Workshop

Planning Orthognathic Surgery 2010

Kamal F. Busaidy, BDS, FDSRCS, Associate Professor, Dept. Oral and Maxillofacial Surgery.

Overview of the Workshop

Setting goals Clinical evaluation Radiographic evaluation Cephalometric tracing and analysis Photographs Mounting of models Formulating the surgical plan Performing prediction tracings (The VTO) Model surgery and constructing splints The TMJ and orthognathic Surgery Planning for stability Pitfalls in planning and execution
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 Primary references:
Modern Practice in Orthognathic Reconstructive Surgery (Edited by William H. Bell)

Essentials of Orthognathic Surgery (Johan Reyneke)

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Goals in Orthognathic Surgery

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The Key to Successful Planning

Find out where you are Determine your destination Plan your journey Allow for contingencies Communicate with the team

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What problem are we addressing?

Inability to incise or chew Speech impediment Oral health (dental, periodontal) Poor esthetics
Facial soft tissue Facial hard tissue Dental

OSA TMJ Primary versus secondary growth disturbance Psychological issues

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What is success?
In the eyes of the patient success is measured by
Addressing the original complaint Absence of adverse outcomes Stability of result Assuming there is no underlying psychiatric issue!

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Clinical Evaluation of the Orthognathic Surgery Patient

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The Team Approach

Orthodontist OMS General Dentist ENT Plastic surgeon Periodontist Prosthodontist Psychiatrist Pulmonologist/Sleep physician
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OMFS Evaluation
Stage 1 Stage 2 Stage 3 Initial evaluation/Feasibility Pre surgical evaluation Post surgical evaluation (Long term)

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Coordination of Care

Referring Practitioner

OMFS:1st Evaluation

Ortho:1st Evaluation

ENT / PRS etc OMFS: 2nd Evaluation

Ortho Treatment

OMFS: Surgery Ortho 2nd Evaluation Ortho Treatment Finalization

OMFS: 3rd Evaluation

Ortho 3rd Evaluation

Perio / Pros etc

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Patient Evaluation
1. Complaint + History 2. Health Status 3. Assessment of Facial Esthetics 4. Routine Dental Examination 5. Orthodontic Evaluation 6. Cephalometric Evaluation 7. Photos 8. Dental casts * Psychological Assessment
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Facial Esthetics

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Facial Esthetics
1/3

1/3

1/3

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Facial Esthetics
ULL 21mm (+/- 2 mm) Men ULL 19 mm (+/-2 mm) Women

Incisor Show at Rest 2 - 4 mm

Note lip-tooth relationships at rest and when active!

1/3 2/3

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Facial Esthetics
Nasofacial Angle 30 - 40 o o Nasomental Angle 120 -132 o o Mentocervical Line 80 95 to Vertical o o Mentocervical Line 110 120 to Nasomental Line o o Nasolabial Angle 100 - 110
Powell and Humphreys: Proportions of the Aesthetic Face. New York, Thieme-Stratton, 1984
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Dental Esthetics
Tooth Location (Midline)

Tooth Size
Tooth Shape Tooth Number Tooth Orientation Emergence Tooth Color
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Dental Esthetics
Arch Form Occlusal Plane Occlusal Level Overbite Overjet Buccal Corridor Surrounding Tissues
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Case Example

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Case Example
SMILE REST

12 mm

9 mm
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Case Example

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Case Example

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Case Example
Class II Skeletal Pattern (*mandible) Increased incisal show No increased LFH! Close bite (?traumatic) Maxillary cant

Ocular dystopia
Unstable occlusion. Poor bridges (shape/color)
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Radiographic Evaluation of the Orthognathic Surgery Patient

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Radiographs
Lateral Cephalogram Panoramic Dental Xray Periapicals SMV PA Cephalogram Others (MRI/CT/Bone scan/Wrist Films)
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MRI/CT/Bone scan/Wrist Films

TMJ meniscus position OSA Complex craniofacial deformities Local growth disturbance (Condylar Hyperplasia) Systemic growth disturbance (Excess growth hormone) Autoimmune arthritis Assessment of completion of growth

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PA Cephalogram
Symmetry (particularly gonial angles, symphysis) Position of proximal segment post op Position of internal fixation post op

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SMV
Thickness of mandible (Superseded by CBCT!) Flaring of rami (vertical ramus osteotomy) Position of proximal segment post op Position of internal fixation post op

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Periapicals
Periodontal bone loss Proximity of apices (multi-piece segments) Periodontal bone loss post op

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Panoramic Radiograph
Third Molars Inferior alveolar nerve position Intraosseus pathology (best screening tool) Position of fixation post op Position of condylar head post op

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Lateral Cephalogram
Skeletal proportions Growth prediction Cessation of growth Soft tissue measurements Planning (primary tool)

Position of fixation post op Baseline post op status***

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Cone Beam CT

Dolphin Imaging

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Lateral Cephalogram

What is wrong with this Lateral Ceph?

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Lateral Cephalogram
Nasion Pt point Porion Basion Xi Point Gonion Pm Point Pogonion Menton Gnathion PNS Orbitale ANS A Point

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Ba- Basion: the lowest point on the anterior margin of the foramen magnum, at the base of the clivus Po-Porion: the midpoint of the upper contour of the external auditory canal (anatomic porion); or, the midpoint of the upper contour of the metal ear rod of the cephalometer (machine porion) Pt- the point at about 11 0clock on the outline of the pterygomaxillary fissure adjacent to the foramen rotundum Or-Orbitale: the lowest point on the inferior margin of the orbit ANS-anterior nasal spine: the tip of the anterior nasal spine Point A: the innermost point on the contour of the premaxilla between the anterior nasal spine and the incisor tooth Pog-Pogonion: the most anterior point on the contour of the chin Pm-Suprapogonion: the point where the anterior curvature of the mandible changes from concave to convex Me- Menton: the most inferior point on the mandibular symphysis Na-Nasion: the anterior point of the intersection between the nasal and frontal bones Go- Gonion: the midpoint of the contour connecting the ramus to the body of the mandible Gn-Gnathion: the most outward and everted point on the mandibular symphysis PNS-Posterior nasal spine: the tip of the posterior nasal spine of the palatine bone, at the junction of the hard and soft palate Xi- The point in the middle of the ramus, approximately in line with the occlusal plane FH-Frankfort Plane: the horizontal reference plane in the heads natural position extending from the porion to orbitale
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Hands-on Exercise
Lateral Ceph Pencil Protractor/Ruler
Identify the points marked in the previous slides, (then trace the outlines of the skeleton as described), and start measuring the pertinent angles using Ricketts analysis.
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Lateral Cephalogram
MARK THESE POINTS ON YOUR CEPHALOGRAM Porion Basion Xi Point Pt point Orbitale PNS ANS A Point Nasion

Gonion Pm Point Pogonion Gnathion Menton

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Facial Depth (Angle) 87 +/- 3

Nasion

Frankfort Horizontal Porion 87 Orbitale

o

Pogonion
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Mandibular Plane Angle: 26 +/- 4

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Mandibular Plane Gonion Pogonion Menton

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Facial Axis: 90 +/- 3

90 Basion

Skull Base

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Maxillary Depth: 90 +/- 3

90

A point

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Convexity at point A: 2mm +/- 2 mm

A point

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Lower incisor to APog: 1mm +/- 2 mm

A point

Pogonion
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Xi Point and Functional Occlusal Plane

Xi

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Lower Face Height : 47 +/- 4

ANS Xi 47
o

Pm Point
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Interincisal Angle: 130

130 +/-6
o

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Other Analyses

32 +/-5

Approximately Parallel

112 +/-6 112 +/-6 130 +/-6

o o

90 +/-7

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Evaluation of Soft Tissue on Lateral Ceph

30-40
o

UFH: 130
o

100-110

LFH: 120-132
o
o

85-95

CHECK THAT THE PATIENT IS IN REPOSE, KB 2010 WHICH THIS PATIENT IS NOT

Clinical Photography

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Clinical Photographs

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Clinical Photographs

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Mounting the Case

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Take the impressions Interocclusal records Face bow record Mount the casts Measuring in 3 planes of space

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Impressions
2 sets of upper impressions 2 sets of lower impressions Block out brackets with wax to prevent distortion of the impression Avoid bubbles/voids in pour-up

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Interocclusal Record
Record occlusion in centric relation (Potential
disparity with centric relation when asleep)

Avoid displacement from premature contacts

(Wax is not ideal for occlusal records)

Alternatives:
Record occlusal relationship supine Deprogramming Short general anesthetic!

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Facebow Recording
Find Frankfort Horizontal (Easier said than done!)

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A Common Reference Plane

The Frankfort plane identified clinically should correlate with the Frankfort plane on the articulator AND the lateral Ceph

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True Frankfort versus Clinical

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Radiographic Frankfort

Projected Frankfort Clinical Frankfort

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Identifying True Frankfort

J Oral Maxillofac Surg. 2001 Jun;59(6):635-40; discussion 640-1.

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Identifying True Frankfort

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A Common Reference Plane

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Facebow Recording
Find Frankfort Horizontal (Easier said than done!) Ensure the facebow is centered on the face Lock down the hinges to prevent distortion of record

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Midlines and occlusal angulations/cants are consistent with clinical picture

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Mount Two Sets of Casts

B
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Erickson Model Block and Platform

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3 Planes of Measurement

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3 Planes of Measurement

RIGHT SIDE DOWN!

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3 Planes of Measurement

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3 Planes of Measurement

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Formulating the Surgical Plan and the VTO

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When I hand articulate the models can I get a good occlusion? Segmental maxilla / (Segmental mandible) / More Ortho
No Yes

Proceed to Next

Is the position of the anterior maxilla acceptable?

No Yes

Proceed to Next

Maxillary osteotomy

Mandible acceptable?
No No. There is an AOB Yes

Mandibular osteotomy

Maxillary osteotomy +/Mandibular osteotomy

No

Is the position and form of the chin acceptable?

Yes

Genioplasty

Finished

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Prediction Tracing: Exercise One

Visualized Treatment Objective (VTO) for Mandibular Sagittal Split Osteotomy

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Exercise 1: VTO for BSSO Setback

Trace the cephalogram and indicate in the mandible where the osteotomy will be placed

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Take a new piece of tracing paper and trace over the original: only trace structures in the maxilla and above. Trace the soft tissues of the nose and upper lip.

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Reposition the prediction tracing on the original such that the maxillary teeth of the prediction tracing meet the mandibular teeth on the original tracing in class 1 Trace the mandible ANTERIOR to the osteotomy line, including the teeth. Trace the soft tissues of the lower lip and chin.

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Reposition the prediction tracing such that the skull bases and orbits coincide. Rotate the prediction tracing around the axis of rotation in the condylar head until the inferior border of the proximal mandibular segment seems aligned with the inferior border of the distal segment. Trace the proximal mandibular segment. Note the degree of overlap. This corresponds to the amount of mandibular setback.
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Exercise 2: VTO for Le Fort 1

Prediction Tracing: Exercise Two

Visualized Treatment Objective (VTO) for Maxillary Le Fort 1 Osteotomy

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Trace the cephalogram and indicate in the maxilla where the osteotomy will be placed

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Take a second piece of tracing paper and trace again all the structures that will NOT move during the osteotomy (i.e. above the osteotomy cut). Stop tracing the soft tissue of the nose at the supra-tip break. Mark a horizontal line that corresponds to the level of desired maxillary incisal vertical height

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Rotate the top sheet around the axis of rotation in the condylar head until the tip of the lower incisors protrude above the horizontal line by 2 to 3 mm. This represents the overbite. Trace the entire mandible and the soft tissue of the neck and chin up to the labiomental fold.

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Reposition the top tracing over the original such that the maxillary dentition occludes with the new mandibular dentition in class 1. Pay particular attention to the incisal relationship. Trace the maxilla and the maxillary teeth. Trace the remainder of the nose and upper lip, then complete the tracing of the lower lip.

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Reorient the prediction tracing on the original such that the skull bases and orbits coincide. Examine the degree of movement of the maxilla in 2 planes. Make a note of these measurements. Examine the degree of autorotation of the mandible. Examine also the effect on the chin prominence and assess whether a genioplasty is required.
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Exercise 3: VTO for 2-Jaw Surgery

Prediction Tracing: Exercise Three

Visualized Treatment Objective (VTO) for Bimaxillary Osteotomy (Le Fort 1 and BSSO)

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Trace the cephalogram and indicate in the maxilla AND mandible where the osteotomies will be placed

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Take a new sheet of tracing paper and trace over the original: only trace structures that will NOT move in either the maxillary or mandibular osteotomies. Stop tracing the soft tissue of the nose at the supra-tip break Indicate the desired vertical height of the incisal edges of the maxillary teeth with a horizontal line. Indicate with a vertical line the desired AP position of the incisal edge of the maxillary incisors
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Rotate the top sheet around the axis of rotation in the condylar head until the tip of the lower incisors protrude above the horizontal line by 2 to 3 mm. This represents the overbite. Trace the mandible.

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The degree of reverse overjet indicates the amount the mandible must be set back.

Reposition the prediction tracing such that the maxillary incisal edge rests in the indicated ideal position. Align the maxillary occlusal plane with the occlusal plane of the mandibular teeth on the prediction tracing. (Note that the maxillary teeth NEED NOT be in class 1 occlusion with the mandibular teeth at this point!) Trace the maxilla and the maxillary teeth. Trace the remainder of the nose and the upper lip.
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Your prediction tracing should look like this now. Label this tracing IPT (Intermediate Prediction Tracing)

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Take a new sheet of tracing paper and trace over all hard structures on the first prediction tracing except the mandible. It is recommended that you use a different color pencil. Trace soft tissues down to and including the upper lip. Label this tracing FPT (Final Prediction Tracing)

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Place the Final prediction tracing (FPT) over the Intermediate Prediction Tracing (IPT) in such a way that the maxillary teeth on the FPT meet the mandibular teeth on the IPT in class 1. Trace the mandible ANTERIOR to the mandibular osteotomy line. Trace the mandibular teeth.

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Reposition the FPT on the IPT such that the skull bases and orbits coincide. Rotate the FPT around an axis of rotation on the condylar head until the inferior border of the proximal mandibular segment aligns with the inferior border of the distal mandibular segment. Trace the proximal mandibular segment. The overlap indicates the amount of mandibular setback.
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Place the FPT on the original tracing of the cephalogram such that the lower incisor and symphysis of both coincide. Estimate the predicted chin and lower lip shape.

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Your FPT should now look like this. Measure the vertical and AP predicted movement of the maxilla and mandible and record the measurements. Note that the post-surgical occlusal plane in this example was determined by the occlusal plane of the mandible after rotation; however the occlusal plane can be adjusted (within limits) to fit the needs of the individual case.

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Soft Tissue Predictions Mandible

Advancement
Chin 100% Lower Lip 70%

Setback
Chin 90% Lower Lip 90% Upper Lip 20%
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Soft Tissue Predictions Maxilla

Advancement
Nasal Tip 30% Upper Lip 50% at incisor level (70% - 90% with VY closure) Upper lip shortens 1-2 mm

Setback
Upper Vermillion 50% - 60% (Less with VY) Subnasale 30% (Less with VY) Upper Lip 10%
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Soft Tissue Predictions Maxilla

Inferior
Lip length increases 10-15%

Superior
Subnasale 20% up Nasal Tip 20% up Lip 10% up (Less if VY)

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Predicting Chin Position Horizontal distance to 0-Meridian

0-Meridian

0-Meridian: Perpendicular to FH from soft tissue forehead. Chin should be 0-3mm ahead of this line

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Predicting Chin Position FH to Z Line

Z Line

78 +/- 10

Z Line: Tangent to most protrusive lip and soft tissue chin

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Predicting Chin Position H Line to NB

H Line

H Line: Tangent to most protrusive lip and soft tissue chin

8 +/- 2

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Review of Process in Planning. Start with the Maxilla

1. 2. 3. 4. 5. 6. Predict ideal A.P. position of maxilla form lateral ceph Predict ideal superior/inferior position of anterior maxilla from clinical incisal show Set occlusal plane: Use Xi point, Frankfort Horizontal and mandibular occlusal plane as primary guides Find required lateral repositioning of maxilla from clinical assessment of midlines Assess cant from clinical measurement and mounted casts Assess maxillary arch width from models

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Detailed Process in Planning (continued)

7. 8. 9. Trace the new maxilla and mandible positions (VTO) as we did in the exercises. Re-analyze using Ricketts to compare the VTO to cephalometric norms. Record the intended changes in vertical, transverse, AP and arch width dimensions of the posterior and anterior maxilla and the intended amount of set back/push forward at the mandibular osteotomy.

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Detailed Process in Planning (Step Back)

10. Are the movement planned so far reasonable. If not start again and redistribute the movements between the maxilla and mandible, or change the plan entirely, (SARPE or more orthodontics)

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Detailed Process in Planning (Chin and Profile)

11. 12. 13. Assess the projected soft tissue profile, particularly the chin Proceed to model surgery Verify on the models that the movements are surgically feasible

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Model Surgery and Splint Construction

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Model Surgery
1. Calculate the new measurements that would give the desired new maxillary cast position (AP, Vertical and Transverse). Segmentalize the upper segment if necessary and make occlusal adjustments to give best intercuspation Mount maxillary model to new position using the Erickson model block and platform Mount mandibular model to new position (in occlusion with upper model) on the articulator Verify movements correlate with intention Note magnitude of movements in all planes Verify movements are surgically feasible Construct splints

2. 3.

4.
5. 6. 7. 8.

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Adjust Occlusal Surfaces

Segment maxillary cast at this stage to achieve best occlusion if performing multipiece Le Fort 1

Record where occlusal adjustments are made so that they can be duplicated intraoperatively
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Remount Upper Cast to Desired Position in Space

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Maxillary Post op cast with Mandibular Post op cast

Final splint ONLY

CONSTRUCT FINAL SPLINT FIRST

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Maxillary Post op cast with Mandibular Pre op cast

Final splint AND Intermediate splint

CONSTRUCT INTERMEDIATE SPLINT SECOND

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Final Splint

Final Splint capable of being wired into maxillary dentition to support maxillary fixation
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Intermediate Splint

Intermediate Splint should locate positively in Final Splint

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Summary
Take the records meticulously Verify that the A casts match the B casts Verify that the mounted casts match the clinical picture Perform the model surgery on one set of casts Construct the splints in correct sequence for the planned surgery.

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TMJ Considerations in Orthognathic Surgery

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The Normal TMJ

What does a normal TMJ look like and how do we identify it?
Clinically Radiographically MRI

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Goals of Orthognathic Surgery as Relate to the TMJ

Restore/maintain normal range of opening Eliminate/avoid joint pain and noises Achieve stable condyle and meniscus position in fossa when teeth are in centric occlusion Where is the ideal location for the condyle?

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Condylar Malposition
Condylar sag: Inferior displacement of the condylar head within the glenoid fossa

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Central Condylar Sag

Condyle is positioned inferiorly in the fossa No contact between condylar head and articular fossa in centric occlusion Immediate malocclusion on release of fixation (assuming no hemarthrosis or joint edema is present)

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Central Condylar Sag

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Peripheral Condylar Sag

Contact between condylar head and articular fossa may support the inferiorly positioned condylar head Immediate or late relapse Late relapse associated with condylar resorption

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Peripheral Condylar Sag

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Condylar Resorption

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Other Causes of Condylar Malposition

Posterior positioning of condyle is associated with increased risk of post-operative symptoms of popping and locking. Limit that the condyle may be posteriorly positioned increased by
Supine, paralyzed state Improper surgical technique Condylar sag

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Other Causes of Condylar Malposition

Uneven contacts between the proximal and distal segments may cause the condyle to become laterally or medially displaced when fixation is applied

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Minimizing Condylar Malposition

Avoid creating intrarticular edema or hemarthrosis
Support during split Support during mobilization Avoid rotating the condyle around its long axis

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Minimizing Condylar Malposition

Avoid bad splits; they complicate condylar positioning!

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Minimizing Condylar Malposition

Ensure adequate stripping of medial pterygoid to eliminate interference to distal movement of distal segment. Reduce bony interferences, especially on mandibular setback.

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Minimizing Condylar Malposition

Eliminate uneven contact between osteotomized segments that prevent passive, even and stable apposition

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Minimizing Condylar Malposition

Gentle use of clamps to hold segments whilst placing fixation

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Minimizing Condylar Malposition

Use shims of bone to eliminate intersegmental gaps

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Minimizing Condylar Malposition

Avoid lag screw fixation Positional screws are fine

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Minimizing Condylar Malposition

Plates can be adapted in order to provide passive fixation. More difficult to achieve with positional screws.

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Minimizing Condylar Malposition

Positioning the condyle prior to fixation
Direction of force Magnitude of force

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Minimizing Condylar Malposition

Ensure adequate bone removal at posterior of maxilla in Le Fort 1 osteotomy

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Minimizing Condylar Malposition

Avoid heavy post-op elastics as the effect on the occlusion may be more temporary than you think!

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Idiopathic Condylar Resorption

Progressive alteration of the condylar shape with decreased mass bilaterally, in temporomandibular joints that previously exhibited normal growth patterns AICR (Adolescent Internal Condylar Resorption)

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Risk Factors for ICR

Female Age 15-30 Pre-op TMJ disease Mandibular hypoplasia High mandibular plane angle Small posterior face height Posterior inclination of condylar neck

Large mandibular advancement Counterclockwise rotation IMF Posterior repositioning of condylar head in fossa Increase in ramus length

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Idiopathic Condylar Resorption

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Idiopathic Condylar Resorption

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Treatment and Prognosis

Re-osteotomy alone has 50-100% failure rate Stabilization of occlusion with occlusal splint prior to re-osteotomy has similar failure rate Orthodontic occlusal compensation and stabilization achievable in some Advanced cases require condylectomy and joint reconstruction (alloplastic or costochondral)

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Effect of Orthognathic Surgery on the Symptomatic TMJ Patient

Lack of consistency in terminology used to categorize TMJ disease Populations are often poorly described Outcomes are poorly defined Lack of information on the post-op condylar position in patients studied

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Concomitant TMJ and Orthognathic Surgery for Symptomatic TMJ Patients

Pts without symptoms from TMJ pathology can become symptomatic after orthognathic surgery Pts with anterior disc displacement prior to BSSO will most likely not improve, and may get worse IVRO in a pt with ADD improves disc-condyle relationships and pain
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Concomitant TMJ and Orthognathic Surgery for Symptomatic TMJ Patients

Goncalves et al (JOMS April 2008). Retrospective cohort study, looking at 51 pts with pre-op TMJ symptoms and compared concomitant TMJ + orthognathic surgery to orthognathic surgery alone. Demonstrated improved stability and relief of symptoms in the former group after 31 months follow up

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Summary
Perform a baseline TMJ exam on every patient Avoid intra-operative trauma to the TMJ that might cause intra-articular edema Take care with positioning and fixation of the segments Orthognathic surgery may induce symptoms from the TMJ Consider treating the TMJ first if disease is present

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Stability Issues

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Instability
Early: From the time of surgery up to week 8 After 8 weeks

Late:

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Long Term Stability in Maxillary Osteotomies

MORE STABLE

Impaction Setback Advancement Downgraft Expansion (**SARPE) Advancement with downgraft

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LESS STABLE

Long Term Stability in Mandibular Osteotomies

MORE STABLE

Advancement*** (Proportional to advancement)

LESS STABLE

Setback

***Idiopathic Condylar Resorption

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Limiting Long Term Instability

Bone grafting especially when downgrafting a maxilla by 5mm or more Conservative moves, not ambitious. (*Cleft cases) Overcorrection especially when doing a mandibular setback (easier to correct a relapsing class II with ortho than a relapsing class III) ? Rigid fixation versus IMF. ? Positional Screws versus miniplates

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Pitfalls in Planning and Execution

Leaving appliance activated at time of surgery Inadequate strength of arch wire at surgery Inadequate incisor decompensation (leads to inappropriate incisal relationship) Inaccurate pre-op occlusal record (condylar position) Inadequate root divergence before segmentalizing Hasty split (fracture or nerve damage) Occlusal splint too thick Poor condylar position during application of fixation Excessive torque on proximal segment during fixation

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Pitfalls in Planning and Execution (continued)

Compromising blood supply
Gingivae during flap for segmental osteotomy Over-ambitious advancement Le Fort 1 level

Tear of palatal mucosa during segmentalization Condylar sag (very difficult to plan for) Failure to check condylar position post-op Setback of mandible in presence of a flat chin-throat angle Planning for >6mm posterior maxillary impaction Weak brackets/hooks at time of surgery
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