DIAGNOSIS & TREATMENT

PLANNING IN
ORTHOGNATHIC SURGERY
PRESENTED BYNIKHIL SRIVASTAVA
MODERATED BYDr. DEEPIKA KENKERE

Contents
Introduction
Development of orthognathic surgery
Timing of treatment
Envelope of discrepancy
Treatment objectives
Indications
Contraindications
Systematic Clinical Patient evaluation
Radiographic evaluation
Visualised Treatment Objective
Model surgery
Phases of orthognathic surgery
Orthognathic Procedures
Conclusion

INTRODUCTION
ORTHOGNATHIC SURGERY is the art and
science of diagnosis treatment planning and
execution of treatment by combining
orthodontics and oral and maxillofacial
surgery to correct musculoskeletal, dento
osseous and soft tissue deformity of the jaws
and associated structures .

So briefly the surgical procedures undertaken

to improve the facial profile and aesthetics

which are primarily focused on the correction
of disproportions of underlying jaws (GnathosGreek) and their alignment ( Orthos Greek)
are collectively grouped as orthognathic
surgery.

DEVELOPMENT OF ORTHOGNATHIC
SURGERY
Hullihen in 1849 was the first to perform osteotomy on the

mandible to treat deformity caused by a burn.

Later Blair reported mandibular body osteotomy in 1906 and
horizontal osteotomy of the ramus with external approach in 1907.
The introduction of sagittal split ramus osteotomy in 1957, by HL
Obwegeser marked the beginning of the modern era in
orthognathic surgery. This technique was further modified by Dal
Pont in 1961.
In 1921 a German surgeon , Herman Wassmund, reported his
initial attempt to correct a dentofacial deformity by maxillary
osteotomy. Obwegeser later started to perform maxillary surgery
and described Lefort 1 osteotomies in 1969.
The Lefort 1 downfracture technique by Bell in 1975 allowed
repositioning of maxilla in all 3 planes of space.

In 1969 Horowitz emphasized the importance of

orthodontics in the field and integrated it with

orthognathic surgery.
By 1980s it was possible to reposition either or both jaws
, move the chin in all three planes of space, and
reposition dentoalveolar segments surgically as desired.
In 1990s rigid internal fixation greatly improved patients
comfort by making immobilization of jaws unnecessary.
With the introduction of distraction osteogenesis in 1992
by McCarthy and its rapid development since then made
possible for larger jaw movements and treatment at an
earlier age.

MODE OF TREATMENT
Growth Modification

Orthodontic Camouflage

Orthognathic Surgery

ENVELOPE OF
DISCREPANCY
Proffit and Ackerman have described the process

that most clearly allows clarification of treatment

goals.
With the ideal position of upper and lower teeth
shown by the origin of x and y axis the envelope of
discrepancy shows the amount of change that could
be produced by orthodontic tooth movement alone,
orthodontic tooth movement combined with growth
modification and orthognathic surgery.
There is more potential to retract than procline teeth
and more potential for extrusion than intrusion.

ENVELOPE OF
DISCREPANCY
The inner circle, or envelope, represents the limitations of

camouflage treatment involving only orthodontics;

The middle envelope illustrates the limits of combined

orthodontic treatment and growth modification;

The outer envelope shows the limits of surgical

correction.

Envelope of discrepancy
10
6
4

10

12

15

2
5

15

10

Envelope of discrepancy
10
6
4
3
12 10

15

5
25

TIMING OF SURGERY
There is a definitive sequence in which growth is completed in

maxilla and mandible. Growth in width is completed first,

then growth in length and finally growth in height.
Transverse growth of jaws completes before adolescent
growth spurt by 12 yrs, but as jaws grow in length they also
tend to become slightly wider.
Growth in length and height continues through puberty,
growth in facial height continues after cessation in growth in
length upto adulthood.
Orthognathic surgery should be delayed until growth is
completed in patients with excessive growth ,especially
mandibular prognathism.In growth deficiencies surgery can be
considered earlier but rarely before adolescent growth spurt.

TREATMENT OBJECTIVES
Three treatment objectives are fundamental

in orthognathic surgery:
1.Function
2.Esthetics
3.Stability
These three objectives form the basis of goals
in treating patients with dentofacial deformities
and often go hand in hand.

INDICATIONS
Generally ,those deformities in patients which

cannot be camouflaged by conventional orthodontic

methods are candidates for orthognathic surgeries.
1. Non growing patients under surgical envelope i.e.
a positive overjet greater than 8mm, a negative
overjet of 4mm or greater, transverse discrepancy
greater than 3mm and vertical over 5mm are not
orthodontically treatable.
2. Orthognathic surgery is required for cleft palate
patients who have small maxilla due to the growth
inhibitory effects caused by the surgery of the lip
and palate by scarring.

3.Jaw deformity due to the ankylosis of TMJ,

unilateral or bilateral .
4. Those who have severe post surgical traumatic
jaw deformities due to malunited fractures.
5. In patients with obstructive sleep apnea to
enlarge the oral space and therefore prevent the
tongue falling back during sleep.
6. Facial asymmetry caused by unilateral condylar
hyperplasia.
7. Deformities in syndromic patients

CONTRAINDICATIONS
Mild to moderate discrepancies
Growing children
Uncontrolled systemic conditions
Psychological state of the patient
Uncontrolled pathologic conditions

Systematic patient
evaluation
1. ESSENTIAL PATIENT EVALUATIONS
2.ADJUNCTIVE EVALUATIONS.

GENERAL PATIENT EVALUATION:

In this patients complete medical and dental
history should be taken.
Any medical conditions which may complicate
general anesthesia or the surgical procedure
should be evaluated.
In dental history any periodontal or periapical
conditions should be noted and managed.
Also the orofacial functions such as speech,
mastication , respiration etc. must be evaluated

SOCIOPSYCHOLOGIC EVALUATION:
It is important to consider patients motives for
treatment and to determine the patients
expectations from treatment.
There are mainly 2 causes for the patients
dissatisfaction
1. Failure of clinician to inform the patient
clearly of realistic and probable treatment
results( specially esthetic results)
2. Overoptimistic expectations of the patient
regarding the results of the treatment

Three important parameters which are to be checked

before proceeding with clinical examination are:Natural head position
Centric relation
Relaxed lip posture

Once after these 3 things are established one can go

ahead with facial examination.

ESTHETIC FACIAL EVALUATION:

Clinical assessment of face is the most valuable
of all diagnostic procedures.
Examination should be done with head in
natural head position, lips relaxed and teeth in
centric occlusion.
Facial evaluation should be done in:
1. Frontal view
2. Profile view

FRONTAL ANALYSIS:

It is important to assess facial form, transverse dimensions,

facial symmetry & vertical relationship in the upper, middle
and lower thirds of face and lips.
Facial form:
Facial height to width proportion is 1.3:1 for females and
1.35:1 for males. Bigonial width 30% less than bizygomatic
width
Short square facial types are often associated with a Class II
deep bite , vertical maxillary deficiency .
Long narrow face: Vertical maxillary excess ,anterior open
bite, mandibular anteroposterior deficiency.

FACIAL TYPES

TRANSVERSE

DIMENSIONS:
Rule of fifths (Sarver)
Face is divided into five
equal
parts from helix to helix of
outer ear.

Symmetry

Symmetry checked in
relation to facial midline
formed by glabella, nasal
bridge, nasal tip,
philtrum, dental midline
and midpoint of chin.

Vertical relationship

Distance from trichion to

glabella, glabella to
subnasale and subnasale
to menton should be even
(1/3rd)
Lower third can be divided
into upper 1/3rd from Sn to
stomium and lower 2/3rd
from stomium to menton.

In middle third

Evaluation of eyes- Scleral show indicates

midface deficiency

Cheekbones- nasal base-lip contour line

should be a smooth curve

Interruption in maxillary area
-maxillary AP deficiency
Interruption in lower region
- Mandibular excess

Normal upper lip length 20 mm females, 22 males.

Lower lip length 40mm females, 44 mm males.
Lips evaluated in relaxed position and jaws moved apart until

lips just part. Competency, symmetry and shape must be

evaluated.
Incisor exposure evaluated. Influenced by: Vertical ht of
maxilla, lip length, maxillary incisor crown length, shape of
cupids bow
Cant of occlusal plane evaluated relating to interpupillary
plane especially in asymmetries.
Gingival exposure estimated upto 2mm is normal
Amount of surgical superior repositioning dictated by amount
of tooth exposure, lip length, crown length and gender

PROFILE ANALYSIS:In profile the cheek

contour, lips,, nose, nasolabial angle, chin,

chin-throat area should be evaluated.

Lip position relates to underlying dental position such as

maxillary protrusion - lack of lip support.

Mentolabial sulcus deep in Class II pts whereas flattened in
Class III pts.
Surgical or orthodontic retraction of maxillary incisors
should be avoided in large nasolabial angles. Normal 85110 deg
The chin shape and position must be considered especially
while considering genioplasties.
Presence of double chin, chin throat length and angle
must be noted while considering mandibular setback and
advancement procedures.. Chin throat angle normal is 110
deg.

Nasal
projection
The nasal projection measured
horizontally from subnasale to
nasal tip is normally 16 to20mm ,
. Nasal projection is an indicator of
maxillary antero posterior position.
This length becomes particularly
important when planning for
anterior movement of maxilla.

Orbital rim
The orbital rim is an anteroposterior indicator of
maxillary position.
Deficient orbital rims may
correlate positionally with a
retruded maxillary position
because the osseous structures
are often deficient as groups
,rather than in isolation.
The Eye globe normally is
positioned 2-4mm anterior to
the orbital rim.

The surgical maxillary versus mandibular decision is

influenced by the orbital rim position.
Deficient orbital rims dictates the need for maxillary
advancement with all other parameters being normal..

Radiographic Evaluation
LATERAL CEPHALOMETRIC EVALUATION:

Although clinical evaluation must be the

primary diagnostic tool cephalometric analysis
must be the primary tool in determining
surgical treatment.

SOFT TISSUE ANALYSIS

Horizontal relations measured with reference

to a true vertical line passing through

subnasale.

LIP PROMINENCE

FACIAL CONTOUR ANGLE

SKELETAL ANALYSIS

Cephalometrics for Orthognathic

surgery by Charles Burstone
COGS has the following characteristics, which make it

particularly adaptable for evaluation of surgical

orthognathic problems:
1. Chosen landmarks and measurements can be altered
by surgical procedures.
2. It includes all facial bones and a cranial base reference.
3. Rectilinear measurements can be transferred to study
cast for mock surgery.
4. Standards & statistics are available for variations in
age(5yrs-20yrs) and sex.
5. It includes dental, skeletal and soft tissue variables.
6. It can be computerised.

Baseline for comparison of most data is a

horizontal plane (HP), a surrogate FH plane, 7

deg from SN plane.
Most measurements are made from
projections either parallel or perpendicular to
HP.

MEASUREME
NT

FEMALES

MALES

Ar-Ptm (11 HP)

32.1mm

37.1mm

Ptm-N (11HP)

50.9mm

52.8mm

N-A-Pog ang

2.6

3.9

N-A (11 HP)

-2 3.7mm 0.0
3.7mm

N-B (11 HP)

-6.9
4.3mm

-5.3
6.7mm

N-Pg (11HP)

-6.5
5.1mm

-4.3
8.5mm

N-ANS (L HP)

50
2.4mm

54
3.2mm

ANS-Gn (L HP)

61.3
3.3mm

68.63.8
mm

CRANIAL BASE

HORIZONTAL

VERTICAL

MAXILLA
&
MANDIBL
E

FEMALE

MALE

PNS-ANS
(11HP)

52.5
3.5mm

57.5
2.5mm

Ar-Go
(linear)

46.8
2.5mm

52
4.2mm

Go-Pg
(linear)

74.3
5.8mm

83.7
4.6mm

B-Pg
(11MP)

7.2
1.9mm

8.9
1.7mm

Ar-Go-Gn
(angle)

122 6.9

119 6.5

7.1 2.5

6.1 5.1

DENTAL
OP upperHP (angle)

A-B (11 OP) 0.40

2.5
U1- NF

-1.1 2

112 5.3 111 4.7

POSTEROANTERIOR CEPHALOMETRIC
ANALYSIS:

Usually advised in patients with facial

asymmetry
1. Triangle analysis: Triangles are constructed
to evaluate the symmetry of the maxilla,
mandible and chin.

DEVELOPMENT OF VISUAL
TREATMENT OBJECTIVES.
Accurate and realistic visual treatment objectives are

developed from the lat ceph tracing in combination with

all data from systemic patient evaluation.
Two types of VTO: the pretreatment objective &
immediate presurgical prediction tracing.
PRETREATMENT VTO :
Used for overall treatment planning . Consists of:
1. Orthodontic prediction tracing to illustrate desired
presurgical tooth movements and resulting soft tissue
changes.
2. Surgical prediction tracing predicting surgical
repositioning of jaws and soft tissue changes.

IMMEDIATE PRESURGICAL VTO:

Prediction tracing few days before surgery plans the definitive surgical
movements and soft tissue changes.
Model surgeries are also performed at this stage
Uses of VTO:
1. To assess accurately the profile esthetic results of proposed surgery
and orthodontics.
2. To evaluate treatment options.
3. To determine desirability of adjunctive surgical procedures such as
genioplasty.
4. Help determine the sequencing of surgery and orthodontics.
5. To help decide if extractions are necessary & which teeth to extract.
6. To determine anchorage requirements.

ORTHODONTIC PREDICTION
TRACING
Correct planning of orthodontic tooth

positioning before surgery and accurate

execution of presurgical orthodontic plan will
enhance surgical potential and esthetic
results.
The following steps are followed in prediction
tracing of mandibular advancement.

Step 1: Original tracing

in black .
Draw ideal facial depth
angle (Between line
passing through N to pt
A & FH plane: 90 deg)
Draw ideal facial
contour angle (between
upper facial plane and
lower facial plane: -11
to -15 deg)

Step 2: Prediction tracing done in red anterior

to vertical osteotomy line and above

horizontal osteotomy line .Repositioning of
chin done. Teeth, lowerlip & chin traced in
dotted line.

Assessment of occlusal plane and curve of

spee

Step 3: Mandibular advancement along

occlusal plane

Step 4: Trace remaining structures

Step 5: Placing teeth in ideal position

Step 6: Decision regarding tooth extraction

Step 7: Establishment of molar relation and

arch length post extraction.

Step 8: Soft tissue prediction and completion

MODEL SURGERY
The primary goal of the model surgery is to

functionally and spatially simulate the

patients jaw and dental structures as
accurately as possible to allow accurate
simulation of the interdental surgery.
The preoperative structures can be measured
and recorded. The surgical movement of the
jaws or dentoalveolar segments as indicated
by prediction tracings, is simulated on the
cast and the specific spatial changes are then
recorded.

The first step in defining the patients

deformity in three planes of space is to place

the dental casts on an anatomic articulator
using facebow transfer in centric occlusion.
Next the plaster is trimmed to simulate the
maxilla and mandible as closely as possible.
Reference lines are drawn on the mounted
casts to record their positions in three planes
of space.

MODEL SURGERY FOR MANDIBLE

1. Draw a horizontal osteotomy line parallel to the
2.
3.
4.
5.
6.

mandibular occlusal plane.

Draw vertical reference lines from the cusps of the molar,
canine, and central incisors to the base of the cast.
Measure the length of the vertical lines and record the
data.
Cut the mandibular cast on the horizontal osteotomy line.
Advance the cast into more favorable dental occlusion.
Measure anteroposterior vertical and rotational
movements and compare them with the premovement
data.

MODEL SURGERY FOR MAXILLA

Draw horizontal osteotomy line as close as possible to

lefort I
Draw 2 horizontal lines, one line 5mm above the
osteotomy line and one line 5mm below it( 10mm total
between lines) this is done because the lateral walls of
the maxilla are not parallel and taper downword.
Draw vertical lines from the buccal cusps of the teeth
to the base of the cast.
Measure the length of vertical lines and record the
data.
Cut the cast along the osteotomy line.

Perform anteroposterior cast repositioning

a. advance the cast

b. superior repositioning
c. down fracture.

PHASES OF ORTHOGNATHIC
SURGERY
The complete treatment protocol in

orthognathic surgeries can be divided into 3

stages:
1. Presurgical orthodontics
2. Surgical phase.
3. Postsurgical orthodontics

Time estimates for surgical orthodontic treatment

Stage of treatment

Time
required

Comments

1. Presurgical
orthodontics

918months

Interval varies with difficulty of

alignment

2. Surgery
/hospitalization

1-5days

Hospital stay typically requires 1

or 2 days. One jaw surgery now
can done without overnight
hospitalization

3. Patient under
surgeons care before
beginning
postsurgical
orthodontics

3-8 weeks

Less time is required with rigid

fixation (3 to 5 weeks) than with
maxillomandibular fixation (5 to
8 weeks)

4. Postsurgical
orthodontics

3-6 months Interval longer than 6 months

indicates a problem or
inadequate preparation

Different orthognathic procedures

and effects involved
Procedures
Maxillary
advancement

Effects
Widens nasal base
Highlights Para nasal areas
Reduces nasal prominence
Highlights upper lip
Shades the chin

Maxillary setback

Retracts Para nasal areas

Increases upper lip length
Decreases interlabial gap
Lowers tip of the nose
Highlights chin

Mandibular
advancement

Increases height of the lower third

Increases chin projection
Reduces lower lip eversion
Increases lower lip protrusion

Mandibular setback

Increases lower lip show

Reduces height of the lower third
Reduces chin prominence
Reduces lower lip eversion
Reduces lower lip protrusion
Highlights paranasal areas

DIAGNOSIS AND TREATMENT PLANNING

Data base
(case history, patient examination,
Radiographic and model analysis)

Problem list in priority order

Diagnosis

Possible solution to the problem Tentative treatment plan.

Discussed with the patient & modified

Optimal treatment plan

Execution of treatment

MANDIBLE
Ramus osteotomies
Oblique subcondylar osteotomy
The vertical subsigmoid osteotomy
The sagittal split and its modifications
The inverted L and C osteotomies of the ramus
Condylectomy

Osteotomies of the body of the mandible

Segmental procedures
Genioplasties

MAXILLA
1. Lefort I
2.lefort II
3. lefort III
4. Segmental osteotomy

Surgical Techniques
BSSO

Genioplasty

Surgical Techniques
Le Fort I
Le Fort II
Le Fort III

Le Fort III

Le Fort II

Le Fort I

CONCLUSION
Orthognathic surgery has created vast and

exciting opportunities in treatment with

dentofacial deformities and has relieved the
orthodontist of having only compromised
treatment to offer patients with skeletal
disharmony.
A well-planned, systematic & synergestic
approach from both specialities of
orthodontics and surgery is required to
provide the best successful treatment for such
cases.

REFERENCES
Essentials Of Orthognathic Surgery Johan P.

Reyneke
Orthodontics & Orthognathic Surgery :
Diagnosis & Treatment Planning-Jorge
Gregoret
Maxillofacial Surgery- Peter Ward Booth
Petersons Principles of Oral and Maxillofacial
Surgery

K
N
A
H
T
U
O
Y