orthognathic surgery Flashcards
pt C/O for orthognathic surgery
don’t like their appearance and/or functional deficit
psychologist role in orthognathic team
Psychological assessment of patients requesting orthognathic surgery and the relevance of body dysmorphic disorder
- Early recognition of psychological problems (Dysmorphophobia & Neurosis)
- Understand real motivation for surgery
- Postsurgical depression
- Psychological adaptation to the new face
dentist should have brief understanding of the psychological state of pt
how
- What is the patient’s mental state?
Medical history
* previous psychiatric problems
* existing disorders (anxiety & depression sleeping patterns, eating habits)
* shortness of breath, abdominal pain, nausea
If you are in doubt ..psychological consultation
body dysmorphic disorder
Pt requesting for non-existing deformity
* Preoccupation with a defect in appearance, minor defect and excessive concern
* Preoccupation leads to significant distress
* Associated mental disorders (anorexia nervosa)
Characteristics:
* obsession with exaggerated defect,
* doctor shopping
team members for orthognathic surgery
7
- Psychology
- Orthodontist
- Surgical
- Technologist
- Restorative
- Speech and language therapist
- Hygienist
teachnologist role in orthognathic surgery
4
- Model surgery planning
- Provide occlusal wafer to guide the surgery
- Building 3D skull models
- Digital Prediction of final occlusion
orthodontist role in orthognathic surgery
3
- Early recognition of dentofacial deformities
- Orthodontic preparations before and after surgery
- Follow up
importance of dx and tx planning for orthognathic surgery
The correct dx
The combined orthodontic and surgical approaches 90% of time (coordinate)
* Prediction planning
Pt needs to like the face – cannot undo surgery
Surgical correction isn’t reversible
causes of facial deformities
3 categories
Family trait
racial characteristics
Congenital deformity (e.g. hemifacial microsomia, Treacher Colllins), trauma (could also be acromegaly if continued growth into adult)
history of pt should assess
cause of deformity
psychological motivation
dysmorphophobia
hypochonriacal neurosis
extra oral exam of pt for orthognathic surgery
Aesthetic proportions
Front
* Vertical asymmetry
* Lip and Nose morphology
* Horizontal asymmetry (Mediolateral)
Profile
Antero-posterior relationship
* Lips - Length, Competence, Muscle activity, Vermillion, Teeth rest/smiling (2mm at rest, full crown smile)
* Chin - Asymmetry, mentalis
front on EO assessment consists of
3
Vertical asymmetry
Lip and Nose morphology
Horizontal asymmetry (Mediolateral)
lips assessment EO
5
Length
Competence
Muscle activity
Vermillion
Teeth rest/smiling (2mm at rest, full crown smile)
chin assessment EO
2
asymmetry
mentalis
intra oral assessment for orthognathic surgery
10
- General dental assessment
- Occlusal relationship
- Central line discrepancy relative to the face
- The overjet (2-3mm) and overbite(3mm, cover 1/3 LI)
- Crossbite
- Occlusal canting tilt
- Incisors’ inclination
- Crowing and spacing
- Tongue size, mobility, speech pattern
- Cleft cases and velopharyngeal incompetence (hypernasal tone)
special investigations needed for orthognathic surgery
3
radiographs
study models (casts)
photographs (2D, 3D)
radiographs used for orthognathic surgery
3
OPT
* Impacted and unerupted teeth, pathology
* trabeculation pattern of the bone
Cephalographs
* Lateral ceph. to assess jaw bones in relation the base of the skull (tracing)
* PA ceph. to assess asymmetry vert. and lat.
Periapicals
* Occlusal
* CT scanning
how to make study models for orthognathic surgery needs
4 steps
impressions
face bow
wax bite
articulator mounted
use of study models for orthognathic surgery
7
- Study occlusion
- Orthodontic analysis
- Orthognathic surgery planning
- Model surgery – move how you want to move pt
- Occlusal wafer for surgery – guide surgeon
- Assess surgical changes
- Assess long-term stability/relapse
5 photos types needed for orthognathic surgery pt
- 2D full face at rest and smiling
- Right and left profiles
- Teeth in occlusion (anterior and posterior)
- 1:1 profile photograph (photo. Montage)
- 3D imaging for 3D soft tissue analysis following surgery – prediction planning, can get pt opinion
possible dx that require orthognathic surgery
3 categories, 8 options
Maxilla abnormality
* Prognathic or retrognathic (hypoplasia)
* Vertical excess or vertical deficiency
* Narrow or wide maxilla
* Asymmetry
Mandible abnormality
* Prognathic or retrognathic
* Asymmetry
Chin
* Progenia or retrogenia
* Vertical deficiency/excess
can be any combination of these
maxilla abnormalities that need orthognathic surgery
4
Prognathic or retrognathic (hypoplasia)
Vertical excess or vertical deficiency
Narrow or wide maxilla
Asymmetry
mandibular abnormalities that need orthognathic surgery
2
Prognathic or retrognathic
Asymmetry
chin abnromalities that need orthognathic surgery
2
progenia or retrogenia
vertical deficiency/excess
what 3 facial areas can be abnromal to require orthognathic surgery
maxilla
manidble
chin
or combo
pt options if they have an abnormality in maxilla/mandible/chin
4
Orthodontic treatment only
Combined ortho/surgical treatment majority - majority of cases
Surgical treatment only
do nothing
what does combined ortho/srugical tx entail
6 possible stages
- Tooth alignment, eliminating crowding, spaces, and cross bite
- Alteration and co-ordination of the arches
- Correction of incisors’ inclination (de-compensation)
- Flattening the occlusal plane
- Surgical fixation
- Postsurgical orthodontic fine tuning
surgical procedures for maxilla
2 classes
le Fort I osteotomy
* superior (too long need to move up),
* inferior (deficient and no tooth show so bring down),
* forward (deficient and behind mandible)
Anterior maxillary osteotomy
* posterior - cannot just move back like mandible due pterygoid plates
surgical procedures for mandible
2
Advancement
**Sagittal split osteotomy **- ramus split from body so mandible can move forward/upward/downward/right/left
Set-back
sagittal split osteotomy,VSSO
surgical options for chin
genioplasty - advancement, set-back, rotation
what is used for orthognathic surgeries
usually combination of anatomical abnormalities
so Augmentation and reduction (mix of all the surgical techniques)
Set in place with plates in screws
4 adv of surgery first approach
followed by ortho
- Reduction of the duration of the treatment
- Faster orthodontic tooth movement
- Immediate improvement in facial appearances
- Cost effectiveness
describe tx carried out here
Le fort I maxillary osteotomy fixed in place with 4 plates
Sagittal split osteotomy fixed in place with 2 plates
Genioplasty with 1 plate
No wires needed
