Orthognathic Surgery

Munir Patel
Nomenclature

 Mesial toward dental midline

 Distal away from dental midline
 Labial toward the lips
 Buccal toward the cheek
 Apex toward the root tip
 Lingual toward the tongue
 Incisal toward the biting surface (anterior dentition)
 Class I Occlusion

 Angle Class I (neutro-occlusion)

 Maxilla = Mandible
 Mesiobuccal cusp of the maxillary first molar
articulates wihtin the mesiobuccal groove of the
mandibular first molar
 Class II Occlusion

 Angle Class II (disto-occlusion)

 Maxilla > Mandible (Mandibular
underdevelopment)
 Mandibular first molar articulates distal to the
mesiobuccal cusp of the maxillary first molar
 Division 1: Overjet
 Division 2: Overbite
Class II Occlusion

 Angle Class II (mesio-occlusion)

 Maxilla < Mandible
 Mesiobuccal groove of the mandibular
first molar is mesial to the mesiobuccal
cusp of the maxillary first molar
Dental Compensation

 Tendency of teeth to teeth to tilt in a direction which minimizes a dental malocclusion

 Masks the true degree of skeletal discrepancy
 Orthodontist needs to fix the dental compensation, which will make the malocclusion more
obvious and allow the surgeon full motion of the jaw to fix the orthognathic abnormality
Cephalometric Eval
Basics
 SN Line – corresponds with skull base
 SNA Angle - increased in maxillary protrusion
and drease in retrusive
 A point – innermost point in the depth of the
concavity of the maxillary alveolar process
 SNB Angle – increased prognathic and
decreased is retrognathic
 B point – innermost point on the contour of the
mandible between the incisor tooth and the bony
chin
 ANB Angle: Indicates the relative position
between maxilla and mandible with average
being 2 degrees
Planes

 Franfort Horizontal – Porion to inferior

orbital rim
 SN – sella turcica to nasion
 Maxillary plane – posterior nasal spine to
anterior nasal spine
 Occlusal Plane – between molars and
incisors
 Mandibular plane – gonion menton
Clinical Evaluation

 Facial thirds/fifths
 Facial covexity/concavity
 Facial asymmetry
 Nose
 Chin
 Dental asymmetry
 Facial proportions are only idealized concepts -
guidelines
Clinical Evaluation

 Skeletal eval, soft tissue and skin eval

 Panorex xray (third molar removed 6 mo before orthognathic surgery)
 Lateral cephalometric
 3D CT or dental casts
Treatment Planning

 Facial Shape
 Symmetry
 Malar Projection
 SNA
 SNB
 Incisal show – most important finding for vertical height of maxilla
 Lip repose ideally showing 3mm of incisal show in men and up to 5mm in women
 Occlusal cant – have patient bite on tongue blade and compare angle to that of the inner
canthal line.
Timing of Surgery

 Matched to skeletal maturation

 Females: 14-16 yrs
 Males: 16-18 yrs
 Any question of growth status, can get xray of hand to look for closure of growth plates
Pre-Operative Planning

 Orthodontic alignment of the dentition

 Decompensate of the anterior dentition
 Dental extractions (lower 3rd molars ext 6 mo prior to BSSO)
 Cuts of sagittal splint will go very close to 3rd molars, and if they were left in, it leaves less bone
for the fixation
 Post-surgical orthodontic treatment will continue 3-6mo after surgery
Maxillary Deformities
Le Fort I Osteotomy
Lefort I Incision
Lefort I subperiosteal dissection
Lefort I Nasal Mucosal Dissection
Le Fort I Horizontal Osteotomy
Le Fort I Posterior and Vertical Osteotomy
Le Fort I Separation of Nasal Septum
Le Fort I Down-Fracture
Le Fort I

 Splint placed
 MMF established
 Vertical height maxilla verified
 Superior movement requires nasal septum
trimming and ostectomy
 In large impactions, inferior turbinates
should be trimmed to avoid airway
obstruction
 Inferior movement requires bone grafting of the
gap with free bone grafts from iliac crest, outer
table of skull, or allogeneic bone
 Condyles seated and maxilla rotated into position
 Plates can now be applied
Maxillary Complications

 Relapse early/immediate or late

 Necrosis of gingiva, maxilla (very rare)
 Bleeding (usually descending palatine artery)
 Blindness (very rare)
 "Numb" palate is expected and should be discussed pre-op
 Alar Widening
 Wide nose after advancement (do alar cinch suture)
 Buckle of septum – deviated nose (trim septum in impaction)
Mandibular Deformities
Sagittal Split
Osteotomy
 Most commonly used osteotomy for
mandibular advancement, set-back, or
rotation
 Rigid fixation easily applied
 Predictable results
Sagittal Split
Osteotomy
 Incse well lateral to the dentition, leave adequate medial
mucosal shelf to aid in final closure
 Incision 1-2 cm below the occlusal plane to the region of
the first molar
 Through periosteum, expose the lateral border of the
posterior body, angle, and ascending ramus
 Expose inferior mandibular border
 Partially strip the anterior ramal border of the temporalis
muscle and place a retractor superiorly onto the coronoid
process. Curved Koscher clamped to the coronoid works
well
 At medial ramus – stay subperiosteal and note
mandibular foramen
 Sagittal Split Osteotomy
 Protect neurovasc bundel with medial ramus retractor
 Reciprocating saw
 Tip of saw should penetrate only the anterior cortex
 Between the second and first molar
 Ensure vertical osteotomy continues through the inferior
mandibular border to the medial lingual cortex
 Then use osteotome to deepen and separaate the osteotomy
 Mesial tooth-bearing segment moves independent of the
distal condylar segment and can be repositioned into final
occlusion with little resistance
BSSO Inferior Alveolar
Nerve Safety
 Make sure before split is complete, the
nerve is entirely within the distal segment
 If it traverses from the proximal to the distal
segment, release it gently with an osteotomy
against the inner cortex of the proximal
segment
 BSSO Internal Fixation
 Done with positioning screws, plates, or combinations
 Screw placement is usually performed with either transbuccal instrumentation or angulated drills or
screwdrivers.
 Minimal of two and preferably three bicortical position screws are placed between the buccal and lingual
cortices
 Minimal of two screws on each side of osteotomy for plates
Mandibular Complications

 Inferior alveolar nerve injury

 Unfavorable split
 Relapse/Malocclusion
 Immediate TMJ not seated
 Late unstable
 Tooth injury
 Open bite postfixation
 Condyles not seated properly in glenoid fossa
 Inadequate posterior maxilllary bone resection during the impaction
 Rigid internal fixation
 Screw through nerve
Summary

 ESSENTIAL: Correct diagnosis of deformity

 Clinical Exam
 Photos & Skeletal radiographs
 Cephalometric Analysis
 Dental models
 Problem List/ Treatment plan
 Model Surgery and Splints
 Pre-Op orthodontics
 Orthognathic Surgery
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