Orthognathic Surgery Ronal
Orthognathic Surgery Ronal
Orthognathic Surgery Ronal
Ronal
Supervisor:
Drg Abel Tasman Sp.BM (K)
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
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;
6
4
10 5 2 7 12 15
2
15 10
Envelope of discrepancy
10
6
4
3 5
12 10 5 2 25
15
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
2.ADJUNCTIVE EVALUATIONS.
GENERAL PATIENT EVALUATION:
In this patient’s 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 patient’s motives for
treatment and to determine the patient’s 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:-
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 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
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 – 85-
110 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
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 III
Le Fort I
Le Fort II
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
Peterson’s Principles of Oral and Maxillofacial Surgery