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Drg Abel Tasman Sp.BM (K)
 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

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 (Gnathos- Greek) and their
alignment ( Orthos – Greek) are collectively grouped as
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
 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 1980’s 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 1990’s 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.
 Growth Modification

 Orthodontic Camouflage

 Orthognathic Surgery
 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.
 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 5 2 7 12 15

15 10
Envelope of discrepancy


3 5
12 10 5 2 25

 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.
 Three treatment objectives are fundamental in
orthognathic surgery:

These three objectives form the basis of goals in treating

patients with dentofacial deformities and often go hand
in hand.
 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
7. Deformities in syndromic patients
 Mild to moderate discrepancies
 Growing children
 Uncontrolled systemic conditions
 Psychological state of the patient
 Uncontrolled pathologic conditions
Systematic 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
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
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:-

Natural head position

Centric relation
Relaxed lip posture

Once after these 3 things are established one can go ahead with
facial examination.
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
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.
 Rule of fifths (Sarver)
Face is divided into five equal
parts from helix to helix of outer
 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
 In middle third
Evaluation of eyes- Scleral show indicates midface
 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
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 antero-

posterior 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..
 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.
 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
 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.
1. Draw a horizontal osteotomy line parallel to the
mandibular occlusal plane.
2. Draw vertical reference lines from the cusps of the molar,
canine, and central incisors to the base of the cast.
3. Measure the length of the vertical lines and record the
4. Cut the mandibular cast on the horizontal osteotomy
5. Advance the cast into more favorable dental occlusion.
6. Measure anteroposterior vertical and rotational
movements and compare them with the premovement
 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
 Cut the cast along the osteotomy line.
 Perform anteroposterior cast repositioning
a. advance the cast
b. superior repositioning
c. down fracture.
 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 Comments
1. Presurgical 9-18months Interval varies with difficulty of
orthodontics alignment
2. Surgery 1-5days Hospital stay typically requires 1 or 2
/hospitalization days. One jaw surgery now can done
without overnight hospitalization
3. Patient under surgeons 3-8 weeks Less time is required with rigid
care before beginning fixation (3 to 5 weeks) than with
postsurgical orthodontics maxillomandibular fixation (5 to 8
4. Postsurgical 3-6 months Interval longer than 6 months
orthodontics indicates a problem or inadequate
Different orthognathic procedures
and effects involved
Procedures Effects
Maxillary advancement 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 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
Data base
(case history, patient examination,
Radiographic and model analysis)

Problem list in priority order –


Possible solution to the problem – Tentative treatment plan.

Discussed with the patient & modified

Optimal treatment plan

Execution of treatment
 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
1. Lefort I
 2.lefort II
 3. lefort III
4. Segmental osteotomy
Surgical Techniques

 Genioplasty
Surgical Techniques
Le Fort III
 Le Fort I
 Le Fort II
 Le Fort III
Le Fort II

Le Fort I
 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.
 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