3. Introduction
Malocclusion can be due to many possible
reasons but they can be treated by:-
1. Modification of growth
2. Orthodontic camouflage which produces a
dental compensation for the skeletal
compensation.
3. Surgical repositioning of the jaws and/or
dentoalveolar segments
The term orthognathic originates from the words
orthos and gnathos (Gr. orthos = straight;
gnathos = jaw). Orthognathic surgery refers to
surgical procedures designed to correct jaw
deformities.
4. HISTORY
Hullihen is regarded as the first surgeon to
describe a mandibular orthognathic surgical
procedure. In 1849, he reported an anterior
subapical osteotomy.
Jaboulay and Berard (1898), Kostecka (1931)
performed operations on condylar neck and
upper part of ramus by closed blind approach.
Surgical treatment for mandibular prognathism
started in early 19th century.
In 1959, Trauner and obwegeser introduced
sagittal split osteotomy as the beginning of a new
era of orthognathic surgery.
5. American surgeons modify the technique for
maxillary surgery that has been developed in
europe
Epker, bell and wolford developed lefort-1
maxillary downward fracture ,so that we can keep
the maxilla stable in all 3 planes of spaces.
By 1980 progress has reached such an extent to
reposition either or both the jaws to move chin in
all 3 planes of spaces.
Rigid internal fixation made it possible for comfort
and better immobilization was achieved.
6. Envelope of discrepancy
Envelope of discrepancy shows how much of
change can be produced by various treatment
modalities.
3 5 25
2
5
15
5101
2
4
6
10
7 12 15
2
5
15
2510
4
6
10
7. INDICATIONS
Severe skeletal class II &class III cases
Skeletal open bite and deep bite cases
Deep over bite in non growing individuals
Extreme vertical excess or deficiency in maxilla or
mandible
Severe dentoalveolar problem
Extemely compromised periodontal situation
Skeletal asymmetry
9. There is no use of using a single diagnostic tool
to implicate appropriate treatment as edward
angle once hoped
Untill recently, hard tissues of the facial skeleton
were the focus of diagnosis and treatment
planning
It is now clear that the soft tissues are the
limiting factor in the changes that can be
produced in treatment and obtaining appropriate
soft tissue proportions is the primary goal of
treatment
10. Patient evaluation
Patient concerns or chief complaints,
Clinical examination,
Radiographic imaging and analysis,
Dental model analysis.
11. PATIENT’S CONCERNS
What are your concerns or problems?/what do you think is wrong
Have you had previous treatment for this condition,
and what was the outcome?
Why do you want treatment?
What do you expect from treatment?
12. History taking
Personal information
Chief complaint - Motivation questionnaires
Medical history
Dental and orthodontic history
Pre-surgical growth assessment
16. The ideal face in both
males and females is
vertically divided into
equal thirds by
horizontal lines at the
hairline, the nasal base,
and the menton
18. Fronto temporal point (
0.65 )
Zygion ( 0.75 )
Gonion ( 0.66 )
19. 6 – 8 yrs of age
Symmetry of canthi
Eyelids – ptosis, entropion, ectropion
Sclera, ocular imbalance
Scleral show – mid facial defieciency
Eyelid laxity – snap test
20. NOSE
Both males & females show more growth in
vertical ht than anteroposterior projection of nose
but downward growth is greater in males
Form and symmetry
Location of deformity
Alar base width (34 + / - 4 mm)
A dorsal hump in the nose
develops when class I & II malocclusion
is present & is more pronounced in boys
21.
22. • Alar width / nasion to
pronasale
= 3/5
• Cheek prominence
• 8 – 12 mm laterally
• 10 – 20 mm inferior to
lateral canthus
•Ears
• Upper 1/3rds just above
the canthal level.
24. Lips
Width of lips equal to
interpupillary distance
If asymmetry exists
- Cleft lip
- Facial nerve
dysfunction
- Dental skeletal
deformity
Gull wing upper lip
has to be
differentiated from
vertical maxillary
Normal patient 3 3 3 3 3 3
Vertical maxillary
excess
6 6 6 6 6 6
Gull wing deformity 2 4 6 6 4 2
25. LIPS
The height of center part of upper lip trails behind the
vertical height of the lower face in childhood & then
catches up during & after adolescence.
Lip incompetence is common in children
What looks like incompetent lips in childhood or early
adolescence is merely a reflection of incomplete soft
tissue growth
Lip height
Females :
Upper lip - till 14
Lower lip - continues to grow up to the age of 16
Males : growth of both upper & lower lip continues
into late teens
26. Lip thickness is maximum during the conclusion
of adolescent growth spurt & then decreases
during late teens.
27. Smile evaluation
A balanced smile is achieved by appropriately positioning the teeth and gingiva in
the area that is displayed by lip animation during smiling (dynamic display zone).
The amount of incisor and gingival display
The transverse dimension / broadness of the smile
The smile arc
Buccal corridor
Negetive space
28. Incisor and gingival display
The difference between social and enjoyment smile is not
the activity of orbicularis oris musculature but of orbicularis
29. Chin
Tapered / squarish
Pinch test – semiquantitative assessment of
subcutaneous fat
Sub platysmal and supra platysmal fat -
differentiated
30. PROFILE VIEW
Fore head
Slopes anteriorly
Accentuated at supra orbital rim
Frontal bossing
Supra orbital hypoplasia
Glabellar angle
Gl- N to N – prs
132 + / - 15 degrees
31. Soft tissue proportions: profile
view.
The prominent part of the forehead (glabella)
should be approximately the same as the base of
the nose, and the forehead should slope gently
posteriorly.
The radix (the depth of the concavity at the base of
the forehead) should be prominent to obscure the
eyelash on the opposite side.
Lateral orbital rims – 8 to12 mm
behind the anterior projection of globe.
Infra orbital rim – 2mm anterior
to the globe.
33. The contour of the alae
from the base of the
nose to its tip should be
well defined to form a
"scroll".
The bridge of the nose
(nasal dorsum) should
then be a straight line
from the base of the
radix to the nasal tip
cartilage, and there
should be a slight
prominence of the tip
relative to the bridge.
34. Naso labial angle – 90 to 110
degrees
2
• Alar base has to be supported by
skeletal nasal bone.
• Nasal bridge – 5 – 8 mm ant to
globes
• Nasal tip ( prn ) – subnasale :
subnasale – alar base crease = 2:1
• If values of 1: 1 – maxillary
defeciency
36. Labiomental fold
The labiomental sulcus should form a shallow S
curve, with the upper and lower portions similarly
shaped. The prominence of the chin should be
slightly less than the prominence of the lower lip.
The angle between the lower lip, chin, and
deepest point along the chin-neck contour should
be approximately 90 degrees
37. Cervico mental area
Mandibular angle- Inferior border defenition
- well defined in profile
- skin laxity, cervical facial lipomatosis, high
mandibular plane angle are conditions – obscure
the defenition.
Neck – chin angle and length
- normally 110 degrees
- PoG – neck chin angle : distance is 50 mm.
38. TMJ Examination
• The range of movements
• Deviation from normal movements
• Any pain during movement
• The joint sounds.
39. Intra-oral examination
Soft tissues
General periodontal condition
Tongue size, position and activity
Mentalis muscle activity
Finger or thumb sucking
Hard tissue
Dental assessment
40. Periodontal evaluation
Adequate attached gingiva
Maintain bone around the necks of each of the teeth
at the interdental osteotomy sites
53. Ar- PTM :
The greater the distance
between Ar-PTM, the
more the mandible will
lie posterior to the
maxilla, assuming that
all other facial
dimensions are normal.
Therefore, one factor for
prognathism or
retrognathism can be
evaluated by this
measurement of cranial
base.
54. HORIZONTAL SKELETAL
PROFILE
N-A –Pg (Angle):
gives an indication of
the overall facial
convexity. A positive
(+) angle of convexity
denotes a convex
face; a negative (-)
angle denotes a
concave face.
56. VERTICAL SKELETAL AND
DENTAL
Middle third facial height :
Distance from N to ANS
Posterior maxillary height :
PNS-N
Lower third facial height :
ANS – GN
Divergence of mandible
posteriorly : M.P-H.P
angle(clockwise or counter -
clockwise rotations of the
maxilla and mandible)
57. U1 to NF: Anterior
maxillary dental height
L1 to MP: Anterior
mandibular dental
height
These two
measurements define
how far the incisors
have erupted in relation
to NF and MP
respectively.
58. Max. molar to NF :
Posterior maxillary
dental height
Mand. Molar to MP:
Post mandibular
dental height
59. MAX-MAND. RELATION
ANS-PNS: This
measurement along
with the N-ANS and
PNS– N gives a
quantitative
description of the
maxilla in the skull
complex.
60. Ar - Go : Length of
Mandibular ramus
Go - Pg : Length of
Mandibular body
Ar - Go - Gn Angle :
Gonial angle that
represents the
relationship between
ramal plane and MP.
Vertical /Horizontal growth
B - Pg : Distance from B
point to line perpendicular
to MP through Pg
describes chin
prominence.
61. DENTAL
OP- upper HP:
AB – OP:
U1 to NF angle & L1
to MP angle: These
angulations determine
the procumbency or
recumbency of the
incisors.
85. The first horizontal plane connects the medial aspects
of the zygomaticofrontal sutures.
The second horizontal plane connects the center of
the zygomatic arches.
The third horizontal plane connects the jugal
processes.
A fourth horizontal plane runs through the menton and
is parallel to the first plane.
Grummons article JCO 1987
90. Errors in cephalometric measurements
Radiographic cephalometry is a two dimensional
representation of three dimensional object.
a)Radiographic projection error
Magnification
Distortion
b)Errors within measuring system
c)Errors in landmark identification
Quality of radiographic image
Precision of landmark definition
Reproducibility of landmark location
The operator and registration procedure
91. Limitations of cephalometric radiographic
analysis
1)Growth pattern not taken into consideration
2)Mean values are based on different
population
3)Two dimensional representation of three
dimensional object
4)Form and functions not taken into
consideration
92. A combination of various cephalometric
norms and variables should be compiled
to arrive at a proper diagnosis.Although
innumerable controversies exist in the
field of cephalometrics, it is still a very
significant & effective diagnostic tool.
Conclusion:
93. Methods of model surgery:
Simple method.
Anatomically oriented model
surgery.
94. Anatomically oriented model surgery.
In complex cases, especially where multiple bimaxillary
movements are required, it is essential to use a more
refined technique such as the following variant of a
popular “North American method”
95. In this technique, in addition to the impressions
and sqash bite, a face-bow recording is taken.
1. The working models are anatomically trimmed
and articulated on the semi adjustable articulator
using the face-bow recording and then the
standard squash bite.
Technique:
96.
97. 2. Horizontal and vertical reference lines are drawn
on the mounting plaster to register the post-operative
position of each maxillary and mandibular segments
before surgery.
Two sets of parallel horizontal lines A/A and B/B are
drawn on the upper and lower models. These are
easily done by rotating the detached model with the
felt pen.The B lines should be
just clear of the apices
of the teeth, and not
less than 15mm from
the A lines. These
lines will be used to
plan the vertical
98. 3. Three vertical lines VC,
VB, VM are drawn from
upper base line (A) to the
lower baseline (A) on each
buccal segment.
These will help to indicate
the anteroposterior
movements achieved by the
model surgery.
Upper and lower midlines
are also drawn.
Marked models with the
recorded distances.
99. 4. The vertical distances
from the buccal cusp tips of
the three reference teeth to
their A base lines are
recorded to help calculate
any vertical movements.
Transverse changes are
recorded by the inter-canine
and inter-molar distances
measured across the palate
and recorded by taking
reference points on the
canine tips and the
Cuspal reference points
are used for transverse
100. When all the reference
lines have been drawn
and the measurements
completed, the
osteotomy lines are
drawn between A and B
lines to correspond with
the bone cuts.
The plaster mounting
assembly is then
sectioned at the
osteotomy sites with a
saw or large abrasive
disc and the whole arch
or segments are
Interrupted line is the
proposed osteotomy site.
101. Maxilla is reassembled with the wax after the
osteotomy cuts. Mandible closes in to the intermediate
occusal relationship.
Intermediate wafer is made at this stage.
102. Lower segmental set-down of 3mm is carried out with
the forward slide of 5mm to correct the interarch
occlusal relationship.
103. Anterior view: models showing the upper midline
split to widen the intercanine width and the lower
anterior set-down.