF
THIRD MOLAR REMOVAL
• INDICATIONS
– IMPACTED TOOTH
– SPACE DISCREPANCY, WHEN TOOTH WILL
ERUPT IT WILL B UNFUNCTIONAL
– MALALIGNED
– ASSOCIATED PATHOLOGY
– RECURRENT PERICORONITIS
– LOCATION WITHIN THE OSTEOTOMY SITE
THIRD MOLAR REMOVAL
• TIMING
– UPPER 3rd MOLAR
• AT TIME OF SURGERY
• 9-12 MONTHS BEFORE SURGERY
– LOWER 3rd MOLAR
• 9-12 MONTHS BEFORE SURGERY
• AT THE TIME OF SURGERY, IF MODIFIED BSSO USED
WOLFORD, DAVIS J OMS
• REMOVAL AT A LATER TIME
 TIME ESTIMATES
• PRESURGICAL ORTHODONTICS
2 TO 12 MONTHS/ 12 -24 MONTHS LUTHOR F MORR5IS B J OMS 03

• SURGERY/ HOSPITALIZATION
BSSO/ GENIOPLASTY NO OVERNIGHT STAY
MAXILLARY/ DOUBLE JAW SURGERY 1-2 DAYS
• SURGERY TO POSTSURGICAL
ORTHODONTICS
3 TO 8 WEEKS
DEPEND ON TYPE OF FIXATION, MOBILITY STATUS
• POSTSURGIACL ORTHODONTICS
3 TO 6 MONTHS
PRE-SURGICAL ORTHODONTICS
• ALIGNMENT
• LEVELLING BY INTRUSION
VERTICAL POSITION OF LOWER INCISOR DETER FACE HT
ANT DENTOALVEOLAR SURGERY
EXCESS CURVE OF SPEE IN LOWER
ANT OPEN BITE (MAXILLA)
• A-P POSITION OF INCISORS
A-P POSITION OF TEETH DETERMINE AMOUNT OF A-P JAW
MOVEMENT (DECOMPENSATION CLASS II, III)
• ARCH COMPATIBILITY
– SIMILAR MAXIL & MAND ARCH FORM/ WIDTH B
ESTABLISHED
– ORTHO EXPANSION LIMIT 2-3 mm/SIDE, I.e HALF CUSP C.B
– IF MORE THAN THIS SURGERY (SEGMENTAL)
– IF EXPANSION ORTHO, IT CAN BE DONE POSTSURGICALLY
– IF SURGICAL EXPANSION, DON’T DO EXPANSION IN
PRESURGICAL ORTHO
 POST SURGICAL ORTHODONTICS

• LEVELLING BY EXTRUSIOJN
• ROOT PARALLELING AT
OSTEOTROMY SITE
• DETAILED TOOTH POSITIONING
 PRE OR POST SURGERY
• POSTERIOR CROSS BITE
CORRECTION

• LEVELLING BY EXTRUSION
FINAL SURGICAL PLANNING
• PRESURGERY RECORDS

• CEPHALOMETRIC PREDICTION AND

MODEL SURGERY
 PREDICTABILITY OF MAXILLARY
SURGERY IN LE FORT I OSTEOTOMY
RON JACOBSON AJO 2001

• LE FORT I MAXILLARY AND

MAXILLOMANDIBULAR SURGERY IS
ACCURATE

• IN 80 % OF SAMPLE, RESULTS OF SURGERY

WERE WITHIN 2 mm OF PRE SURGICAL
PREDICTION. IN 43 %, RESULTS WERE
WITHIN 1 mm
MODEL SURGERY
MODEL SURGERY
MODEL SURGERY
 PROBLEMS DURING MODEL
SURGERY
• TOOTH INTERFERENCES
• LACK OF BANDS ON LOWER 7
• PRESENCE OF BANDS ON UPPER 7

• INCOMPATIBLE CANINE WIDTH

• LACK OF SPACE FOR INTERDENTAL
OSTEOTOMY CUTS
• 4-5 MM OF SPACE IS REQUIRED
 STABILIZING ARCH WIRES
AND SPLINTS
• STABILIZING ARCH WIRES
– PASSIVE
– FULL DIMENSION
– ATTACHMENTS FOR MMF
• SPLINTS
– POSITINING THE TEETH
– STABILIZATION
• SPLINT TYPES
– SEPARATE INTERMEDIATE & FINAL SPLINT
– COMBINED SPLINT
• SPLINT QUALITIES
– THIN 1-2 mm
– WIRE IN THE EDGE
– WORN TILL POST SURGICAL ORTHODONTICS
 POST SURGICAL
ORTHODONTICS
• TYPE OF FIXATION
• REMOVAL OF SPLINT AND & STABILIZING WIRES
AT THE SAME TIME BY ORTHODONTIST
OTHERWISE CR-CO DISCREPANCY
• WORKING ARH WIRES
16 MIL STEEL
IF TORQUE OF U INCISOR
RECTANGULAR M NITI/ BRAIDED STEEL
• LIGHT VERTICAL ELASTICS
3/8 INCHES BOX ELASTICS
CLASS II, CLASS III, CROSS ELASTICS
FIRST 4 WEEKS FULL TIME INCLUDING EATING
2nd 4 WEEKS FULL TIME EXCLUDING EATING
3rD 4 WEEKS ONLY DURING NIGHT
IN THE END PT B WITH OUT ELASTICS FOR 3-4 WEEKS
 STABILIZATION AFTER
OSTEOTOMY
• TRADITIONAL FIXATION AND
STABILIZATION

• RIGID INTERNAL FIXATION

TECHNIQUES
TRADITIONAL FIXATION AND
STABILIZATION

• TRANSOSSEOUS WIRE FIXATION

• MAXILLOMANDIBULAR
IMMOBILIZATION (6-8 WEEKS)
• TWO JAW SURGERY -
SKELETAL SUSPENSION WIRES
 RIGID INTERNAL FIXATION

• FOR MAXILLARY OSTEOTOMIES

• FOR MANDIBULAR OSTEOTOMIES

 RIF FOR MAXILLARY
OSTEOTOMIES

• PIN SYSTEM

• BONE PLATES
 RIF FOR MANDIBULAR
OSTEOTOMIES
• SCREW FIXATION
• LAG/ COMPRESSION SCREW
• POSITION/ BICORTICAL SCREW

• BONE PLATES
 RIF ADVANTAGES
• COMFORT
• CONVENIENCE
• EARLY RETURN TO FUNCTION
• SAFE IN IMMEDIATE POSTOPERATIVE PERIOD
• RAPID BONE HEALING
• INCREASED STABILITY
• FASTER REDUCTION OF POSTOPERATIVE EDEMA
• REHABILITATION OF MUSCLES AND TM JOINT
 RIF DISADVANTAGES

• TECHNICALLY DIFFICULT
• EXPENSIVE
• INCREASED RISK OF INFECTION
• NEED FOR PLATE REMOVAL
• NEUROSENSORY DISTURBENCES
• TOOTH DEVITALIZATION
• POSTOPERATIVE TM JOINT SYMPTOMS
SURGICAL PROEDURES
 MAXILLARY SURGERY
LE FORT 1 OSTEOTOMY
– TRADITIONAL LE FORT 1 OSTEOTOMY
– MAXILLARY STEP OSTEOTOMY
– HIGH LE FORT 1 OSTEOTOMY
– MAXILLARY HORSESHOE OSTEOTOMY
 TRADITIONAL LE FORT 1 OSTEOTOMY

• STRAIGHT LINE CUT

FROM PIRIFORM RIM TO
PTERYGOID PLATE AREA
• SEPARATION AT
PTERYGOID PLATE -
TUBEROSITY AREA,
LATERAL NASAL WALL,
SEPTUM/VOMER AREA
• RAMPING EFFECT
 MAXILLARY STEP OSTEOTOMY
• HORIZONTAL CUT
PARALLEL TO FRANK.P. 4-5
mm ABOVE CANINE APEX
FROM PIRIFORM RIM TO
ZYGOMATIC BUTTRESS.
• IN BUTTRESS AREA,
VERTICAL CUT OF 5-8 mm,
HORIZONTAL CUT AT
LOWER LEVEL TO
PTERYGOID PLATES.
• NO RAMPING EFFECT
HIGH LE FORT I OSTEOTOMY
• ANTERIORLY CLOSE TO
INFRAORBITAL RIM

• DIRECTED POSTERIORLY AT
BUTRESS AREA AT A LOWER LEVEL.
MAXILLARY HORSESHOE OSTEOTOMY

• HORIZONTAL PALATAL SHELF ATTACHED

TO NASAL SEPTUM AND LATERAL NASAL
WALLS.
• MOBILIZATION OF MAXILLARY
DENTOALVEOLUS
• SELECTED CASES OF VERTICAL
MAXILLARY EXCESS.
 AFFECTS ON GROWTH
• LEFORT I OSTEOTOMY ELIMINATES
FURTHER A-P GROWTH, WHILE
VERTICAL ALVEOLAR GROWTH
REMAIN UNCHANGED.
IN NORMALLY GROWING MANDIBLE CLASS III
(MOGAVERO, BUSCHANG, WOLFORD. AJO 1997)
• MAXILLARY HORSE SHOE
TECHNIQUE GOOD
POSTSURGICAL GROWTH IN 3 PLANES
 AGE FOR SURGERY
WOOLFORD 2001

• DEFICIENT/ NORMAL MAXILLARY GROWTH

– NORMAL GROWTH CANT B EXPECTED AFTER SURGERY
– RECURRENEC OF CLASS III
– EARLY SURGERY IF NEEDED
– PARENTS B WARNED OF SECOND PROCEDURE
• EXCESSIVE MAXILLARY GROWTH
– NO STUDY
– POSTSURGIACL GROWTH MAY BE DEPENDENT ON THE
SELECTED PROCEDURE
• VERTICAL MAXILLARY EXCESS
– VERTICAL GROWTH CONTINUE AT THE RATE AS OF PRE
SURGICALLY
– POSTSURGERY AP GROWTH IS AFFECTED, GROWTH VECTOR
IS DOWN & BACKWARD
 MANDIBULAR RAMUS
SURGERY
• SAGITTAL SPLIT OSTEOTOMY
• VERTICAL OBLIQUE RAMUS
OSTEOTOMY
• COMBINED VETICAL RAMUS AND
SAGITTAL OSTEOTOMIES
• INVERTED L RAMUS OSTEOTOMY
SAGITTAL SPLIT OSTEOTOMY
 SAGITTAL SPLIT OSTEOTOMY

• INDICATIONS
– ADVANCEMENT
– SETBACK
– ASYMMETRIES

• CONTRAINDICATIONS
– DECREASED POSTERIOR MANDIBULAR HEIGHT
– THIN MEDIAL LATERAL WIDTH OF RAMUS
– SEVERE RAMUS HYPOPLASIA
– SEVERE ASYMMETRIES
 SAGITTAL SPLIT OSTEOTOMY
ADVANTAGES DISADVANTAGES
– QUICKER HEALING – NERVE DAMAGE
– ADVANCEMENT – FRACTURE ON
– SETBACK
LINGUAL ASPECT
– ASYMMETRIES
OF RAMUS
– OCCLUSAL PLANE
ALTERATION – DIFFICULT TO
– RIF CORREST SEVERE
– UNDISTURBED ANGLE ASYMMETRIES
OF MANDIBLE
– UNDISTURBED
MUSCLES OF
MASTICATION
VERTICAL OBLIQUE RAMUS OSTEOTOMY
 VERTICAL OBLIQUE RAMUS
OSTEOTOMY
INTRA ORAL/ EXTRA ORAL
CONTRANDICATIONS
• LARGE
INDICATIONS
• SETBACK
SETBACKS
UNLESS TEMPORALIS, LAT PTER,
MASSETRER ARE DETACHED FROM
• ASYMMETRIES DISTAL SEGMNET

REQUIRING • LARGE
SETBACK ADVANCEMENT
• LENGHENING
THE RAMUS
UNLESS TEMPORALIS, LAT PTER,
MASSETRER ARE DETACHED FROM
DISTAL SEGMNET
 VERTICAL OBLIQUE RAMUS
OSTEOTOMY
ADVANTAGES
• EASY
• PROGNATHISM
• ASYMMETRIES

DISADVANTAGES
• DIFFICULT TO CONTROL POSITION OF CONDYLE
• OPEN BITE POSTOPERATIVELY
• DELAYED HEALING
• DIFFICULT TO USE RIF
• LONG TERM USE OF INTER ARCH ELASTICS
 COMBINED VETICAL RAMUS
AND SAGITTAL OSTEOTOMIES

• 10 - 15 mm
MANDIBULAR
ADVANCEMENT
• PREVIOUS RAMUS
SURGERY
• ASYMMETRY
• DISADVANTAGES OF
BOTH THE
PROCEDURES
 INVERTED L RAMUS OSTEOTOMY
EXTRA & INTRA ORAL

INDICATIONS
– SETBACK
– ASYMMETRIES
– ADVANCEMMENT
– RAMUS LENTHEINMG
– THIN RAMUS

CONTRAINDICATIONS
– ABNORMAL POSTERIOR LOCATION OF MANDIBULAR
FORAMEN
– MANDIBULAR ADVANCEMENT WITHOUT GRAFTING
 INVERTED L RAMUS OSTEOTOMY

ADVANTAGES
DISADVANTAGES
• NEED BONE GRAFTING FOR RAMUS LENTHEINING/
PROGNATHISM
• ADVANCEMENT
ASYMMETRIES
• HEALING TIME
UNCHANGED MAY BE INCREASED
CORONOID PROCESS &WHEN GRAFTSMUSCLE
TEMPORALIS ARE
• NOT USED
LARGE SETBACK
• RAMUS LENTHENING/ ADVANCEMENT WITH GRAFTING
• RIF
• AFFECTS ON GROWTH
• NO AFFECT ON RATE OF GROWTH
• ALTERATION OF PROXIMAL SEGMENT
ALTER DIRECTION OF SUBSEQUENT
GROWTH
• AGE OF SURGERY
• PREDICTABLE FROM 12 ONWARD
• SSO AFTER ERUPTION OF 2nd MOLAR
 AGE FOR MANDIBULAR
SURGERY
WOOLFORD 2001

• POSTERIORLY PLACED MANDIBLE

– NORMAL GROWTH RATE
PREDICTABLE STABLE POST SURGRERY RESULTS,
FUTURE RATE OF GROWTH IS UNALTERED BY SURGERY
– DEFICIENT GROWTH RATE
INITIALLY PROGRESSINELY WORSENING MANDIBULAR
RETRUSION. IF SURGERY DONE ORIGINAL MALOCCLUSION
RECURR.
SURGERY IS DONE IN CASES WHER MALNUTRITION DUE TO
MASTICATORY DYSFUNCTION, AIRWAY COMPROMISE, SPEECH
DISORDERS, PSYCHOSOCIAL DEVELOPMENT, TMJ ANKYLOSIS
 AGE FOR MANDIBULAR
SURGERY
• ANTERIORLY PLACED MANDIBLE
– NORMAL GROWTH RATE
RATE OF GROWTH IS UNALTERED, HARMONIOUS POST OPERATIVE
MAXILLARY & MANDIBULAR GROWTH, MAINTENANCE OF
SURGICAL RESULT
– ACCELEARTED GROWTH RATE
OPTION 1
DEFER SURGERY UNTIL GROWTH IS COMPLETE
OPTION 2
SURGERY DURING GROWTH + OVERCORRECTION.
ADDITIONAL SURGERY IF OVERCORRECTION IS
INSUFFICIENT OR EXCESS GROWTH.
BETTER TO PERFORM SURGERY AFTER MOST OF
MAXILLARY GROWTH STOPS (14 IN FEMALE, 17 IN MALE) TO
FACILITATE ESTIMATION OF OVERCORRECTION
OPTION 3
SURGICALLY ELIMINATE FURTHER MANDIBULAR GROWTH
WITH HIGH CONDYLECTOMY AND CORRECTION OF JAW
DEFORMITY
SEGMENTAL JAW SURGERY

• MAXILLA

• MANDIBLE
 SEGMENTAL JAW SURGERY
MAXILLA

• ANTERIOR SUBAPICAL OSTEOTOMY

– WASSMUND TECHNIQUE
– WUNDERER TECHNIQUE

• POSTERIOR SUBAPICAL OSTEOTOMY

WASSMUND TECHNIQUE
WUNDERER TECHNIQUE
POSTERIOR SUBAPICAL
OSTEOTOMY
 SEGMENTAL JAW SURGERY
MANDIBLE
• BODY OSTECTOMY
• MIDLINE OSTEOTOMY
• INFERIOR BORDER OSTEOTOMY
• ANTERIOR SUBAPICAL OSTEOTOMY
• TOTAL SUBAPICAL OSTEOTOMY
• POSTERIOR SUBAPICAL OSTEOTOMY
BODY OSTECTOMY
MIDLINE OSTEOTOMY
INFERIOR BORDER
OSTEOTOMY
ANTERIOR SUBAPICAL
OSTEOTOMY
TOTAL SUBAPICAL
OSTEOTOMY
POSTERIOR SUBAPICAL
OSTEOTOMY
 DOUBLE JAW SURGERY

• POSITIOING MAXILLA FIRST

• POSITIOING MANDIBLE FIRST

 POSITIOING MAXILLA FIRST
• SOFT TISSUE INCISION & INITIAL BONY CUTS OF
BSSO ARE DONE, BUT COMPLETE SEPARATION OF
2 MANDIBULAR SEGMENTS NOT DONE
• LEFORT I IS DONE
• INTERMEDIATE OCCLUSAL SPLINT + MMF.
• MAXILLA IS REPOSITIONED, STABILIZED AND
FIXED.
• MMF IS REMOVED
• BSSO COMPLETED
• DISTAL TOOTH BEARING SEGMENT OF MANDIBLE
IS REPOSITIONED WITH FINAL OCCLUSAL SPLINT,
MMF
• MANDIBULAR OSTEOTOMY SITES ARE
STABILIZED AND FIXED
 POSITIOING MANDIBLE FIRST

• INDICATIONS
– DIFFICULTY IN STABILIZING THE MAXILLA AFTER
LEFORT I
– REPEAT LEFORT I + BONE GRAFTING
– MULTI SEGMENT LEFORT I

• PROCEDURE
– BSSO COMPLETED/ RIF DONE
– INTERMEDIATE SPLINT USES INTACT MAXILLA AS
GUIDE
– LEFORT I OSTEOTOMY DONE
– FINAL OCCLUSAL SPLINT HELPS TO STABILIZE & FIX
THE MAXILLA
 AUGMENTATION WITH
IMPLANTS
• MATERIALS
– AUTOGENOUS BONE & CARTILAGE
– ALLOGENIC BONE & CARTILAGE
– ALLOPLASTIC MATERIAL
• SILASTIC HYDROXYLAPATITE PROPLAST

• LIMITATIONS
– BONE ALLO/ AUTOGENOUS RESORPTION,
UNPREDICTABLE EFFECT ON CONTOURS
– ALLOPLAST UNDERLYING BONE RESORPTION,
MIGRATION, INFECTION
– CARTILAGE CALCIFY WITH TIME, NO SUBSTANTIAL
CHANGE IN SHAPE.
– CALVARIAL BONE RESISTANT TO RESORPTION THAN
NONMEMBRANOUS BONE ( ILLIAC CREST DONAR SITE)
AUGMENTATION AREAS

– PARANASAL
– INFRAORBITAL MALAR
– MADIBULAR BORDER AUGMENTATION
• ANTEROINFERIOR
• POSTEROINFERIOR
• ANTEROLATERAL
– CHIN AUGMENTATION
 BONE GRAFTS
• AUTOGENOUS
• FREEZE DRIED ALLOGENIC
• HYDROXLAPATITE
 CHANGES IN CONDYLE
• MAXILLARY SURGERY ONLY
NO CHANGE PROFITT 1994
• MANDIBULAR ADVANCEMENT
SHORTENING OF CONDYLE IN 5 %
PROFITT 1992, 1995

• LITERATURE REVIEW (1966-2001)

MANDIBULAR ADVANCEMENT + RIF
KERSY, MAJOR
ANGLE ORTHOD 2003
 CHANGES IN CONDYLE
• LITERATURE REVIEW (1966-2001) KERSY, MAJOR
ANGLE ORTHOD 2003
• CONDYLES ARE DISPLACED POSTERIORLY,
INFERIORLY WITH FORWARD ROTATION.
DISPLACEMENT WAS LESS IN CPD GROUP.
DISPLACEMENT WAS CLINICALLY INSIGNIFICANT
• POSTERIOR 67 % (1.6 mm)
SUPERIOR 60 % ( 1.2 mm)
INFERIOR ( 1.2 mm)
ANTERIOR
INFERIOR (DISTAL) ROTATION 61% (8.6’)
SUPERIOR ROTATION (3.2’)
NO DIFFERENCE B/W RT & LFT SIDE
CHANGES IN CONDYLE
• INTERCONDYLAR ANGLE INCREASES
ANTERIOR MOVEMENT OF MEDIAL & POST OF
LATERAL POLE (OPPOSITE TO OTHER STUDIES)
• NO SIGNIFICANT CHANGES IN MEAN
INTERCONDYLAR ANGLE OR INTERCONDYLAR
WIDTH REGARDLESS OF AMOUNT OF
ADVANCEMENT
• SIGNIFICANTLY MORE ROTATION OF CONDYLE WITH
RIGID FIXATION THAN WITH THE WIRE FIXATION
• INTERCONDYLAR ANGLE WAS DECREASED BY
2.5’(ROTATION OF MEADIAL POLE POST AND
LATERAL POLE ANTERIORLY.
INTERCONDYLAR DISTANCE WAS INCREASED BY 2
mm
CHANGES IN CONDYLE
• POSTSURGICAL TMJ REMODELLING &
DEGENERATIVE CHANGES HAVE BEEN IMPLICATED
IN POSTSURGICAL RELAPSE

CONCLUSION
• NATURE OF CONDYLAR & GLENOID FOSSA
REMODELLING HAS NOT BEEN ESTABLISHED
• CHANGES IN DISK POSITION & MORPHOLOGY HAVE
NOT BEEN ESTABLISHED
• CHANGES IN CONDYLE POSITION PRESENT WITH
LARGE INDIVIDUAL VARIABILITY
 STABILITY IN
ORTHOGNATHIC SURGERY
PROFITT, TURVEY, PHILIPS 1996

VERY SATBLE

MAXILLA UP
MANDIBLE FORWARD
CHIN, ANY DIRECTION
 STABILITY IN
ORTHOGNATHIC SURGERY
SATBLE

MAXILLA FORWARD
MAXILLA, ASYMMETRY
 STABILITY IN
ORTHOGNATHIC SURGERY
SATBLE
RIF

MX UP + MN FORWARD
MX FORWARD + MN BACK
MANDIBLE ASYMMETRY
 STABILITY IN
ORTHOGNATHIC SURGERY
PROBLEMATIC

MANDIBLE BACK
MAXILLA DOWN
MAXILLA WIDER
 RELAPSE IN MANDIBULAR
ADVANCEMENT
KERSY 2003, DONG 2001, BERGER 2001

• OSTEOTOMY SLIPPAGE
• PRETREATMENT MANDIBULAR PLANE ANGLE
HIGH MANDIBULAR PLANE ANGLE
• CONDYLAR POSITION AFTER SURGERY
• CONDYLAR SAG
LACK OF SEATING OF CONDYLE IN GLENOID FOSSA
• CONDYLAR COMPRESSION WITH MORPHOLOGIC
CHANGE
RELAPSE 9-18 MONTHS AFTER SURGERY
• IDIOPATHIC CONDYLAR RESORPTION
• PRETREATMNENT DISK STATUS
 RELAPSE IN MANDIBULAR
ADVANCEMENT
• COUNTERCLOCKWISE ROTATIONAL
ADVANCEMENT
• AMOUNT OF CHANGE PRODUCED BY SURGERY
LARGE ADVANCEMENT (> 6-7 mm)
• NATURE OF MALOCCLUSION
• HOST REMODELLING CAPACITY
• STRETCHING OF SUPRAHYOID MUSCULATURE
• PARAMANDIBULAR CONNECTIVE TISSUE
STRECTH
• TYPE OF FIXATION USED
• LEVEL OF SURGEON’S EXPERIENCE
 ROLE OF HYOID BONE IN
RELAPSE
JOHN P HATCH 2001

• SUPRAHYOID MUSCULATURE IMPORTANT ROLE

IN MANDIBULAR RELAPSE
• POSITIONAL CHANGE IN HYOID BONE OCCUR IN
POST ORTHOGNATHIC PERIOD
• MASTICATORY, SUPRA AND INFRA HYOID
MUSCLES ARE IMPORTANT CONTRIBUTORS
 ROLE OF HYOID BONE IN
RELAPSE
• VERTICAL POSITION OF HYOID BONE & POINT B
AFTER SURGERY HYOID BONE MOVES SUPERIORLY, THIS
POSITION IS STABLE FOR LONG TERM, AND HAS LITTLE
INFLUENCE ON POST TREATMENT STABILITY OF POINT B
AND MANDIBULAR PLANE
• HORIZONTAL POSITION OF HYOID BONE & POINT B
HYOID BONE MOVES FORWARD WITH SURGERY. POST
SURGERY RELAPSE IS GREATER IN WIRE GP (- 4.3mm) THAN
IN THE RIF GP (-1.3 mm)
POST SURGERY CHANGE IJN HYOID BONE POSITION IS
RELATED TO HORIZONTAL MOVEMENT OF POINT B
RIF r= 0.45 WIRE r= 0.51
 RIF Vs WIRE FIXATION IN
MANDIBULAR ADVANCEMENT
CALOGERO DOLCE 2001

• AT 5 YR POST SURGERY, BOTH RIF & WIRE

GP SIMILAR OVERJET OVERBITE
• IN WIRE GP FLARING OF MANDIBULAR
INCISORS COMPENSATED FOR CONTINUED
SKELETAL RELAPSE (42 %) OF SYMPHYSIS
• IN RIF GP THERE WAS TRANSINET
ANTERIOR MOVEMENT OF SYMPHYSIS
AND POST MOVEMENT OF LOWER
INCISORS
 INFERIOR REPOSITIONING
LE FORT I OSTEOTOMY
FABIO COSTA 2000
• INFERIOR POSITIONING STABILIZED WITH WIRE FIXATION
AND BONE GRAFT HIGH PERCENTAGE OF RELAPSE
• INFERIOR REPOSITIONING STABILIZED WITH RIF ONLY IS
NOT PREDICTABLE FOR MOVEMENTS GRAETER THAN 2
mm.TO CORRECT VERTICAL DEFICICIENCY OF ANTERIOR
MAXILLA 5.4 mm INFERIOR MOVEMENT IS REQUIRED
• INFERIOR REPOSITINING STABILIZED WITH RIF AND BONE
GRAFT IS PREDICTABLE
• INFERIOR REPOSITIONING STABILIZED WITH RIF AND
ALLOPLASTIC MATERIAL (HYDROXYAPATITE) LOWEST
PERCENTAGE OF RELAPSE
• BETTER TO PERFORM ANTERIOR INFERIOR MOVEMENT
THAN WHOLE MAXILLARY INFERIOR MOVEMENT
MANDIBULAR DEFICIENCY
IN PTS WITH SHORT OR
NORMAL FACE HT
• BSSO ADVANCING & BRINGING MANDIBLE DOWN
ANTERIORLY
• POSTERIOR MAXILLA SHOULD NOT BE ELONGATED
• ANTERIOR MAXILLA CAN B ROTATED DOWN TO SOLVE
ESTHETIC PROBLEM OF INFRA ERUPTED INCISORS
• EXCESS POST FACE HT
POSTERIOR MAXILLA BE ROTATED UPWARD
• LEVELLING BY EXTRUSION MAINLY POSTSURGICALLY
• LATERAL EXPANSION OF MAXILLARY ARCH
• IN EXTRACTION CASES
• IF LEVELLING IS DONE PRESURGICALLY, CLOSE EXT
SPACES
• IF LEVELLING IN POSTSURGICAL PHASE, LEAVE 1-2 mm OF
EXT SPACE
LONG FACE PROBLEMS
• MAXILLARY SURGERY IS THE PRIMARY
PROCEDURE
• MANDIBULAR SURGERY, IF NEEDED
– IF NORMAL LENGTH, BUT ROTATED DOWN AND BACK
NO NEED
– IF SHORT IN LENGTH, MANDIBULAR ADVANCEMENT
• LEVELLING CURVE OF SPEE PRESURGICALLY BY
INTRUSION
• IN ANTERIOR OPEN BITE WHERE MAXILLARY
SEGMENTAL SURGERY WILL BE DONE,
LEVELLING OF FULL ARCH NOT BE DONE,
LEVELLING WITHIN THE SEGMENTS B DONE
• IF CURVE OF SPEE HAS TO BE LEVELLED BY
SEGMENTAL OSTEOTOMY, SAME
CONSIDERATIONS FOR LOWER ARCH
• 3-5 mm SPACE B/W TEETH AT PLANNED
INTERDENTAL OSTEOTOMY SITES
 CLASS III PROBLEMS
MAXILLARY DEFICIENCY/
MANDIBULAR EXCESS
• COMPATIBLE ARCH FORMS
• PROGRESS RECORDS TO EVALUATE AP &
TRANSVERSE CORRECTION AND
COMPATIBILITY BECAUSE MANDIBLE
CANT B ADVANCED AS IN CLASS II CASES.
• SUBMENTAL LIPECTOMY
• REDUCTION CHEILOPLASTY OF LOWER
LIP