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ORTHOGNATHIC SURGERY

& LEFORT 1 OSTEOTOMIES

BY
NIKHIL ASOK
DEFINITION

 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 deformities of the jaws and associated structures.
Objectives
 Basic therapeutic goals:
 Function
 Aesthetics
 Stability
 Minimizing the treatment time
 Specific therapeutic goals:
 Masticatory / Swallowing
 Functional occlusion
 Opening and closing of jaws TMJ dysfunction
 Structural abnormalities
 Myofascial pain
 Speech
 Stability of orthodontic results
 Improve dental and periodontal health
 Improve psychosocial impairments
Envelope of Discrepancy
CRITERIA FOR SUCCESS

 Healthy musculature and temporomandibular joints


 Facial balance(Tweed, Down, Steiner, McNamara – Averages for general
population)
 Correct static and functional occlusion (Andrews six keys, Overjet, overbite and
symmetrical midlines Condyles in glenoid fossa)
 Periodontal health (Alveolar bone Gingival tissue)
 Resolving the patient’s chief complaints
 Stability of dental, skeletal, and growth changes
 Maintaining or increasing airway
Overview of Facial Planning Process

 Patient concerns
 History
 Clinical examination
 Radiographic and imaging analysis
 Dental model analysis
Patient Concern

 What are your concerns or problems?


 Have you had previous treatment for this condition, and what was the
outcome?
 Why do you want treatment?
 What do you expect from treatment?
HISTORY

 Personal information
 Chief complaint
 Medical Dental and orthodontic history
 History of the TMJ and musculature
General facial characteristics:

 David Sarver (1998) quoted that symmetry, balance and morphology are
important in production of good front face esthetics.
Clinical
Examination
PROFILE ESTHETICS
CEPHALOMETRIC ANALYSIS

SURGICAL ANALYSIS PREDICTION

HARD TISSUE SOFT TISSUE

1. COGS 1. Arnett et al
2. QUADRILATERAL 2. Burstone et al
3. McNAMARA 3. TOMAC – TONY G McCOLLUM
MODEL SURGERIES

 Maxillary surgeries
 Impressions
 Wax-bite
 Face-bow transfer
 Mounting of the casts on a semi adjustable articulator
 Vertical reference lines are drawn – A/P positioning or arch rotation
 Horizontal reference lines
PREDICTION

 To assess accurately the profile aesthetic results of the proposed surgery


and orthodontics
 To determine the desirability of adjunctive surgical procedures such as
genioplasty
 To help determine the sequencing of surgery and orthodontics
 To help decide on extractions
 To determine anchorage requirements
Proportionate Template

 It was intended initially to use clear plastic templates inscribed with


standardized facial outlines.
 Templates – Numeric standards for the sex specific templates were charted
out based on the data published by Riolo et al. from the University of
Michigan Elementary and Secondary School Growth Study(1974)
 The proportionate template is designed for use on adults and is used mainly
in treatment planning associated with orthognathic surgery.
 Angular measurements rather than linear measurements are used when
comparing individuals to “normal” and individuals of different sizes..
Philosophy of the Template

 The proportionate template is based on the principle of the visual


comparison of lateral cephalometric tracings with average normal
tracings.
 It may be argued that a single template cannot be used for all individuals
because of variations in body height.
 But since body (or craniofacial) proportions of all individuals should be
similar regardless of height, only templates of different sizes would be
needed for comparison
 To compare lateral head film tracings of persons with craniofacial skeletal
dysplasia, a template having average skeletal proportions was developed from
the data of Broadbent and co-workers. These data were based on the recordings
of 5,000 individuals.
 To accommodate variations in skull size, four templates were designed.
 The average template was developed by averaging geometrically the dimensions of the
sample.
 The large template was intended for larger than average persons,
 and the small template for persons with smaller than average craniums and jaws.
 In addition, an extra-large template was designed for much larger than average
individuals.
Method of Application

 Select the appropriate template


 Method 1 – The mid S-J point of the template is superimposed on that of the
tracing, and the template is adjusted to the point where the Ba-N lines on
the template and the tracing are parallel to each other.
 Method 2 – Points basion and nasion in the correctly selected template will
approximately overlie the same points on the tracings. When superimposing
Ba-N, both S-J lines will be parallel to each other. The template is then
raised or lowered, keeping the Ba-N lines parallel until both of the mid S-J
points are equidistant from the Ba-N line
Interpretation

 The relative spatial position of maxilla and mandible


 Length of maxilla.
 Length of mandible.
 Vertical dimensions
 Incisor inclination.
 Cant of mandibular plane
SEQUENCE OF ORTHODONTICS &
SURGERY ???

 THE TWO PATIENT CONCEPT


 Patient 1 – Our patient
 Patient 2 – The feasibility model surgery & prediction ceph
 The Orthodontist can then decide if it would be easier to treat the patient
after surgery, or if it would be preferable to resolve specific orthodontic
problems before surgery.
 When pre-surgical orthodontics is necessary, specific goals for this ttmnt are
established & once they are met, surgery is done
PRE SURGICAL ORTHODONTICS

INTRA ARCH OBJECTIVES

In the initial stages of treatment, orthognathic


and conventional orthodontic mechanics have
some similar objectives, like to position the teeth
ideally relative to their apical bases through
establishment of correct torque, proper elimination
of rotations, flatness of the plane of occlusion and
eliminating tooth arch length discrepancies.
Intra-arch mechanics in orthognathic cases
should be designed to achieve the ultimately
desired post surgical interdigitation and allow for
establishment of class I canine and molar
relationship after surgical treatment.

If extractions are necessary to accomplish the


desired objectives, then extraction sites should be
closed unless segmentalizcd surgical closure is
planned.

Even procedures like interdental enamel reduction


must be concluded prior to surgery.
SKELETAL CLASS II cases, dental
compensations include very protrusive
mandibular incisor and upright maxillary
incisor.

SKELETAL CLASS III. Mandibular incisors are


often found to be retroclined while maxillary
incisors are commonly flared forwards.
A patient with a class III skeletal malocclusion
may have dental compensations including
retroclined mandibular incisors and proclined
maxillary incisors. In class II, division
2,malocclusion with a typical retroclination of
maxillary anterior teeth .

Likewise a patient with these malalignment will


respond to class II elastics for class III patients
class III elastics for class II patients before
surgery.
SEQUENCING OF ORTHODONTIC MECHANICS
PRIOR TO SURGERY:

1) Orthognathic surgery should not be performed


until the adolescent growth spurt is completed .

2) Surgical correction of maxillary and


mandibular deficiency and correction of vertical
maxillary excess can be carried out with a good
prognosis in most patients who are in their mid
teens.
3) However the initiation of orthodontic
treatment often helps patients tolerate
dentofacial deformity during their teen years
even if surgery is some time in the future. The
orthodontic appliance serves as a visible
symbol that the dentofacial correction is
being treated.
Steps in orthodontic preparation:

1) Leveling of the maxillary and mandibular


arch.

2) Establishment of incisor position.


STABILIZING ARCH WIRES:

As presurgical phase is over, doing a model


surgery is a must to check for occlusal
compatibility.

2nd molars banded to increase fixation stability.

Stabilizing arch wires is placed 6 weeks before


surgery so that they are passive when impression
is taken for surgical splint.
STABILIZING WIRES ARE;

1) 17 x 25 steel in 18-slot appliance.

2) 19 x 25 steel or TMA in 22-slot appliance.

Full slot withstands the forces resulting from


intermaxillary fixation.
BEFORE EVERY SURGICAL
PROCEDURE:

 1) Mark on the chart that he/she is a surgical patient.

 2) VTO clearly illustrated on the chart determining.

 a) Presurgical goals (anterior retraction, extraction pattern etc.)

 b) Anchorage requirements.

 3. Step by step chart written for reference


INDICATIONS OF LEFORT 1

 Altering the vertical dimension of maxilla


 Superior positioning in long face syndrome
 Inferior positioning.
 Anteroposterior movements of maxilla
 In cleft palate patients , congenitally deficient maxilla
 Maxillary advancement
 Maxillary set back in maxillary prognathism (only 3-5mm is possible)
 Levelling of occlusal plane.
 Surgical expansion of maxilla
 Narrowing of maxilla
MAXILLARY SURGERY

LE FORT 1 OSTEOTOMY
 TRADITIONAL LE FORT 1 OSTEOTOMY
 MAXILLARY STEP OSTEOTOMY
 HIGH LE FORT 1 OSTEOTOMY
 MAXILLARY HORSESHOE OSTEOTOMY
 SAME
Protocol

 Positioning of the patient-10 degree head elevation


 Hypotension GA (90mm/Hg systolic*)
 Infiltration of the soft tissue with a vasoconstrictor 2% lidocaine (1;100000)
TRADITIONAL LE FORT 1 OSTEOTOMY

 STRAIGHT LINE CUT


FROM PIRIFORM RIM TO
PTERYGOID PLATE AREA
 SEPARATION AT
PTERYGOID PLATE -
TUBEROSITY AREA,
LATERAL NASAL WALL,
SEPTUM/VOMER AREA
MAXILLARY STEP OSTEOTOMY

 HORIZONTAL CUT PARALLEL TO


FRANK.P. 4-5 mm ABOVE CANINE
APEX FROM PIRIFORM RIM TO
ZYGOMATIC BUTTRESS.
 IN BUTTRESS AREA, VERTICAL CUT OF
5-8 mm, HORIZONTAL CUT AT LOWER
LEVEL TO PTERYGOID PLATES.
HIGH LE FORT I OSTEOTOMY

 Hugo Obwegesser 1969 described a high Le fort I osteotomy for correction


of midfacial hypoplasia in cleft lip and palate patients.
 This was named Quadrangular Le Fort I osteotomy by Keller & Sather 1989.
Here the advancement of both the infra orbital rim and a portion of the
zygomatic complex is done.
 This is mainly indicated in patients with maxillary-zygomatic horizontal
deficiency, with class III skeletal malocclusion and normal nasal projection.
This is ideal in management of midface hypoplasia with midline problems or
transverse deficiency.
Procedure

 The osteotomy cuts are placed on the lateral wall of maxilla from the
pyriform aperture at the level of the infra orbital nerve.
 The osteotomy is extended laterally below the level of the infraorbital nerve
to the tuberosity and pterygoid plate region.
 The maxilla is down fractured after detaching the nasal septum,
pterygomaxillary disjunction and ostectomising the lateral nasal wall.
 Bone grafts are used in the infra orbital region and also in the
pterygomaxillary junction.
MAXILLARY HORSESHOE OSTEOTOMY

HORIZONTAL PALATAL SHELF ATTACHED TO


NASAL SEPTUM AND LATERAL NASAL WALLS.
MOBILIZATION OF MAXILLARY DENTOALVEOLUS
SELECTED CASES OF VERTICAL MAXILLARY
EXCESS.
SURGICALLY ASSISSTED MAXILLARY
EXPANSION (SAME)

 Brown first described SAME in 1938 - midpalatal split


 A LeFort I type of osteotomy with a segmental split of the maxilla and the
placement of a triangular unicortical iliac graft for correction of maxillary
constriction was presented by Steinhauser in 1972.
Indications:
Skeletal maxillomandibular transverse discrepancy greater than 5mm
Significant TMD associated with a narrow maxilla and wide mandible
Failed orthodontic expansion
Necessity for a large amount more than 7mm of expansion
Extremely thin and delicate gingival tissues with buccal gingival recession
Significant nasal stenosis
Widening of the arch following collapse associated with the cleft palate deformity
EFFECTS ON GROWTH

 LEFORT I OSTEOTOMY ELIMINATES FURTHER A-P GROWTH, WHILE


VERTICAL ALVEOLAR GROWTH REMAIN UNCHANGED.
(MOGAVERO, BUSCHANG, WOLFORD. AJO 1997)
 MAXILLARY HORSE SHOE TECHNIQUE
GOOD POSTSURGICAL GROWTH IN 3 PLANES
CLASSII DIVISION 1 DEFORMITY
WITH NORMAL OVERBITE

 Outline of treatment:
 Presurgical
 1. Consider extraction usually with 15, 25, 34 and 44.
 2. Place lower appliances, utility arch and begin lower canine retraction.
 3. Place upper appliances, align and level, begin upper Molar
advancement.
 4. Placement of class III elastics as necessary
 5. Finish lower canine retraction.

 6. Retract lower incisors.

 7. Upper space closure.

 8. Coordinate arches.

 9. Impression to determine feasibility of surgery.


Primary goals to achieve:

 Class I molar and canine relationship with significant transverse or


vertical problems.

 Once these goals have been achieved the patient is ready for surgery.

 The arch wires are now tied with ligatures wire to prevent inadvertent
disengagement of the wires and the patient is referred for surgery.
Surgical

 Orthodontic Surgical maxillary expansion followed by mandibular


advancement

 When mandibular advancement surgery is planned for patient when a


transverse discrepancy of 6 mm or more exists, combined orthodontic surgical
expansion of maxilla is recommended as a part of the treatment plan.

 The need for this is determined by observation after placing the models into
the desired antero-posterior position .

 When the transverse discrepancy is truly skeletal, combined orthodontic


surgical expansion of maxilla is indicated.
Anterior Maxillary Osteotomy With
Augmentation Genioplasty:

 Seldom used in treatment of class II dentofacial deformity. Since results


in poor esthetic results.
 Used when patients has a good functional posterior occlusion.
 Prominent upper lip and teeth with acute NLA.
 Lower arch well aligned and in proper anteroposterior position.
 Recessive chin can be corrected with augmentation genioplasty.
VERTICAL MAXILLARY EXCESS

 Lefort I superior repositioning of the maxilla with augmentation


genioplasty.

 PRESURGICAL ORTHODONTIC TREATMENT:

 1.Place the appliances, align and level.

 2.Coordinate arch forms.

 3.Elastics as necessary to place lower incisors in the proper antero-


posterior position.
Details of treatment:

 Presurgical orthodontics required.

 Can have orthodontic appliances placed and can immediately go for


surgery.

 Either single piece or a segmentalized procedure.

 With or without extraction of upper 1st premolar.

 Lower arch may need to be set up presurgically


 The A-P and transverse positions of the lower teeth at the time of surgery
are critical because they determine the upper tooth to lip relationship both
antero-posteriorly and symmetry.
 Extraction decision in lower arch depends on the prediction tracing.
 Non-extraction - Both the arches are aligned and leveled independently.
 Class III elastic may be used if necessary.
 Extractions - Mechanics is same, for maximal retraction of anterior.
FACTORS AFFECTING STABILITY OF
TREATMENT:

 INAPPROPRIATE VERTICAL MECHANICS :

 Extrusion of anterior and intrusion of posterior teeth" must be avoided.

 Presurgical orthodontic expansion of maxilla is contraindicated


 DEFICIENT/ NORMAL MAXILLARY GROWTH
 NORMAL GROWTH CANT BE EXPECTED AFTER SURGERY
 RECURRENEC OF CLASS III
 EARLY SURGERY IF NEEDED
 PARENTS B WARNED OF SECOND PROCEDURE
 EXCESSIVE MAXILLARY GROWTH
 NO STUDY
 POSTSURGIACL GROWTH MAY BE DEPENDENT ON THE SELECTED
PROCEDURE
 VERTICAL MAXILLARY EXCESS
 VERTICAL GROWTH CONTINUE AT THE RATE AS OF PRE
SURGICALLY
 POSTSURGERY AP GROWTH IS AFFECTED, GROWTH VECTOR IS
DOWN & BACKWARD
References

 Epker Stella Fish – Dentofacial Deformities (volume 1).


 Epker Stella Fish – Dentofacial Deformities (volume 2).
 Fonseca othognathic surgey – (volume 2)
 The quadrangular osteotomy revisited. Paul J W Stoleinga &John J A
Brouns. Journal of Cranio Maxillofacial surgery. 2000 : 28: 79 2013; 84.
 Maxillary osteotomies. R. Gunaseelan. Indian journal of Oral &
Maxillofacial surgery. 1998 : VIII : 9 -14. Johan P. Reyneke, Oral Maxillofacial
Surg Clin N Am 19 (2007) 321–338

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