Surgery in orthodontics

surgical procedures that are commonly carried out in orthodontics

1. 1 Surgery in Orthodontics Ujwal Gautam Roll no. 431 BDS 4 th year (2009 batch) BPKIHS

2. 2 Major procedures Orthognathic surgeries Cosmetic surgeries Minor procedures Extractions therapeutic extraction serial extraction carious teeth malformed teeth supernumerary teeth impacted teeth Surgical uncovering of teeth Frenectomy Pericision Corticotomy

3. Orthognathic surgeries corrects dento -facial disproportions involving the maxilla, the mandible or both in all three planes of space 3

4. Indication If neither growth modification procedures nor orthodontic camouflage provides solution NOT a substitute but adjunct to or in conjunction with orthodontic treatment. 4

5. 5 Camouflage v/s Surgery Decision for camouflage or surgery must be made before treatment begins Greater emphasis on soft tissue consideration essential when camouflage versus surgery is considered

6. 6 Envelope of Discrepancy

7. 7 Surgery preferred over Orthodontic Camouflage for; Long Vertical Facial pattern Moderate or severe antero -posterior jaw discrepancy Crowding >4-6 mm Exaggerated features Transverse Skeletal problem

8. Contemporary Surgical Techniques: Mandibular Surgery Maxillary Surgery Dentoalveolar Surgery Distraction Osteogenesis Adjunctive Facial procedures 8 LeFort I osteotomy Segmental osteotomies Sagital Split osteotomy Oblique sub condylar osteotomy Rhinoplasty Genioplasty Sub mental procedures Lip procedures Surgically assisted rapid Palatal Expansion (SARPE)

9. Class III mandibular excess 9

10. C lass II mandibular deficiency 10

11. H orizontal deficiency and vertical chin excess 11

12. C lass II maxillary protrusion 12

13. Excess vertical growth of maxilla and down and back rotation of mandible 13

14. Class III maxillary deficiency and mandibular excess 14

15. Distraction Osteogenesis based on manipulation of a healing bone osteotomized area is stretched before calcification has occurred in order to generate the formation of additional bone formation and investing soft tissue Patients with craniofacial syndrome are the prime candidates Advantages of distraction are that Larger distances of movement are possible than with conventional orthognathic surgery, and Deficient jaws can be increased in size at an earlier age Disadvantage is that precise movements are not possible 15

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17. Adjunctive Facial procedures improve the esthetics of the patient to improve the soft tissue contours beyond what is available from repositioning the jaws 17

18. Rhinoplasty cosmetic surgery of the nose focused on the contour of the nasal dorsum, the shape of the nasal tip and the width of the alar base particularly effective when nose is deviated to one side, has a prominent dorsal hump, or has a bulbous or distorted tip. Usually follows LeFort I osteotomy which compromises the appearance of nose 18

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20. Chin Augmentation or Reduction most frequently used adjunct to orthodontics Improves the stability of the lower incisors as well as enhancing facial appearance tightens the suprahyoid musculature and produces desirable changes in chin-neck contour Reduction of the chin with osteotomy can be a possibility to camouflage a skeletal Class III problem 20

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22. Extractions Most commonly undertaken minor surgical procedures in conjunction with orthodontic therapy. 22

23. Therapeutic extraction for gaining space Choice of teeth extraction is based on number of factors including the amount of arch length-tooth material discrepancy, the direction and amount of jaw growth, the facial profile, the state and position of teeth in particular and the entire dentition and finally the age of the patient. Integrity of alveolus should be maintained Permanent 1 st premolars are the most commonly extracted teeth 23

24. Serial extractions interceptive orthodontic procedure usually initiated in the early mixed dentition when severe arch length discrepancy exists includes planned extraction of certain deciduous teeth and later specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into normal alignment 24

25. Procedures Dewels method Tweeds method Nance method 25

26. Extraction of supernumerary, impacted and ankylosed teeth Involves removal of local cause of malocclusion 26

27. Surgical extraction of bilateral unerupted supernumerary teeth in maxillary central incisor region 27

28. Impacted teeth can be guided into normal position by removal of overlying soft tissue and removal of bone covering orthodontic guidance can be required using attachments to guide erupting tooth into arch 28 Surgical uncovering of impacted teeth

29. Frenectomy surgery to remove the interdental fibrous tissue and reposition the frenum Generally performed for Midline Diastema maxillary midline diastema is often accompanied by the insertion of a thick, fleshy fibrous labial frenum into a notch in the alveolar bone. 29

30. frenectomy performed prior to space closure Merit- removal of etiology Space closure can be easily attained orthodontically Demerit- scar tissue that could prevent orthodontic space closure . 30

31. frenectomy should be performed after space closure Merit- reduces the risk of scar tissue formation that can prevent closure of midline diastema. post surgical scar tissue stabilizes the teeth together. Demerit- during closure, soft tissue may be enlarged and sore preventing complete space closure. if the space is large and frenal attachment is thick, it may not be possible to completely close the space before surgical intervention, requiring multiple stages of treatment. 31

32. Frenectomy and midline diastema 32

33. Corticotomy undertaken in patients having dental proclination with spacing Involves sectioning of dento -alveolar region into multiple small units to hasten orthodontic tooth movement Although the nerve supply to the teeth is interrupted, sensation usually returns and endodontic treatment almost never required 33

34. Pericision Also known as circumferential supracrestal fibrotomy Adjunct to an retention procedure after corrrection of rotations performed to counter the relapse tendency of the stretched gingival fibres – trans- septal and alveolar crest group in derotated tooth Surgical sectioning of gingival fibres performed a few weeks before removal of orthodontic appliance or if it is performed at the same time the appliance is removed, a retainer must be inserted almost immediately . 34

35. References Proffit W. R.; Contemporary Orthodontics; Mosby Inc ; 4/e; 2007 Bhalajhi S. I.; Orthodontics The Art and Science; Arya (MEDI) Publishing House; 4/e; 2009 Proffit , White, Sarver; Contemporary Treatment of Dentofacial Deformity; St . Louis, Mosby,2003 Singh G.; Textbook of Orthodontics; Jaypee Brothers Medical Publishers Ltd; 2/e; 2007 35