Orthognathic Surgery

WHAT DO YOU NEED TO KNOW?

Definition
Indication and contraindications
Advantages and disadvantages
Criteria for orthognathic surgery
Steps in orthognathic surgery
Risk and complication of orthognathic surgery
 DEFINITION

Orthognathic treatment is defined as the

treatment of dento-facial deformities.
Orthognathic surgery is the surgical correction of
abnormalities of the mandible, maxilla, or both
The underlying abnormality may be present at
birth or may become evident as the patient
grows and develops or may be the result of
traumatic injuries
 DEFINITION

Orthognathic surgery is concerned with the

correction of dento-facial deformity
In majority of cases a combined surgical and
orthodontic approach is required to achieve an
optimum result
WHO NEEDS ORTHOGNATHIC
SURGERY?

Orthognathic surgery is necessary for those

cases with a skeletal discrepancy outside the
limits of orthodontic treatment either because of
their severity or a lack of growth

Usually performed when growth is virtually

complete.
 The role of orthodontist

To achieve an occlusion which has good function,

aesthetics and stability

To enable the achievements of optimal facial aesthetic

To provide the best means of intraoperative

intermaxillary fixation

To provide for the attachment of post-operative

intermaxillary elastics
 Indications
1. Dentofacial problems too severe for orthodontics alone

2. Non-growing adults

3. Children with cranial-facial syndromes and severe

dentofacial abnormalities, distraction osteogenesis
may be considered.
 Indications

4. Cases where there are specific documented signs of

dysfunction.

These may include conditions involving airway

dysfunction such as sleep apnea, temporomandibular
joint disorders, psychosocial disorders and or speech
impairments
 Examples of indications

1. Severe anteroposterior discrepancies (class II/ class III

malocclusions)

2. Vertical discrepancies (open bite/ deep overbite)

3. Transverse discrepancies

4. Skeletal asymmetry
 Contraindications

Growing patients

Mild malocclusion

Patient with body dismorphic syndrome

Medical problems
 Advantages

Aesthetic
75% - 80% of patients seeks aesthetic improvement

Psychological
About 90% of patients who undergo orthognathic surgery
report satisfaction with the outcome and over 80% say
they would recommend such treatment to others and
would undergo it again

Functional
Able to speak and eat normally
 Disadvantages

Surgical risk
Relapse
Unsatisfied with results
Motivated patients
Availability of surgeons + orthodontist
Cost
 Criteria for Orthognathic Surgery
(The American Association of Oral and Maxillofacial Surgeons, 2008)

1. Anteroposterior discrepancies

2. Vertical discrepancies

3. Transverse discrepancies

4. Asymmetries
 1. Anteroposterior discrepancies

Maxillary/mandibular incisor relationship: overjet of 5mm

or more, or a 0 to a negative value (norm 2mm).

Maxillary/mandibular anteroposterior molar relationship

discrepancy of 4mm or more (norm 0 to 1mm).
 2. Vertical discrepancies

Open bite
No vertical overlap of anterior teeth.

Unilateral or bilateral posterior open bite greater than 2mm

Deep overbite with impingement

or irritation of buccal or lingual soft tissues of the opposing
arch.

Supra eruption of a dentoalveolar segment due to lack of

occlusion.
 3. Transverse discrepancies

Presence of a transverse skeletal discrepancy which or

cross bite
 4. Asymmetries

Anteroposterior, transverse or lateral asymmetries

greater than 3mm with concomitant occlusal asymmetry.
 Steps in Orthognathic Surgery

1. Diagnosis and treatment planning

2. Pre-surgical orthodontics
3. Orthognathic surgery
4. Post-surgical orthodontics
 1. Diagnosis and Treatment
Planning
A team approach is essential -orthodontist and surgeon
to produce a coordinated treatment plan (joint clinic)

Establish whether they are concerned with their skeletal

pattern, the position of their teeth or a combination of two

The patient should be made fully aware of the various

treatment options, the advantages, disadvantages and
short and long term complications of each of possible
treatment
 2. Presurgical orthodontics
This involves the preparation of patients for surgery by
correcting abnormal tooth position due to the underlying jaw
deformity.
This generally takes 18-24 months, with appointments every
four to six weeks.
AIMS:
Alignment
Decompensation
Arch coordination
Creation of space for interdental osteotomy cuts
Falitation of the placement of temporary intermaxillary
fixation during surgery.
Lateral chephalogram and intra-oral
photograph bebore and after
presurgical surgery for
management
Class III malocclusion.
Increase in reverse overjet during
decompensation.

Do some cephalometric
tracing alalysis
ANALYSIS UTILIZING THE
CEPHALOMETRIC TRACING
Describe the subjects dento-facial
morphology
Quantitative description of morphological
deviations
Make diagnostic and treatment planing
decisions
Evaluate change over time - treatment
induced and growth process
Cephalometric Evaluation

Identification of anatomic landmarks

Landmarks: stable reference structures and maxillary and mandibular
skeletal and dental
Graphically relating the dento-facial elements to these reference
structures
Angular and or linear measurements
METHODS OF CEPHALOMETRIC
ANALYSIS
Two basic approaches
Metric approach - use of selected linear and angular measures
Graphic approach - overlay of individuals tracing on a reference
template and visual inspection of degree of variation
Metric Method - Use of selected linear and
angular measures
Graphic Method - Use of a Composite
Template
GOALS OF CEPHALOMETRIC ANLYSIS

Evaluating relationships, both horizontal and vertical of 5 major functional

components of the face:
the cranial base;
the maxilla; the mandible,
the maxillary and mandibular dento-alveolus
REFERENCE LINES

Frankforts Horizontal (porion to orbitale)

Sella - Nasion line
True horizontal plane
True vertical plane
Reference Lines

sella nasion

porion orbitale
SNA
SNA82
8222
deg
deg
NA
NATO
TOFH
FH90
33deg
deg
90
SKELETAL HORIZONTAL - MAXILLA

s n

FH

a
SNB
SNB80
8022
deg
deg
N-PG
N-PGTO
TOFH
88
8866deg
FH
deg
SKELETAL HORIZONTAL - MANDIBLE

n
s

FH

b
Pg
ANB
ANB2222deg
deg

SKELETAL HORIZONTAL - MAXILLA TO

MANDIBLE

B
FH
FHTO
TOGOGN
GOGN
22 5 deg
22 5 deg
YYAXIS
AXIS59
5966
deg
deg SKELETAL VERTICAL
LFH
LFH55%
55%OF
OF
TFH
TFH

FH

GO

ME GN
INTERINCISAL
INTERINCISAL
130
13055deg
deg

DENTAL - UPPER TO LOWER INCISOR

U1
U1TO
TOFH
FH110
110
55deg
deg
U1
U1TO
TONA
22deg
22deg
NA
DENTAL - MAXILLARY INCISOR
U1
U1TO
TONA
NA
4mm
4mm

FH

A
L1
L1TO
TONB
NB
25deg
25deg
L1
L1TO
TONB
4mm
4mm
NB
DENTAL - MANDIBULAR ANTERIOR
L1
L1TO
TOGOGN
GOGN
91 6deg
91 6deg

GO B

GN
NASOLABIAL
NASOLABIAL
ANGLE
ANGLE102
102
88deg
deg
L.LIP
L.LIPTO
TOEE SOFT TISSUE
PLANE
PLANE-2-2
2mm
2mm
Limitations of the Metric Method

Stable reference structures are only relatively stable

Validity of landmarks
Error in landmark identification
Graphic Method

Template
Changes between 2 time points
Superimposition Method - on the
cranial base
Maxillary and mandibular
superimposition
Limitations of Cephalometric Analysis

Individual variability
Ethnic variability
Gender variability
 Space created for interdental cuts distal to the maxillary canines.
The reserve tip of canines produced intentionally to move the canine
root away from osteotomy site.
 At the end of presurgical phase, heavy rectangular
stainless steel archwires are placed (0.019 x 0.025 SS)

Metal hooks are crimped directly into the archwire

Metal hooks are crimped directly into the archwire
 3. The surgical phase of
treatment
Prior to surgery records should be taken so that final
surgical plan can be confirmed

This include study models, photographs

and lateral cephalogram

The models should be mounted on a semi adjustable

articulator
 Acrylic intermediate and or final interocclusal
wafers are also constructed from the models

This is carried out on an inpatient basis. A typical length of

stay is around two nights. Post-surgical intensive care is
rarely required.
Type of surgical procedure:

Bilateral sagittal split mandibular osteotomy

Vertical subsigmoid osteotomy
Mandibular distraction
Le fort I maxillary
Le fort II maxillary
Le fort III maxillary
Segmental osteotomy
Genioplasty
Range of surgical movement:
- Maxilla can be moved forwards, upwards and
downwards
- Mandibula can be moved forwards and backwards
- Chin can be moved forwards, backwards, upwards and
downwards
 Bilateral sagittal split mandibular osteotomy

Vertical subsigmoid osteotomy

 Mandibular distraction

Le fort I maxillary
 Le fort II maxillary

Le fort III maxillary

 Segmental osteotomy

Genioplasty
 4. Postsurgical orthodontic
Postoperative recovery time is typically two weeks following
a single jaw procedure and three weeks following a
bimaxillary (upper and lower jaw) procedure.

1-7 days post operatively, light intermaxillary elastics may need

to be placed to detail the occlusion

In the arch where most vertical movement is required, a more

flexible archwire may be used such as rectangular nickel
titanium

In the opposing arch where vertical movement is not required, a

stiffer rectangular steel wire can remain in place
 The postsurgical orthodontic usually last 3 6 months
depending on the degree of presurgical orthodontic
already carried out

At completion of treatment the fixed appliances are

removed and retainers are fitted
Postsurgical stage, with light vertical
elastics to maintain the vertical
position of the teeth
Maxillary archwire .017x.025 beta-
Ti
Mandibular archwire 0.16 SS
 Risk and Complications

1. Preoperative (orthodontic complications)

2. Intra operative
3. Postoperative
1. Preoperative (orthodontic
complications)
Decalcification of enamel

Gingival recession

Alveolar bone loss

Root resorption
2. Intraoperative

Damage to the neurovascular bundle during mandibular

osteotomy leading to parasthesia, this occurs in 32% of
patients and can be disturbing for 3% of patients

Loss of blood supply to part of maxilla

Hemorrhage
 Failure of bone to split cleanly

Failure to relocate the osteotomised fragments into their

correct preplanned position

Damage to the teeth adjacent to osteotomy site

Fatality
3. Postoperative

Failure of the osteotomy to undergo bony union

The bone plate perforates through mucosa with chronic

infection

Relapse towards the preoperative position

 Hierarchy of stability
Proffitet al. (1996, 2007) have researched extensively on the stability
of different orthognathic procedures and produced the widely used
Hierarchy of Stability;
This gives guidance to clinicians regarding those procedures with the
best long-term stability.
Stability after surgical repositioning of the jaws varies a great deal,
depending on the direction of movement, type of fixation used and the
surgical technique that was employed.
Superior repositioning of the maxilla is the most stable procedure and
closely followed by mandibular advancement in patient with normal or
decreased anterior face height
Problem: horizontal deficiency and vertical chin excess
Surgical procedure: vertical reduction with vertical
advancement of the chin
Problem: Class II mandibular deficiency
Surgical procedure: sagittal split osteotomy with
advancement
Problem: Excess vertical maxillary
growth
Surgical prosedure: Le fort I osteotomy
with maxillary impaction
Problem: Class III with mandibular excess
Surgical procedure: sagittal split osteotomy with
setback
Problem: Class III maxillary deficiency
Surgical procedure: Le fort I osteotomy with maxillary
advancement
Problem: Class III maxillary deficiency mandibular excess
Surgical treatment:
Le Fort I osteotomy of maxillary advancement
Sagittal split osteotomy of mandibular with setback
Problem: Facial asymmetry
Surgical procedure:
Differential Le fort I of maxilla
sagittal split rotation of mandible
differential genioplasty
Bedankt
Voor uw
Aandacht