Pre & post surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

Pre and Post Surgical
Orthodontics
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Introduction
1. Pre Orthodontic Preparation – Control of
pathologic problems
2. Pre-surgical orthodontics
3. Final surgical preparations
4. Surgery and postoperative care
5. Post-surgical orthodontics
6. Retention
Pre and Post Surgical Orthodontics
Dr. Punit Thawani

Before Orthodontics
•

Adult Patients
a)
b)
c)
d)

Chronic systemic diseases
Pregnancy
Prolonged use of drugs
Dental problems

Dr. Punit Thawani

Before Orthodontics
a) Chronic systemic diseases
– Hypertension and diabetes
– Taxes patient compliance
– Drugs and diet alteration

b) Pregnancy
– general anesthesia
– surgery must be delayed for 4-6 months
after delivery
Dr. Punit Thawani

Before Orthodontics
c) Prolonged use of
Drugs
–

–

interactions with
general anesthetics
Prostaglandins
Prostaglandin inhibitors

Corticosteroids and NSAIDs

Chronic Arthritis

Dr. Punit Thawani

Other drugs

Tricyclic antidepressants,
antiarrtiarrhythmic drugs,
antimalarial drugs

Before Orthodontics
•

Phenytoin
– gingival overgrowth
– seizures may be exacerbated by orthodontic
appliances

•

Dryness of the mouth
– irritation due to the orthodontic appliance
– smooth appliance
– oral hygiene

Dr. Punit Thawani

Before Orthodontics
d) Dental Disease
• Caries control
–

•

0.05% NaF
mouthrinse

Missing teeth
–
–

Bridges – need
removal
Riding pontic

Dr. Punit Thawani

Before Orthodontics
•
•
•

Metal crowns
Porcelain crowns
Acrylic crowns

Dr. Punit Thawani

Before Orthodontics
Periodontal problems
• oral hygiene
maintainance
• Hopelessly mobile
teeth
–

Offer better
stabilization during
surgery than
removable partial
dentures.

Dr. Punit Thawani

Before Orthodontics
Mucogingival considerations

Dr. Punit Thawani

Before Orthodontics
•

Mucogingival considerations –
Maintenance of attached gingiva
•

Orthodontic expansion of the dental
arches
• Surgical incisions in the vestibule.
– Class III correction & Genioplasty

•

Ressective osseous surgery

Dr. Punit Thawani

Before Orthodontics
Implications of reduced periodontal support
• Lighter force
• Greater counter-moments are needed for
tooth movement

Dr. Punit Thawani

Before Orthodontics
Impacted and
unerupted teeth.
• Growing
children –
unerupted teeth
may be encountered
during the
osteotomy cuts.

Dr. Punit Thawani

Before Orthodontics
•

Adults – maxillary canines and third
molars can be removed at the time of
LeFort I osteotomy

Dr. Punit Thawani

Before Orthodontics
Mandibular 3rd molars
• Remove 6 months before a BSSO, so that the
socket is properly healed at the time of surgery
• Complications –
–
–
–

Bad split
Chances of infection
Difficult to use rigid internal fixation, due to the
space occupied by the tooth.
Increased chances of fracture

Dr. Punit Thawani

Surgical and orthodontic treatment
BASIC OUTLINE
•

Pre-surgical orthodontics
- removes dental
compensations, and
positions the teeth
properly in relationship
to the individual skeletal
bases.

Dr. Punit Thawani

• Heavy archwires are placed and the
appliance is used for stability and
fixation during surgery.

Dr. Punit Thawani

• Active orthodontics is reinitiated to
refine the occlusion.

Dr. Punit Thawani

Pre-Surgical Orthodontics
Goals –
1. Align and level teeth without concern for
dental occlusion.
2. Establish proper anterior-post. and
vertical position of the incisors.
3. Achieve arch compatibility.

Dr. Punit Thawani

General guideline • Post surgical orthodontics (Between 4-6
months)
If the patient is not properly prepared –
• Surgery cannot be carried out effectively,
• Quality of the result is diminished
• Post surgical orthodontic treatment time
increases
Dr. Punit Thawani

•
1.
2.
3.
4.

Selection of the appliance
Stability
Esthetics
Slot Size
Bonding vs Banding

Dr. Punit Thawani

Stability
• Stabilize the teeth against
stresses encountered at
surgery and during IMF
• PAE is recommened
• Begg appliance for surgical
patients
– rectangular wire in the
ribbon mode.
Dr. Punit Thawani

Esthetics
Lingual appliances
• Impossible to use the appliance for IMF
• Post op – patients have difficulty in
mouth opening
• Hugo et al (J Adult Orthod &Orthognath Surg 2000)
– use of labial appliances just before the
surgery and thereafter until the end of the
treatment.
Dr. Punit Thawani

•

•

Width of the labial
brackets have been
reduced to increase
esthetics
Extremely narrow
brackets have poor
rotational and tip
control.

Dr. Punit Thawani

Tooth colored brackets
• Plastic brackets
– Fracture
– Poor torque control

•

Ceramic brackets
– Good torque control
– Brittle and can fracture
– Should be prepared with alternative
measures

Dr. Punit Thawani

Slot Size
Either slot size – 18 or 22
• 17x 25 ss for 18 slot
• 21x25 ss or TMA for 22 slot
• segmented arch mechanics - 22 slot
Bonding vs banding –
• bond anteriors, and band posteriors.
• perio problems, bands are to be avoided
Dr. Punit Thawani

Appliance modifications
1. Extreme prescriptions must be avoided.
“Extraction series” – too much tip
Opposite side bracket should not be used

Dr. Punit Thawani

2. Include all teeth in
strap up
Mand. 2nd molars –
before surgery
Max. 2nd molars –
after surgery
3. Auxillary molar tubes
and headgear tubes
• lingual attachments Cross elastics
Dr. Punit Thawani

4. Brackets with adequate mesio-distal and
rotational control – twin brackets ½ the m-d
width of the tooth
single brackets with rotational wings
• Integral hooks in the brackets
–
–
–

Help in stabilization
Long hooks should be avoided
brackets may get dislodged if these hooks are used
for stabilization, hooks on the archwire preferred.

Dr. Punit Thawani

Alignment of the
arch
• Principles of
alignment remain
the same.
• Initial tipping
–
–

undersizes, round
and resilient wires.
free sliding, freedom
to tip and light
continuous forces.

Dr. Punit Thawani

Leveling of the Arch
Presurgical

Postsurgical

Intrusion

Extrusion

Dr. Punit Thawani

•

Final vertical height ➫
Position of the lower incisors
– Increase the face height → the lower incisors
should not be intruded
– In patients with normal or excessive face
height, the lower incisors must be intruded
pre-surgically

Dr. Punit Thawani

Final position of the incisors is
determined pre surgically

Dr. Punit Thawani

Segmental procedures ➫
Teeth should be leveled within the
segments

Dr. Punit Thawani

Ant – post positioning of the incisors
• Affects the sagittal placement of the jaws
during surgery
• dental compensations must be removed
• Movements opposite to camouflage

Dr. Punit Thawani

•

Extraction pattern in surgical patients
–
–
–

Opposite to camouflage
Worsening of the occlusion
Extraction of teeth during the surgery itself

Dr. Punit Thawani


Dr. Punit Thawani

Over – treatment
• Orthodontic relapse + IMF
• Wire fixation with IMF
– Mandible tends to slip back
– Low. Ant . Procline, U ant. Retrocline

•

Rigid fixation
– Very short period of IMF
– No need to overcorrect.

Dr. Punit Thawani

Segmental surgeries
• Establish torque of incisors pre surgically
• ½ extraction site left open

Dr. Punit Thawani

Anchorage consideration
• Opposite directions of movement
• Intermaxillary elastics
• Extra oral forces rarely needed
• Small amount of space can be left open

Dr. Punit Thawani

Arch compatibility
• Shape and width
• Co-ordinated arch wire

Dr. Punit Thawani

•
•

•

Torquing of roots
Not more than 5
mm of dental
expansion
½ cusp cross-bite
can be corrected
post-surgically

Dr. Punit Thawani

Confirming compatibility of arches –
• Class II patient
– Protrude the mandible

•

Class III patient
– Frequent models

Dr. Punit Thawani

•

At the end of the pre-surgical phase, the
patient should be in a full sized
rectangular steel wire which will help
stabilize the teeth during surgery

Dr. Punit Thawani

Stabilizing wires
•

Full dimension, filling the slot
– 17 x 25 ss for 18 slot
– 21 x 25 ss or TMA for 22 slot
– 19 x 25 wire in a 22 slot is acceptable

•

Attachments for IMF
– Attachments on the arch-wire are preferred
– Kobayashi hooks not useful

•

The stabilizing wire must be passive

Dr. Punit Thawani

Stabilizing wires

Dr. Punit Thawani

Final surgical Planning
2 weeks before surgery
• OPG
• Lat. Ceph
• Casts
• Photos – intra and extra-oral
• PA ceph – if there is facial asymmetry
• IOPAs and occlusal view if needed.
• Face bow transfer onto an articulator if needed
Dr. Punit Thawani

•

OPG
– Root proximity at osteotomy site
– Confirm with IOPAs

•

Lateral Ceph.
– For pre surgical prediction

•

Models
– Model surgery
– Preparation of the splint

Dr. Punit Thawani

Need for a facebow transfer
1. Mand. dentition – condylar relation maintained
Mand. is required to auto-rotate
Segmental subapical procedures of the mandible.
2. In case of 2 jaw surgeries

Dr. Punit Thawani

•

Condyle - mandibular dentition relation
is to be chanced during surgery, a
facebow transfer is not needed.

•

Mounting on a simple articulator will do.

Dr. Punit Thawani

Model Surgery
Purpose of model surgery
• 1) To verify that the planned movements
are possible
• 2) To relate the mandibular and
maxillary dentitions in the position
where the surgical splint will be made.

Dr. Punit Thawani

Model Surgery
Model surgery – 4 weeks after
stabilizing wire is placed

Dr. Punit Thawani

Model Surgery - 2 jaw surgery
Impressions
Wax bite to record
Pre surgical occlusion

Face-bow record

Dr. Punit Thawani


Casts mounted on semi-adjustable articulator

Dr. Punit Thawani


Mounting of maxillary cast with spacer

Dr. Punit Thawani


Blue plaster used for initial mounting
Dr. Punit Thawani


Jig positioned in articulator
Dr. Punit Thawani


Maxillary cast stabilized with putty
Dr. Punit Thawani


Initial mounting plaster removed
Dr. Punit Thawani


Maxillary impaction
Dr. Punit Thawani


Measurement of amount of impaction
Dr. Punit Thawani


Simulation of mandibular autorotation
Dr. Punit Thawani


Intermediate splint
Dr. Punit Thawani


Mandible advanced to desired position
Dr. Punit Thawani


Final splint fabricated
Dr. Punit Thawani


Final Splint
Dr. Punit Thawani


If the jig is not available, markings can be made
on the cast
Dr. Punit Thawani

Model Surgery – ‘Piggy-back’ splint

Casts mounted on articulator
Dr. Punit Thawani


Max. cast sectioned and positioned as required
Dr. Punit Thawani


Duplication of maxillary cast
Dr. Punit Thawani


Mandibular cast positioned – hinge articulator
Dr. Punit Thawani


Wires made as required
Dr. Punit Thawani


Final splint made
Dr. Punit Thawani


Final splint placed back on original mounting
Dr. Punit Thawani


Intermediate splint made with final splint in place
Dr. Punit Thawani


Intermediate and final splints
Dr. Punit Thawani


‘Piggy – back splints’
Dr. Punit Thawani


Piggy – back splint on the casts
Dr. Punit Thawani

Requirements of the splint
•

Fit the teeth
accurately

•

Minimum thickness
– not more than 2
mm

Dr. Punit Thawani

Requirements of the splint
•

Excess acrylic
should be trimmed
off the buccal
aspect, to allow for
proper visual
verification during
surgery and oral
hygiene
maintenance.

Dr. Punit Thawani

Model Surgery - Problems
•

Dental interferences – Further presurgical orthodontics?
Interference in second molar region
• Usually caused due to not bonding lower
2nd molar and bonding upper 2nd molar.

Dr. Punit Thawani

•
•

Condylar distraction
Trim cusp or prolong pre-surgical
orthodontics

Dr. Punit Thawani

•

Incompatibility of canine
widths
–

–
–

•

Easy to check in Class II –
not Class III
Can result in ant. Open-bite
Go back to lighter wire

Lack of space between roots
to place osteotomy cuts

Dr. Punit Thawani

During Surgery
•

Splint used to help attain final occlusion

•

Segmental osteotomies – wire placement

•

IMF with splint in place

•

Teeth might penetrate thro splint

•

Splint should be in place until start of
post surgical orthodontics

Dr. Punit Thawani

Post Operative Events
•

Hospitalization
– 2-3 days for single jaw
– 4-5 days for double jaw

•
•
•
•

Facial edema – 2-3 weeks
Resumes partial function in 2 weeks
Mastication after 6-8 weeks
Complete bone healing – 6 months

Dr. Punit Thawani

Post Operative Care
•

1 week soft diet
– Milk, mashed potatoes, scrambled eggs

•

After 2 weeks – more chewing
– Chapattis, vegetables, and meat in small
pieces

•
•

Progress to normal diet
Normal diet in 6-8 weeks

Dr. Punit Thawani

Post Operative Physiotherapy
•

As soon as the initial intracapsular joint
edema has resolved – after about 1 week.
– 1st week after surgery – open and close
mouth gently within comfortable limits
– Over next 2 weeks – 3 10-15 minute sessions
of opening and closing and lateral
movements.
– 3rd – 8th weeks, range of motion is
increased, and should be normal in 8 weeks.

Dr. Punit Thawani

Post Operative Care
•

Orthodontist should see the pt within the
1st week – review the occlusal status and
check the status of the orthodontic
appliance.

•

Post surgical orthodontics
– adequate bone healing
– adequate mouth opening

Dr. Punit Thawani

Post Operative Care
•
•
•

Rigid internal fixation and jaw exercises
➫ 2-3 weeks
Wire fixation and IMF ➫ 3-4 weeks after
the IMF is released.
Splint and light elastics to guide
occlusion

Dr. Punit Thawani

Post Surgical Orthodontics
•
•
•

•

After adequate healing of bone
(surgeon’s opinion)
Splint and stabilizing wires should be
removed together
Splint and wires provide solid
occlusion
Prevent CO-CR discrepancy

Dr. Punit Thawani

•

Working archwires placed
– 0.016” steel
– 21 x 25 NiTi or Braided Steel
– Stabilizing wire left in place in 1 arch

Dr. Punit Thawani

•

Maxillary segmental procedures
– Teeth across the osteotomy site should be
ligated tightly
– Box elastics are placed on both sides of the
osteotomy site – from one side to the other
– ?

Dr. Punit Thawani

•

Light box elastics
– Extrude teeth
– Guide occlusion
– Elastics crossing osteotomy site?

•

Protocol
– 1st month – full time, including while eating
– 2nd month – Full time, remove while eating
– 3rd month – Night time only

Dr. Punit Thawani

•

Good amount of settling in first month

•

Step bends in archwires

Dr. Punit Thawani

•
•
•

Headgears and extra oral forces
Heavy intermaxillary elastics
Overlay wire for transverse stabilization

Dr. Punit Thawani

•

Finishing with positioners
– Parasthesia after surgery
– Variable biting force

•

At the end
– Proper settling
– Root parallelism – esp. osteotomy site

Dr. Punit Thawani

Retention
•
•
•

Not very different from routine
orthodontics.
Transverse retention
Fixed retainers

Dr. Punit Thawani

Summary
Before
surgery

Alignment
Leveling – by intrusion
Arch compatibility
Preparation of osteotomy site
Before and/or Post. crossbite correction – if
after surgery orthodontic expansion is planned
Leveling by extrusion
After surgery Settling and leveling by extrusion
Root paralleling at osteotomy sites
Detailed tooth positioning
Retention
Dr. Punit Thawani

Clinical Management Of Some
Commonly Encountered Orthognathic
Surgical Patients
1. Mand. Deficiency with normal or
reduced facial height
2. Excessive face height (long face)
3. Class III problems
4. Facial asymmetry
5. Crossbite and open bite
Dr. Punit Thawani

Mand Deficiency with normal or
•
•

•
•
•

Horizontal growth
pattern
Class II molar and
Canine relationship –
often with a div. 2
pattern.
Excessive curve of spee
in the lower arch.
Incisor crowding
Deep bite – usually
causing some gingival
irritation

Dr. Punit Thawani

•
•

•

Chin button well
developed
Deficiency near the
lower lip region –
seen as a deep
mentolabial sulcus,
a curl of the lower
lip and an aged
appearance.
TMJ disorders –
(disputed)

Dr. Punit Thawani

Surgical plan
• In most of these
patients, –

–

Mandibular
deficiency needs to
be corrected
Height of the face
must be increased.

Dr. Punit Thawani

Mandibular subapical procedure vs. BSSO
Subapical procedure
–

When face ht. is not to be increased

BSSO
–

To increase face height

Dr. Punit Thawani


Dr. Punit Thawani

•

Rotation of mandible
– chin moved back and incisors forward

•

Genioplasty if needed
– Reduce chin prominence
– Further increase face height

•

No maxillary surgery to increase face
height

Dr. Punit Thawani

Pre surgical Orthodontics
Position of the incisors –
vertically and sagittally
Vertical – Determines final face height
Sagittal – Determines amount of movement

Dr. Punit Thawani

•

Expansion of arch may be necessary
– Wider part of mandible comes forward
– Can be done orthodontically or surgically
– Extractions may not be required

Dr. Punit Thawani

•

Considerations during model surgery
– Face bow transfer rarely required
– Maintain bilateral symmetry – even if
crossbite develops
– Keep skeletal midlines matching

•

Post surgical orthodontics –
– Level COS by extrusion

Dr. Punit Thawani

Long Face Problems
•
•
•
•

Vertical excess of
post maxilla
↑mand plane
angle
Incisor exposure
Incompetent lips

Dr. Punit Thawani

Long Face Problems
•
•
•

Gummy smile
Narrow maxilla
Cross-bite

Dr. Punit Thawani

Long Face Problems
Surgical considerations
• impacting to maxilla – mandibular
autorotation
• Rotating the mandible upwards and
forwards after a BSSO
• Chin procedures

Dr. Punit Thawani

Long Face Problems
•

Maxillary procedure – Stable – Corrects
most of the problem

•

BSSO with rotation – Soft tissue stretch
– Unstable

•

Chin procedures – used as adjuncts

Dr. Punit Thawani

Long Face Problems
Pre surgical Orthodontics
• Orthodontist must know 2 things –
– Maxilla in 1 piece or segmented? – how
many pieces, and where
– Chin position? - or is proper lip – chin
balance going to be achieved by orthodontic
treatment

Dr. Punit Thawani

Long Face Problems
•

Segmented procedures
– Align within the segment
– Stabilize with a wire with step, or segments
of 21 x 25 SS wire
– Roots of adjescent teeth

•

Leveling
– If mild, by intrusion
– If severe - surgically

Dr. Punit Thawani

Long Face Problems
•

Expansion
–
–
–
–

Orthodontically
Surgically
But not both
Causes more relapse

Dr. Punit Thawani

Long Face Problems
•

Maxillary impaction
–
–
–
–
–

↑ wrinkles on the cheek
Drastic reduction in incisor exposure
Widening of alar bases
Aged appearance
More tolerated in younger individuals than
adults

Dr. Punit Thawani

Long Face Problems
•
•

If maxilla is moved back - ↓lip support
Maxilla may have to be moved forward to
get good lip support

•

Genioplasty – avoid major jaw surgery

Dr. Punit Thawani

Long Face Problems
Before model surgery
• How much is the maxilla going to be
moved
• How to reduce residual overjet (if any)
• Surgical expansion? – Prepare overlay
wire

Dr. Punit Thawani

Long Face Problems
Post surgical Orthodontics
• Segmental procedures – torque on
anteriors
– Flexible rectangular wires in upper
– 0.016” SS in lower

•

Stabilizing transverse corrections

Dr. Punit Thawani

Long Face Problems

Dr. Punit Thawani

Class III patients
•
•
•

•

Flatness in the lower 1/3rd
of the face – especially in
the labio-mental fold.
Soft tissues seem to be
tight.
Midface deficiency –
“sunken in” appearance is
seen.
Thin vermillion border,
and reduced maxillary
incisor exposure at rest.

Dr. Punit Thawani

Class III patients
•

Natural compensation
– Flared upper incisors, retroclined lower
incisors.
– Spacing between lower teeth – should think
of large tongue
– Maxilla may have small or even missing
teeth.
– Check for attached gingiva in lower anterior
– labial region.

Dr. Punit Thawani

Class III patients
•

Surgical techniques
1. Mandibular –
1. (BSSO)
2. Mandibular sub apical procedures
2. Maxillary –
1. Lefort I osteotomy - high level
2. Expansion
3. Genioplasty

Dr. Punit Thawani

Class III patients
•
•

Jaw at fault should be operated
If mandible too prognathic – both jaws
– Too much setback ➫ Double chin

•

Maxillary impaction in case of
hyperdivergent jaws

Dr. Punit Thawani

Class III patients
•
•
•

Jacobs – ‘two patient’ concept
Incisors should be positioned as ideally
as possible to their respective jaw bases,
without concern for inter-arch occlusion.
Maxilla
– require extractions and significant retraction

•

Mandible
– Non extraction or extraction for molar
correction
– Molar inclination correction

Dr. Punit Thawani

Class III patients
•

If upper expansion is needed
– Teeth should be aligned within the segments
– Arches should NOT be co-ordinated
presurgically
– Gross coordination surgically
– Final coordination post surgically

Dr. Punit Thawani

Class III patients
•
•

Frequent progress models
Before surgery, patients should be
informed about –
– Possibility of late mandibular growth
– Large amount of setback – double chin, may
require second soft tissue surgery
– Possibility of nasal changes – alar base
widening and upturning of the nose.

Dr. Punit Thawani

Class III patients
Basic principles to be followed
Check for relapse tendency

Dr. Punit Thawani

Class III patients
Tendency towards relapse
• Moderate class III elastics (200-300
gms)– heavier rectangular wires needed
• Upper incisors can be flared to an extent
• Interproximal reduction, and
retroclination of lower incisors
• Leave larger overjet and overbite

Dr. Punit Thawani

Class III patients
•

If relapse is still expected, the retention
appliance can be made with hooks for
attachment of light class III elastics while
sleeping

Dr. Punit Thawani

Class III patients

Dr. Punit Thawani

Dento-facial Asymmetry
•

More through diagnosis
– PA view
– Submento-vertex
– CT scan

Dr. Punit Thawani

Surgery in children
• Severe or progressive asymmetry
– Hemifacial microsomia
– mandibular ankylosis due to condylar
fracture

Dr. Punit Thawani

•

Principle of treatment –
– Modify growth to its full potential so that the
child grows out of the deformity

•

Initial functional appliance treatment
– Eliminate need for surgery
– Make surgery easier
– Help in muscular adaptation

Dr. Punit Thawani

•

Role of orthodontist –
– Growth guidance after surgery
– Maintenance of normal joint function
– Alignment of permanent teeth

Dr. Punit Thawani

Asymmetry problems in adolescents
• Continue growth guidance
– prevents bimaxillary problems

•

Problems of excessive growth
– Hemifacial hypertrophy

•

Orthognathic surgery at the end of
growth

Dr. Punit Thawani

Problems of excessive growth
• Diagnosis – 99mTc scan
• After growth – surgical correction

Dr. Punit Thawani

•

In severe cases – surgical correction
before growth is completed
– Only mandibular surgery
– cant of occlusal plane corrected by
functional appliances

Dr. Punit Thawani

Asymmetry in adults
• Extent of surgery –
– Correct asymmetry at its source
– Camouflage

•

Pre and post surgical orthodontics
– similar to any other case

Dr. Punit Thawani

Guidelines –
• More concern about transverse than
vertical asymmetry
• More concern about chin position than
mandibular angles
• Maxillary midline more critical than
mandibular midline

Dr. Punit Thawani

•

If nose and jaw are deviated to the same
side, both should be corrected

•

Asymmetry of higher structures - infraorbital rims, Zygomatic arch – onlay
grafts should be considered

Dr. Punit Thawani

•

Pre-surgical orthodontics
– Matching skeletal and dental midlines
• Asymmetric extractions
• Asymmetric elastics and cross elastics
• Loops and springs
– Know the type of surgery
• Genioplasty
• Ramus osteotomy

Dr. Punit Thawani

•

– Leveling by extrusion
– May be longer in such patients

Dr. Punit Thawani


Dr. Punit Thawani

Cross bites and Open bites in Adults
Adults with cross-bite can be divided into 3
groups
• Patients with a narrow maxilla – (RME
would have been done)
•

Large mandible

•

Patients with mandibular arch locked
within the maxilla (Scissors bite if
unilateral or Brodie bite if bilateral.)

Dr. Punit Thawani

Surgically assisted RME
• Preferable in patients below 25
• Not very predictable between 25-35
• Never done above 35 yrs of age
Osteotomy in the lateral buttress area is
preferred.
Dr. Punit Thawani


Dr. Punit Thawani

Patients with a wide mandible
• Try to treat the jaw at fault
• When in doubt – widen the maxilla
•

Mandibular narrowing
– Step ostectomy in anterior mandible
– Remove bone in premolar region & setback

Dr. Punit Thawani

Interlocking crossbite
(scissors bite, Brodie bite,
‘X’ Occlusion)
• Severe overlapping of
teeth
• Upper jaw has to be
moved superiorly and
laterally (unilateral)
• Mandible can be widened
if necessary – (distraction
osteogenesis) - or
advanced
Dr. Punit Thawani

Pre surgical orthodontics
• Short
• Bonding to lower arch not possible
• Only upper alignment
• Lower arch stabilized by directly bonding
19 gauge wire to teeth during surgery

Dr. Punit Thawani

Post – surgical orthodontics
• Longer than usual
• Aligning lower arch, and refining
occlusion

Dr. Punit Thawani

Adults with open-bite
• Segmental procedures to impact
posterior maxilla
• Segmental procedure to elevate
mandibular anteriors
• If teeth do not respond to orthodontics

Dr. Punit Thawani

•

Segmental procedure to elevate mand.
anteriors

Dr. Punit Thawani

•

Pre surgical orthodontics
– Align within the segments
– Prepare osteotomy site

•

Orthodontic movement should not be
done to correct the defect – relapse

•

Post surgical orthodontics – stabilization
of expansion – at least 6 months

Dr. Punit Thawani

Surgery in Patients with TMJ
Problems
•

General guideline for management

Dr. Punit Thawani

Surgery in Patients with TMJ
Problems
•
•

Orthodontics and/or surgery to correct
occlusion
TMJ surgery
– Not responding to reversible therapy
– Progressive internal joint pathologies

Dr. Punit Thawani

Stability of Surgical Corrections
The stability of orthognathic surgical
procedures depends on the following –
1. Direction of movement
2. Type of fixation used
3. Surgical technique employed

Dr. Punit Thawani

Hierarchy of Stability
Maxillary impaction
Mandibular advancemet (short and normal face)
Genioplasty
Maxillary advancement
Max. up + Mand. forward
Mandible back
Maxilla down
Maxillary widening
Dr. Punit Thawani

Maxillary impaction
• Most stable procedure
• Mandible auto-rotates to maintain the freeway
space
• Wire/IMF vs RIF equally good results
• Wire/IMF
–

–

6 weeks after the surgery - 20% of patients showed
2-4 mm of change in the upward direction
6weeks to 1 year - that much downward movement
of the max

Dr. Punit Thawani


Dr. Punit Thawani

RIF or wire/IMF seemed to make no
significant differences in stability.
More than 90% chance of max being within
2 mm of post surgical position after 1
year
• Bishara et al 1988
• Denison et al 1989
• Proffit et al 1992
Dr. Punit Thawani

Mandibular advancement (BSSO)
• normal or short face height is considered
Wire/IMF
• first 6 weeks post surgery
–

•

6 weeks to one year
–

•

the mand had a tendency to move slightly back.
the changes seemed to be recovered

function

Dr. Punit Thawani

RIF
• smaller tendency to move back
• greater chance of slight forward movement
90% chance of stability
•
•
•
•
Dr. Punit Thawani

Proffit et al 1990
Kouma et al 1991
Gomes et al 1993
Ingervall et al 1994

•

BSSO with rotation to close an open bite
– Soft tissue stretch
– RIF more stable than wire/IMF
– Interpositional bone grafts and heavy plates
• Ritzik et al 1990

Dr. Punit Thawani

Maxillary impaction & mand. Advancement

Wire/IMF
• Individual procedures
– Maxilla ↑
– Mandible ←

•

Unlike the individual procedures
– No recovery between 6 mo to 1 year and
relapse continued in 1/3rd of the patients

Dr. Punit Thawani


•

By the end of 1 year, only 60% of the
patients were judged to have excellent
clinical results
Post surgical bite opening tendency is
seen

Dr. Punit Thawani

RIF
• RIF in mandible improved stability
• Slight relapse of the mandible between 6 weeks
to 1 year
• Over 90% patients were judged to have good
clinical outcomes
• No bite opening tendency is seen.
•
•

Dr. Punit Thawani

Hennes et al – 1988
Sinclair et al – 1991
• Proffit et al – 1992
• Ayoub et al – 1993

Maxillary advancement
• If moved only anteriorly – 80% stable
• If simultaneous downward movement –
unstable
•
•

Dr. Punit Thawani

Proffit et al – 1991
Bishara , Chi - 1992

Mandibular setback
• BSSO and Trans-oral vertical ramus
osteotomy (VRO).
• VRO seemed to be more stable than
BSSO

Dr. Punit Thawani

VRO
• chance of further backward
• but forward relapse also occurred
With BSSO
• no post surgical backward movement,
but forward relapse occured
• RIF with BSSO seemed to make relapse
tendencies worse
Dr. Punit Thawani

VRO
• improper positioning of condyles in fossa
resulted in backward movement
Both procedures
• Change in ramus inclination resulted in
forward relapse
•

Dr. Punit Thawani

Proffit et al (1991)

Inferior repositioning of the maxilla
• wire/IMF - almost all the inferior movement is
lost.
• RIF – strong relapse tendency.
• occlusal forces
• Ways of maintaining the correction are –
–

–
–

use of heavy fixation bars from zygomatic arch to
the maxillary posterior teeth,
use of interpostional bone grafts, or
simultaneous ramus osteotomy
• Proffit et al 1991

Dr. Punit Thawani

Widening of the maxilla
• 1 year later, almost 50% of the expansion was
lost in the second molar region

•

Reduction in post surgical width of about 2
mm in 2/3rd of the patients.
•

•
•

Proffit et al 1992.

Stretching of the palatal mucosa
Modest overcorrection and stringent retention

Dr. Punit Thawani

3 Basic principles that influence post
surgical stability –
•

Stability is greatest when soft tissues are
relaxed during surgery and least when they are
stretched.

•

Neuromuscular adaptation

•

Neuromuscular adaptation affects muscle
length and not muscle orientation.

Dr. Punit Thawani

Long term Prognosis of BSSO Mandibular Relapse
and its Relation to Different Facial Types

Yoshida et al
Angle Orthodontist – March 2000

•
•
•
•

15 patients – BSSO mandbibular setback
Wire/IMF
Followed for 10.3 years post surgery
2 types of facial patterns –
– Mesoprosopic
– Euryprosopic

Dr. Punit Thawani

Long term Prognosis of BSSO Mandibular Relapse
and its Relation to Different Facial Types

•

Yoshida et al
Angle Orthodontist – March 2000

Relapse tendency

– Euryprosopic – forward rotation of mand
– Mesoprosopic – backward rotation of mand.

•

Suggestions to reduce relapse
– Euryprosopic – Sufficient setback
– Mesoprosopic – adequate overbite
– Good post-treatment occlusion

Dr. Punit Thawani

Euryprosopic
Dr. Punit Thawani

Mesoprosopic

Long Term stability of Surgical Open bite
Correction by Le Fort I osteotomy
•
•
•
•

Proffit, Bailey, Phillips, Turvey
AO Feb 2000

54 patients of open bite
26 - maxillary impaction only
26 - had max impaction and mandibular
advancement
Immidiate post surgical records, 1 year
post surgical, and at least 3 years post
surgical cephs were taken.

Dr. Punit Thawani

•

AO Feb 2000

In both the goups, there is

– a tendency for the maxilla and mandible to
move slightly downwards
– maxillary and mandibular posterior teeth to
erupt
– mand anterior teeth to erupt.

•

Hence – increase in mand plane angle
and face height

Dr. Punit Thawani


AO Feb 2000

Dr. Punit Thawani

•
•

AO Feb 2000

Despite skeletal changes, almost no
changes in occlusion
Authors attribute the change to
– Continued growth into adult years
– Inadequate physiologic adaptation in
maintaining the freeway space

Dr. Punit Thawani

Long term stability of mandibular setback surgery: A
follow-up of 80 bilateral sagittal split osteotomy
patients

Mobarak, Espeland, Krogstad and Lyberg
Int J of Ad. Orthod & Orthognath. Surg 2000

•

During surgery – proximal segment
tended to rotate clockwise, changing the
orientation of the ramus to a more
upright position

•

Follow up – Ramus returned to original
inclination

Dr. Punit Thawani

Stability of Le Fort I osteotomy in maxillary inferior
positioning: Review of the literature

Costa et al

•

Starling’s law states that a stretched
muscle has increased contractile strength

•

Fixation techniques
–
–
–
–

Wire fixation and IMF
Rigid fixation only
Rigid fixation and bone grafting
Rigid fixation and alloplastic materials
(porous block hydroxyapetite)

Dr. Punit Thawani


Costa et al

•

Wire/IMF – highest relapse – 50%
overcorrection

•

RIF – more stable upto 2 mm

•

Rigid fixation with autogenous bone stable, and predictable

Dr. Punit Thawani


Costa et al

•

Rigid fixation with porous block
hydroxyapetite showed excellent stability
2 studies

•

Greater relapse in the posterior part of
the maxilla

Dr. Punit Thawani

Mandibular advancement surgery in high angle and
low angle Class II patients: Different long term
skeletal responses.

AJO 2001

•

61 patients

•

BSSO only, no additional procedure
performed, and Rigid internal fixation (RIF)
followed for 3 years after surgery

•

20 patients (20.8 + 4.8) - Low angle group

•

20 patients (43 + 4) - High angle group

•

Remaining 21 patients in the normal group

Dr. Punit Thawani

skeletal responses.

•
•

AJO 2001

Stability of increasing MPA
Dental changes

– retroclination of the lower incisors, while the
upper incisors remained more or less
upright.

Dr. Punit Thawani

skeletal responses.

AJO 2001

Timing of relapse –
• Low angle group about 98% of the
relapse occurred within the first 2
months
• High angle group, the relapse was more
gradual –
•
•
•

30 % in the first 2 months
25 % between 2 months to 1 year
38% in the between 1 year to 3 years

Dr. Punit Thawani

skeletal responses.

•

AJO 2001

Relapse due to –

– Intersegment mobility
– Distraction of condyle

•

Implant studies (Rubenstein et al - 93,
Rebellato et al -94)

•

Most of the relapse due to repositioning
of condyle in fossa

Dr. Punit Thawani

skeletal responses.

•

AJO 2001

Other possible causes for late changes
– late mandibular growth in the original
direction
– residual effects of incompletely adapted
suprahyoid musculature
– Condylar resorption

Dr. Punit Thawani

References
•

Contemporary treatment of Dentofacial
Deformity – Proffit, White & Sarver

•

Surgical Orthodontic Treatment – Proffit and
White

•

Contemporary Orthodontics – Proffit

•

Orthognathic surgery: A hierarchy of Stability
– Proffit et al - Int. J or Adult Orthod
Orthognath Surg 1996

Dr. Punit Thawani

References
•

Lingual Orthodontics and Orthognathic
surgery – Int. J or Adult Orthod Orthognath
Surg 2000

•

Stability of Le Fort I osteotomy in maxillary
inferior positioning: Review of the literature Costa et al - Int. J or Adult Orthod Orthognath
Surg 2000

•

Long term stability of mandibular setback
surgery: A follow-up of 80 bilateral sagittal
split osteotomy patients - Mobarak, et al - Int.
J or Adult Orthod Orthognath Surg 2000

Dr. Punit Thawani

References
•

Correction by Le Fort I osteotomy - Proffit,
Bailey, Phillips, Turvey – AO Feb 2000

•

Long term Prognosis of BSSO Mandibular
Relapse and its Relation to Different Facial
Types - Yoshida et al - AO March 2000

•

Mandibular advancement surgery in high angle
and low angle Class II patients: Different long
term skeletal responses - Mobarak, Espeland,
Krogstad and Lyberg – AJO 2001

Dr. Punit Thawani

Thank you
For more details please visit

Dr. Punit Thawani

Pre & post surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

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