Surgical Orthodontics and treatment Planning presentation

Surgical orthodontics

1. SEMINAR PRESENTATION TOPIC: DIAGNOSIS AND TREATMENT PLANNING IN SURGICAL ORTODONTICS

2. INTRODUCTION Orthognathic surgery to is one of the treatment alternative for the patients who are too old for growth modification and for dentofacial conditions that are too severe for either surgical or orthodontic camouflage. It consists of standard orthognathic procedures to correct jaw deformity, as well as adjunctive procedures genioplasty , septorhinoplasty , and suction lipectomy of the neck. to improve hard and soft tissue contours.

3. Historical perspective Historically, surgery on the mandible preceded that of the maxilla. Hullihen (1849 ) was the first to perform osteotomy surgery on mandible to treat deformity caused by a burn. Vilray Blair for the first time in 1897 performed osteotomy of the mandibular body for the correction of prognathism , called St Louis operation Since the introduction of the mandibular sagittal split ramus osteotomy by Trauner and Obwegeser in 1957 the modern era of orthognathic surgery has begun.

4. Bilateral sagittal split osteotomy (BSSO) with its modifications is a widely accepted procedure on the mandible. In 1960s, Obwegeser started to perform maxillary surgery and described a large series of Le Fort I osteotomies.

5. 5. Evaluation of face 8. Surgical Treatment Objective 6. Cephalometric Evaluation and Simulation 4.Envelope of Discrepancy Diagnosis and Treatment Planning 2. Indications and Contarindiactions 1.Goals 10. Recent Advances in Diagnosis 3. Need vs Demand 9. Surgical Splint Fabrication 7. Occlusogram

6. The orthodontist’s or surgeon’s teamwork also strives to provide a s table, s atisfactory relationship that enhances the overall orofacial h ealth of the patient. The acronym FRESH has been useful as a guide to describe the major goals of orthodontic– orthognathic treatment to patients considering this option. Orthodontics, 6th Edition Current Principles and Techniques By Lee W. Graber, DDS, MS, PhD, Robert L. Vanarsdall , Jr., DDS, Katherine W. L. Vig , BDS, MS, FDS(RCS), DOrth and Greg J. Huang, DMD, MSD, MPH Goals of Surgical Orthodontics

7. FRESH : FUNCTION RELIABLE ESTHETICS ECONOMIC STABILITY SATISFACTION HEALTH

8. Two prerequisites for achieving treatment goals and a successful outcome are : A clear understanding of the patient’s chief concerns and the patient’s treatment goals , documented, clarified, and illustrated through simulation and diagnostic setup A clear explanation by the orthodontist of the treatment goals that can be achieved

9. An orthognatic surgery team, led by the orthodontist and the oral surgeon , carefully develops a problem list, which is reviewed with the patient; this provides an opportunity to discuss the treatment options for achieving the desired outcomes. The orthodontist informs the patient and family, and then all must agree on a plan that they believe will provide the best possible outcome with the least exposure to risk. The plan of action cannot be finalized until the other members of the provider team have contributed to the treatment plan and sequence.

10. Careful integration of each team member’s perspective helps to prevent last-minute surprises—for example, Which jaw is having the surgery ?

11. How much movement is needed?

12. Is two-jaw surgery recommended instead of one-jaw surgery? Such unexpected changes can undermine the outcome and the patient’s trust.

13. NEED VERSUS DEMAND: Stomatognathic system imbalances are generally not life threatening, thus placing their need for treatment into a category of “ elective.” However, because imbalances in the stomatognathic system can have a major negative impact on one’s masticatory function, muscle comfort, dental health, facial aesthetics, and self-esteem, proper treatment is important to each individual patient.

14. Squire et al. found that the following were not considered treatable by the Orthodontics alone: Positive overjet greater than 8 mm 2. Negative overjet of –4 mm or more 3. Maxillary transverse discrepancy greater than 3 mm

15. Proffit and White helped to clarify this discussion of need vs demand for orthognathic surgery with the following statement: “ The indication for surgical-orthodontic treatment is that a skeletal or dentoalveolar deformity is so severe that the magnitude of the problem lies outside the envelope of possible correction by orthodontics alone .” An arbitrary “Envelope of Discrepancy” was developed to illustrate the concept of limitations of various treatment modalities Contemporary Orthodontics By William R. Proffit , Henry W. Fields, Brent Larson, David M. Sarver

16. ENVELOPE OF DISCREPANCY

17. Current Principles and Techniques. Authors: Lee Graber Robert Vanarsdall Katherine Vig Lee Graber Robert Vanarsdall Katherine Vig . 5th Edition Elsevier

18. INDICATIONS FOR SURGICAL ORTHODONTICS

19. INDICATIONS Jaw deformities, Skeletal asymmetries and Severe dento alveolar problems. The Esthetic and functional problems often associated with severe jaw deformities, are reasons for seeking orthognathic surgery. Severe Skeletal Class II & Class III cases. Severe skeletal open bite and deep bite cases. Problems in articulation of speech which are more common in patients with anterior open bite or severe deep bite.

20. 6. TMJ problems, ankylosis of the TMJ (unilateral or bilateral). 7. Periodontal and gingival health such as in traumatic deep bite. 8. Patients with Obstructive sleep apnoea (OSA) to enlarge the oral space and therefore prevent the tongue from falling back during sleep. 9. Compromised masticatory efficiency due to decreased number of functional occlusal contacts. Tumour resection of the jaws and condyles Cleft palate patients who have small maxilla consequent to the growth inhibitory effects of scarring caused by the surgery of the lip and palate.

21. CONTRAINDICATIONS Orthognathic surgery is not indicated for the patients with mandibular prognathism due to tumours of the endocrine glands and endocrine disorders such as acromegaly. The psychological state of the patient is an important consideration before taking a case for the orthognathic surgery. The adults with complex behavioural problems and known psychological disorders may have to be carefully evaluated. Patients with medical problems are not absolute contraindication however, they need to be evaluated on the type and severity of disease and its possible impact during or after surgery.

22. Evaluation of face

23. Esthetic Facial Evaluation:

24. The patient should be examined in natural head posture, with the teeth in centric occlusion and the lips relaxed. Orthodontic and surgical treatment are planned to produce ideal function in centric occlusion. All examination data should therefore be recorded in centric occlusion.

25. Clinical assessment of the chin and throat area is possible only when the head is in natural posture. Note the differences with the head tilted down (a), up (b), and with the head in natural posture (c). The white line represents the Frankfort horizontal (FH) plane. PHOTOGRAPHIC ANALYSIS

26. Individual with vertical maxillary deficiency. Note the change in the shape of the lips and lower facial height with the teeth in occlusion (a) and with the mandible rotated open until the lips just part (b). Patients with vertical maxillary deficiency and severely closed bites should be evaluated in an open bite posture. A wax bite can be placed between the teeth to increase the vertical dimension until the lips just part, as the inadequate height of the maxilla lead to overclosed bites in such patients leading to distortion of their lips. Essentials of Orthognathic Surgery, Second Edition Johan P. Reyneke PHOTOGRAPHIC ANALYSIS

27. It is necessary that the patient be examined with the lips in a relaxed position, because it is impossible to assess the soft tissue relationship to the hard tissue when the lips are forced together. The profile of the lower third is profoundly different when the lips are forced together (a) versus in relaxed state (b). PHOTOGRAPHIC ANALYSIS

28. Frontal analysis:

29. Frontal analysis: From the frontal view, it is particularly important to assess Facial form; Transverse dimensions; Facial symmetry; The vertical relationship in the upper, middle, and lower thirds of the face; The lips; and The nose.

30. Facial symmetry: The maxillary and mandibular dental midlines should be assessed in relation to the facial midline, as well as in relation to each other. It is also important to evaluate the mandibular dental midline in relation to the midline of the chin. This information will assist in treatment planning for correction of mandibular asymmetry by means of mandibular surgery, genioplasty , or both. PHOTOGRAPHIC ANALYSIS

31. Posteroanterior cephalometric radiography is indicated when a clinically significant asymmetry is present. This will allow the clinician to distinguish between bone, soft tissue, or a combination of the two as etiologic factors. Essentials of Orthognathic Surgery, Second Edition Johan P. Reyneke

32. Transverse Dimensions The rule of fifths is a convenient method for evaluating transverse facial proportions. The face is divided into five equal parts each the approximate width of the eye from helix to helix of the outer ears. The outer fifths are measured from the center helix of the ears to the outer canthus of the eyes. Prominent ears may have a profound effect on facial proportions and can be corrected by otoplasty PHOTOGRAPHIC ANALYSIS

33. The medial three-fifths of the face are measured from the outer to the inner canthus of the eyes. The outer border should coincide with the gonial angles of the mandible. In patients with masseter muscle hypertrophy, the gonial angles will fall well lateral to this line PHOTOGRAPHIC ANALYSIS

34. Lips: The lips are extremely critical to overall esthetics . Lip symmetry should be evaluated; if asymmetry exists, its etiology should be determined ( eg , cleft lip, facial nerve dysfunction, underlying dentoskeletal asymmetry, scarring caused by previous trauma, or congenital unilateral microsomia or macrosomia). The lower lip generally exhibits 25% more vermilion than the upper lip , and the lips should be 0 to 3 mm apart in repose . There are specific racial differences in lip thickness and shape that one must bear in mind for the purposes of treatment planning.

35. Profile analysis NOSE CHEEKS PARANASAL AREA LIPS CHIN CHIN THROAT AREA PHOTOGRAPHIC ANALYSIS

36. Nose Nose forms an important aspect of the overall facial esthetics , and the form and function of the nose can be affected by orthognathic surgery In many instances nasal reconstruction may be part of the orthognathic treatment plan; sometimes, rhinoplasty and orthognathic surgery can be performed simultaneously. PHOTOGRAPHIC ANALYSIS

37. Control of the nasal form should also be considered, especially in patients requiring superior repositioning and/or advancement of the maxilla. The nasal tip projection is evaluated by following If BC is greater than 55% to 60% of AB (Nasal Rigde ), the nasal tip usually appears disproportionately overprojected . The general shape of the alar base should resemble an isosceles triangle, with the lobule neither too broad nor too narrow. PHOTOGRAPHIC ANALYSIS

38. Cheeks The cheeks should exhibit a general convexity from cheekbone apex to the commissure of the mouth. This line starts just anterior to the ear, extending forward through the cheekbone, then anteroinferiorly over the maxilla adjacent to the alar base of the nose, and ending lateral to the commissure of the mouth. This line of convexity, called the cheekbone–nasal base–lip curve contour , requires simultaneous frontal and profile examination PHOTOGRAPHIC ANALYSIS

39. Note the smooth, uninterrupted curve of the contour line in an individual with good facial proportions An interruption in the curve of the contour line, indicating maxillary anteroposterior deficiency. (c) An improvement in the curve after advancement of the maxilla PHOTOGRAPHIC ANALYSIS

40. Paranasal areas: The paranasal area plays an important role in distinguishing between middle third deficiency and mandibular anteroposterior excess. Nasal projection: The projection of the nose is measured horizontally from pronasale ( Pn ) to subnasale ( Sn ) and is normally 16 to 20 mm. The ratio of Pn-Sn over Sn – Nb should be 2:1. PHOTOGRAPHIC ANALYSIS Essentials of Orthognathic Surgery, Second Edition Johan P. Reyneke

41. A ratio closer than 1:1 indicates Maxillary anteroposterior deficiency. An increased ratio indicates decreased nasal projection. Patients with a Class III malocclusion, decreased nasal projection, and a short nose should be treated by mandibular setback rather than maxillary advancement. The possibility of rhinoplasty as a second procedure should be discussed with the patient. PHOTOGRAPHIC ANALYSIS

42. Lips in Pofile View: The protrusion, retrusion , and soft tissue thickness of each lip is evaluated with the lips in repose. The Sn-pogonion ( Pog ’) line, also called the lower facial plane , is an important guide in assessing the lip position and planning orthodontic and surgical positioning of the incisors as well as chin. The upper lip should be 3 ± 1 mm ahead of this line and the lower lip 2 ± 1 mm ahead of this line. PHOTOGRAPHIC ANALYSIS

43. Labiomental fold: The lower lip–chin contour should have a gentle S-curve, with a lower lip–chin angle of at least 130 degrees. The angle is often acute in patients with Class II mandibular anteroposterior deficiency because of impingement of the maxillary incisor on the lower lip or macrogenia . PHOTOGRAPHIC ANALYSIS

44. The angle is flattened in individuals with lower lip tension caused by Class III malocclusion. The surgeon considering genioplasty should assess not only the anteroposterior position of the Pog ’ but also the chin shape and the labiomental fold. PHOTOGRAPHIC ANALYSIS

45. Nasolabial angle The nasolabial angle, which is measured between the inclination of the columella and the upper lip, should be in the range of 85 to 105 degrees Surgical or orthodontic retraction of maxillary incisors should be avoided in individuals with large nasolabial angles. In females a slightly larger angle is acceptable whereas a smaller angle is considered esthetically pleasing in males. PHOTOGRAPHIC ANALYSIS

46. In general, the maxilla should never be moved posteriorly, especially in combination with superior repositioning. This surgical movement leads to loss of lip support, increase in nasolabial angle, increase in nasal projection, and flattening of the nasal base. These changes result in poor esthetics and a premature aging effect. The maxilla should be moved posteriorly only in individuals with true maxillary protrusion, which occurs very rarely. PHOTOGRAPHIC ANALYSIS

47. Chin: Although the chin forms a prominent esthetic feature of the face, it has no clearly defined function. Anatomically the chin is considered to be the soft tissue structure below the labiomental fold. Chin projection should be in good balance with the entire profile. The anteroposterior position of Pog ’, however, is not the only determining factor for good chin esthetics . When examining the chin, the clinician should consider the entire complex of structures forming the lower third of the face from Sn to Me’. PHOTOGRAPHIC ANALYSIS

48. Chin-throat area: The presence of a double chin and adipose tissue should be noted. The lower lip– chinthroat angle ( normally 110 degrees ) provides chin definition. The distance from the neck-throat angle to Pog ’ (submandibular length) should be approximately 42 mm. These observations are pertinent when considering mandibular setback or advancement procedures, genioplasty (advancement or reduction), or submental liposuction. PHOTOGRAPHIC ANALYSIS

49. CEPHALOMETRIC EVALUATION AND SIMULATIONS

50. A variety of cephalometric analyses are available to ascertain the location of the dysplasia and its severity. It enables the clinician to : Quantify, classify, and communicate dentofacial deformities; Create a treatment plan via a visual treatment objective; Help plan for tooth extractions; monitor progress during treatment; Study specific changes during and after treatment to evaluate treatment results; and study facial growth.

51. CEPHALOMETRIC ANALYSIS FOR ORTHOGNATHIC SURGERY The cephalometric analysis for orthognathic surgery shows the orthodontist the horizontal and vertical positions of the facial bones and the soft tissue parameters by the use of a steady harmonized system The sizes of the bones are represented by direct linear measurements whereas the shapes are measured by angular measurements. The landmarks and measurements selected in the analysis can be altered by numerous surgical procedures This composite analysis is a combination of different cephalometric analysis

52. Formation Of Surgical Template

53. Surgical Template The principle of the method is to simulate the desired surgical movements by overlaying separate cut-outs of tracing paper of the dentoskeletal segments that will be moved, and pasting them in the desired position. The technique permits visualization of a relatively accurate proposed postoperative dentoskeletal outcome and an estimation of the proposed postoperative soft tissue profile.

54. The technique involves manually tracing the salient features of the craniofacial complex on transparent acetate tracing paper.. Following this, separate tracings are made of the dentoskeletal segments that are planned to be moved on separate sheets of tracing paper, which are overlaid on the original in the desired postoperative positions. a)Tracing the outline of the mandible on tracing paper placed over the lateral cephalometric radiograph.

55. The overlying soft tissue outlines are drawn based on the type of soft tissue change that is predicted in view of the dentoskeletal movements undertaken (b) Cutting the mandibular tracing to allow repositioning of the anterior segment. (c) Repositioning the cut segment to permit visualization of the proposed surgical procedure

56. Cephalometic Surgical Planning for VME: Step 1. Pretreatment ceph tracing is done

57. Step 2 and 3 : Incisor inclination and other presurgical objectives simulated on an overlay tracing (blue). Now on another tracing sheet, the maxillae and mandible are traced separately (green) from this tracing.

58. Once the amount of incisor exposed beneath the upper lip is determined, the ideal amount of superior repositioning of the upper incisor can be determined by the formula: X= (Y-2)/0.80 X= Amount of superior repositioning necessary Y= amount of upper incisor showing Surgical osteotomies are now simulated in maxilla along with mandibular auto rotation with centre of rotation at condyle. Fish LC, Wolford LM, Epker BN. Surgical-orthodontic correction of vertical maxillary excess. Am J Ortho 1978;73:241.

59. Step 4: Final profile tracing (red) is done along with soft tissue changes. .

60. Step 5: The final expected post treatment profile (red) is compared with pretreatment tracing

61. Occlusogram Methods:

62. An occlusogram is a 1:1 reproduction of the occlusal surfaces of plaster models on a sheet of acetate tracing paper. Marcotte and Burstone suggested setting the maxillary teeth around an idealized lower arch form so that it would be possible to do an occlusal simulation.

63. Occlusal simulations permit the orthodontist to quickly see if the maxillary teeth even have the possibility of occluding with the lower correctly. Occlusograms provide a diagnostic tool that permits greater accuracy in orthodontic diagnosis and treatment planning, in case of: Antero Posterior and Horrizontal Discrepancies and Simulation of the Treatment Planning

64. Treatment procedures employing a change in the cant of the occlusal plane, forward or backward rotations of the mandible, and/or surgical procedures can be superimposed Whatever procedures employed, their net effect can be measured as a change on the occlusogram

65. Surgical TreatmentObjective :

66. It was Wolford (1985) who used the VTO for surgical-orthodontic treatment planning and coined the term Surgical Treatment Objective (STO). The objective of treatment simulation is to allow the clinician to visualize and manipulate the skeletal and dental structures, so to compare different treatment alternatives. Surgical Treatment Objective:

67. Uses of an STO: (Taylor 1998)  Plan dental movements. Assess need for extractions Plan mechanics.  Plan type of surgery and nature of osteotomies.  A basis for communication Provides a reasonable prediction of soft tissue changes, that can provide a basis for computer imaging

68. There are five general methods of visualising, planning and predicting surgical-orthodontic treatment outcomes: The Acetate tracings of skeletal structures. Manipulation of patient photographs (cut and past) to illustrate treatment goals. Computerised diagnostic and planning with softwares digitised structures of lateral cephalometric radiographs.

69. . 4. Software that integrates video images with the patient’s lateral cephalograph to aid in planning and predicting surgical orthodontic procedures ( Videocephalometrics ). 5. Three-dimensional computer technology for planning and predicting orthognathic surgery

70. 1. The Acetate tracings of skeletal structures:  Acetate tracings of skeletal structures are manually repositioned over the original cephalometric tracing to simulate the proposed surgical movements.  The two major weaknesses of this technique is that: I. Variability in Soft tissue thickness, tonicity, II. Differences in the surgeon’s manipulation will introduce uncertainties in the soft tissue prediction

71. The lateral cephalogram traced and superimposed onto a profile picture in a ratio of 1:1; this has been called a "photometric plan". The photograph, with the hard tissue points marked, is then cut-up to simulated correction 2. Manipulation of patient photographs (cut and past) to illustrate treatment goals:

72. The necessary surgical movements were then undertaken; followed by the soft tissue response to the hard tissue movements. The end results sometimes looked a bit like a Picasso picture!

73. Using any of the commercially available programmes, the clinician can: Produce a soft tissue profile ‘line drawing’ as a result of manipulation of digitised structures of lateral cephalometric radiographs: 2. Simulate surgical movements on the screen and rapidly compare different treatment options. 3. Computerised diagnostic and planning:

74. 4. Computerised diagnostic and planning software that integrates video images with the patient’s lateral cephalograph to aid in planning and predicting surgical orthodontic procedures ( Videocephalometrics ). Visualisation of facial changes is enhanced as is patient/clinician communication; alternative treatment plans can be evaluated with ease, and realistic patient expectations may be achieved. (Harradine 1985, Sarver 1988, Sinclair 1995).

75. 5. Three-dimensional computer technology for planning and predicting orthognathic surgery: Moss et al (1988) expanded on the early methods of 3-D planning by including laser scanning to model the soft tissue response to hard tissue movements.

76. Two significant advantages of video imaging over other prediction techniques are: By involving the patient in the decision of treatment options, acceptance of the treatment outcome should be improved. Valuable aid in treatment planing decisions by providing a maniputable image .This technique is also helpful on deciding the necessity of adjunctive soft tissue procedures.

77. Newer diagnostic aids:

78. Digital cephalometric and video imaging in treatment planning The current cephalometric analysis systems are supported by powerful software functions that allow possibilities of ‘on screen’ digital image acquisition either directly from a digital cephalostat or through a scanner and ‘on screen cephalometric analysis’ and storage of data as well as on screen mock surgery’, . The process is quick and accurate for the landmarks digitised. The digital photographic images, taken in a standardised manner are calibrated and superimposed on the digital cephalogram image.

79. VIRTUAL SURGICAL PLANNING There are six degrees of freedom of the dental complex that need to be taken into account when orthodontic/ orthognathic movement is being considered Conventionally, two-dimensional radiographs and hand-drawn cephalometrics , in combination with articulator-mounted casts were used to construct the treatment guide.

80. With the widespread availability of computed tomography, three-dimensional imaging and computer-assisted (VSP) has become popular. In severe malocclusion, three-dimensional imaging has become standard of care There are many deficiencies with this technique including the inability to address facial asymmetries and the diffusion of landmarks because of structures overlapping on radiographs.

81. Stereo-photogrammetry (3dMD TM ) Stereo-photogrammetry is a technique for obtaining highly accurate 3D surface images. It can capture the object (a patient’s face) in ~1.5 milliseconds to generate a highly precise digital 3D model of the human anatomy.

82. Greatest advantage is that of its noninvasive nature and secondly very short (~1.5 millisecond) capture speed which is virtually instantaneous and especially suited for imaging young restless children. The images offer possibilities of analysis and landmark on patient’s surface data. It is easy to calculate and compare a number of parameters such as linear, angular and complex surface distances, ratio, areas, volumes, etc.

83. There are numerous programmes available for the analyses and prediction of orthognathic treatment: • OPAL image version 2.2 • Dolphin imaging 10 • Dentofacial Planner 8.05 • Quick Ceph Image • Computer assisted simulation system for Orthognathic surgery (CASSOS)

84. Basic deformities and Surgical Treatment Principles

85. The basic deformities of Facial System are : Mandibular anteroposterior deficiency, (2) Mandibular anteroposterior excess, (3) Maxillary anteroposterior deficiency, 4) M axillary anteroposterior excess, (5) Maxillary vertical deficiency, (6) Maxillary vertical excess, (7) C ases requiring rotation of the maxillomandibular complex,

86. Cases Requiring 15mm of Retraction, or 10mm of Protraction of Upper Incisor as per Envelope of discrepancy Cases requiring > 20mm of Retraction or >10mm of protraction of Lower Incisors as per the Envelope of discrepancy Anteropsterior Discrepancy

87. Example:- Severe Class II, Anteroposterior Maxillary Excess: Mandibular anteroposterior deficiency, Combination

88. Surgical correction CLASS II: The clinician should carefully differentiate between maxillary anteroposterior excess and mandibular anteroposterior deficiency An anterior segmental osteotomy of the maxilla is often performed as part of a multisegment Le Fort I procedure because patients who need anterior maxillary correction often need additional corrections to the maxilla ( eg , superior repositioning and/or expansion of the posterior maxilla). Maxillary setback procedures are seldom indicated. The clinician contemplating such a procedure should consider the esthetic effects carefully before making a final decision

89. The surgical technique of choice is the b ilateral sagittal split ramus osteotomy , which advances the distal (tooth-bearing) segment to maximum dental intercuspation . The position of the maxillary and mandibular incisors controls both the amount the mandible can be advanced as well as the facial height after surgery. The chin may still appear deficient after advancement of the mandible, and an advancement genioplasty may be indicated to improve final esthetics . The clinician makes this decision according to the presurgical visual treatment objective.

90. Severe Class III cases Maxillary anteroposterior deficiency Mandibular anteroposterior excess, Combination

91. Surgical treatment FOR CLAS III The maxilla is advanced by means of a Le Fort I osteotomy. This versatile procedure enables the surgeon to correct discrepancies in the anteroposterior , vertical, and transverse planes. Some cases with chin prominence may require genioplasty also to achieve pleasant profile.

92. Transverse discrepancy Cases Requiring >7mm of Expansion or >3mm of Lingual movement of the Maxillary Molars as per Envelope of discrepancy

93. Example: Severe Cross-bite cases due to Transverse Jaw discrepancy or TMJ disorders out of the scope of Expansion appliances or Functional Therapy leading to Various signs of: Functional disturbances or occlusal trauma, and Esthetic Concerns and Facial asymmetries in severe cases.

94. Vertical discrepancies: Vertical maxillary excess Vertical maxillary deficiency Clockwise rotation of mandible Cases Requiring > 6mm of upper incisor intrusion and >6mm of lower incisor intrusion or 7mm of Molar extrusion and Cases requiring >6mm of Lower incisor extrusion or 7-10mm of Upper Incisor Extrusion

95. The combination of the following characteristics may be considered diagnostic for vertical maxillary excess: Increased mandibular plane and occlusal plane angle Increased interlabial gap Increased incisor exposure under the upper lip Increased total anterior facial height Decreased percentage contribution of upper facial height to total facial height

96. Surgical treatment FOR VERTICAL ,MAXILLARY EXCESS : To correct the vertical discrepancy, the maxilla must be superiorly repositioned by a Le Fort I osteotomy. Two critical elements must be considered in the final treatment planning: How far must the maxilla be superiorly repositioned? After straight vertical repositioning of the maxilla, where will the mandible be?

97. The amount of superior repositioning is critical because moving the maxilla too far superiorly is more detrimental to facial esthetics than leaving the vertical excess uncorrected. Patients with short upper lips show more teeth than patients with long upper lips. Younger patients tolerate ( esthetically and psychologically) more upward movement of the maxilla than do older patient and the upper lip will lengthen with age.

98. Large movements, if not controlled, may lead to widening of the alar base of the nose and tipping up of the nasal tip. Because both effects are controllable, take them into consideration in treatment planning and surgical technique. The mandible will autorotate counterclockwise around a point at the condyle. As a consequence, the mandibular incisors will rotate forward (more so in patients with a high occlusal plane angle).

99. Rotation of the Maxillomandibular Complex : Surgical repositioning of the maxilla, either anteriorly or posteriorly will also take place along the existing occlusal plane. However, whereas superior repositioning of the maxilla will cause the mandible to rotate counterclockwise , inferior repositioning of the maxilla will result in a clockwise rotation of the mandible. .

100. To achieve occlusal contact, the maxilla must be aligned along a “ new” occlusal plane , which is determined by the extent of the autorotation of the mandible Hence, it is the position assumed by the mandible that dictates the final anteroposterior cant of the occlusal plane

101. Maxillary Vertical Deficiency Maxillary vertical deficiency is very often associated with maxillary anteroposterior deficiency, in which the maxilla does not develop in a forward and downward direction. Because overclosure of the mandible makes patients with maxillary vertical deficiency appear clinically similar to those with mandibular anteroposterior excess, the clinician should differentiate between the two deformities.

102. Surgical Treatmen t The surgical treatment objective for patients with maxillary vertical deficiency is to reposition the maxilla forward and downward. The mandible will rotate clockwise, and the vertical height of the face will increase.

103. Two jaw surgery Two-jaw surgery may be indicated in patients with severe Class II/III malocclusion. Here the orthodontist should adopt the “two-patient” concept, in which the mandibular and maxillary arches are treated independently, almost as if they belong to two different patients; however, the two arches should still be compatible.

104. The objective is to align the maxillary and mandibular incisors in both vertical and anteroposterior planes of space, so the surgeon can achieve optimal skeletal and esthetic correction without the limitations of dental interference.

105. Surgical splints Surgical splints can be used in orthognathic surgery, following orthodontic-surgical symbiosis. These splints are used to monitor the maxillomandibular region and three-dimensional intraoperative movements. Designed with occlusal relationship in final position.

106. The use of these splints is conventionally based on findings from a clinico -radiological analysis and preparation by the dental technician using tools like maxillomandibular occlusion waxes and articulator

107. Software and technological tools are now available and reasonably-priced so that it is much easier to develop computer-assisted surgical procedures. The goal is to fabricate splints for maxillomandibular repositioning by printing three-dimensionally from a 3D or cone-beam craniofacial scan of the patient. ( Bachelet J.T., Cliet J.Y., Chauvel -Picard J., Bouletreau P. Observations on the role of surgical splints in orthognathic surgery J Dentofacial Anom Orthod 2016;19:207)

108. The creation of a virtual splint reproducing the corrected relative position of the maxillary and mandibular arches; Three-dimensional printing of the splint on a 3D printer using biocompatible material like PGA (Poly Glycolic Acid). ( Bachelet J.T., Cliet J.Y., Chauvel -Picard J., Bouletreau P. Observations on the role of surgical splints in orthognathic surgery J Dentofacial Anom Orthod 2016;19:207)

109. CONCLUSION: The combined approach of surgical and orthodontic intervention has made possible the correction of certain maxillomandibular deformities and malocclusions not amenable to treatment by surgical or orthodontic means alone . Dental casts, full-face and profile photographs, full-mouth radiographs, or a panoramic radiograph, as well as a cephalometric analysis are all essential for a proper diagnosis. Recent diagnostic aids such as Digital Cepahlometry , CBCT, Stereophtogrammetry , 3-D Models, Visual surgical Planning has made the diagnosis and treatment planning for various Orthognathic cases convenient. It is possible to explain the surgical outcomes to the patient with the help of advanced methods of simulations (VSP)

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114. THANK YOU GOD!!!HEAL THE WORLD