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Oral Board Flashcards > Orthognathic Surgery > Flashcards

Orthognathic Surgery Flashcards

1
Q

Describe your initial work-up for orthognathic surgery.

A

Full patient history and physical

Patient subjective evaluation:
Chief complaint, goals of treatment, history of treatment/ortho

Patient objective evaluation:
Previous medical history, medications, allergies, surgical history, social history, review of systems.

Patient clinical examination:
Full facial examination of horizontal thirds, vertical fifths, profile, 3/4 view, intraoral exam (crossbite, class, tooth show rest/animation). Extraoral/intraoral pictures

Radiographic Examination:
Lateral Ceph, PA Ceph, periapical, CBCT

Position tracing

Model analysis (stone vs digital)

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2
Q

Describe your evaluation of facial thirds.

A

Upper third- hairline to glabella
Male eyebrows horizontal level with supraorbital rim, female peak 10 mm above supraorbital rim
Supraorbital rim projects 10mm in front of cornea

Middle third- glabella to subnasale
Intercanthal distance approximates alar base
Lateral orbital rim is 8-12mm behind cornea
zygomatic projection 10-15 mm lateral and 15-20 mm inferior to lateral canthus

Lower third- subnasale to menton
split 1/3 maxillary to 2/3 mandibular
Lip width- distance from R/L commissure equals interpupillary distance

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3
Q

What are other components of profile evaluation?

A

-Facial thirds
-Evaluation of midlines
-tooth-lip display
-interpupillary distance
Facial fifths (alar base width)
-Smile esthetics

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4
Q

Describe smile esthetics (and average numbers)

A

-Incisor at rest: 2.5mm (1-4mm)
-Incisor smiling: No more than 2 mm gingival exposure (slightly more allowed in females)
-Length of upper lip: Consider interlabial gap, upper lip length will increase with age, will have less incisor show with age (average clinical crown 9-12mm)
-Maxillary cant
-Treat to rest, not smile esthetics to avoid overimpaction of the maxilla

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5
Q

Describe the different profile evaluations.

A

-Dolichocephalic: Long headed
-Mesocephalic: moderate headed
-Brachycephalic: Broad and short headed
-Flat, concave, or convex (glabella, subnasale, pogonion)

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6
Q

Describe average angles in your clinical profile examination.

A

-Frontonasal angle (varies by ethnic group): 125-135
-Nasolabial angle: 85-104 (F>M)
-Lip-chin-throat angle: 110 +/- 5
-Labiomental angle: 120 +/- 10

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7
Q

Describe average lengths in your clinical evaluation

A

-Chin-throat length: 42+6 mm
-Upper lip length: 20-22 +2 mm (M>F)
-Interlabial gap: 0-4 mm lips in repose and in occlusoin

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8
Q

Describe your intraoral examination.

A

-Condition of dentition
-Midlines
-Arch form
-Occlusion in CR (canine/molar angle, OJ, OB, dental/skeletal transverse discrepancy, crowding)

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9
Q

What are the goals of presurgical orthodontics?

A

-Arch alignment and coordination
-Teeth over basal bone
-Leveling-perform as much as possible pre-op
-Ortho movements are extrusive, can cause open bites
-Each mm of curve of spee needs 1.25 mm of arch space or may affect proclination

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10
Q

What is a diagnosis where pre-surgical orthodontics change and how does it change?

A

Class II deep bite/short face
-Tripod the occlusion
-Postop posterior vertical oriented elastics
-Goal is to lengthen facial height

Large vertical steps
-Maintain steps via segment
-Correct with segmental surgery

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11
Q

How is the arch analyzed?

A

Diagnostic models show crowding/spacing

Bolton analysis compares tooth width to arch length

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12
Q

What are the options to increase arch space?

A

-Widen arch with SARPE: >10 mm deficiency after palatal suture has closed. Must overexpand
-Procline incisors
-Interproximal reduction
-Extract premolars: 1st premolars (maximum anterior retraction, gains most space). 2nd premolars requires anchorage, mostly posterior movement

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13
Q

What are the limitations to cephalometric analysis?

A

-Limitations due to basis upon cranial base landmarks. Steiner uses SNA angle with basis that most cranial bases are similar

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14
Q

What are the average measurements in a Steiner analysis?

A

SNA: 82
SNB: 80
ANB: 3
UI-SN (upper incisor to SN): 102-104
LI-MP (lower incisor to MP): 90-95

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15
Q

How is the timing of surgery determined?

A

-Secondary sex characteristics (menarche, shaving, voice change, shoe size change)
-Serial Ceph (6 months apart)
-Hand wrist films
-C-spine (most accurate): 6 stages, mandible growing most stages 3-4, more concavity as maturity continued
-Bone scans (tech 99)

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16
Q

What situations can early surgery be completed?

A

Class II deep bite with deep curve of spee (prevent intrusion of mandibular incisors by orthodontic leveling of curve of spee and shortening of lower face

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17
Q

When should surgery be delayed?

A

Class III, VME w/ open bite

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18
Q

How is model surgery completed?

A

Single jaw- Galetti is adequate as opposing arch is stable reference

Double jaw- Semi-adjustable hinge axis articulator. Need erickson model table, intermediate splint, final splint

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19
Q

What are the ortho requirements prior to surgery?

A

Passive wire, rectangular wire with soldered surgical hooks

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20
Q

Describe your technique for a Sagittal split ramus osteotomy

A

-Incision along external oblique ridge. Raise a full thickness mucoperiosteal flap along body of the mandible. J stripper along inferior border of the mandible. Notched ramus, continuing exposure of the mandibular ramus up to the maxillary mucogingival margin. Careful dissection along medial aspect of ramus above the inferior alveolar nerve. (check with nerve hook, curette to sigmoid notch)
-Horizontal osteotomy that parallels occlusal plane into retrolingual fossa
-Sagittal cut
-Vertical cut to inferior border of mandible
-All cuts through cortex into marrow
-Continue/check cugs with spatula osteotome
-Make sure all areas are moving (smith spreader, inferior border spreader)
-Key problem areas are medial cut/inferior border
-Complete osteotomy
-Strip where needed along distal segment
-Splint and IMF
-Reduce interferences
-Fixate with screws (positional screws, L configuration, no post-op IMF needed)
-Release IMF and check occlusion
-Close

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21
Q

What do you do if you have a buccal plate fracture?

A

-Small superior fracture: stop and reconfirm cuts

-Low buccal plate fracture: can be salvaged by completing split and plating to proximal segment

-High posterior plate fracture: difficult to salvage, may require posterior vertical body osteotomy

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22
Q

What are possible copmlications/solutions during a BSSO?

A

-Buccal plate fracture
-Nerve in proximal segment (cut too medial)
-Medial cut too high/deep (condylectomy, confirm with curette)
-Not seating condyle during fixation (contralateral open bite upon release of IMF)
-Late condylar resorption (poorly understood, more likely in females with class II steep occlusal plane, more than 4 mm advancement with CCW. Treat w/ synovectomy to remove inflammation but may require joint replacement)

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23
Q

What are the advantages/disadvantages of an intraoral vertical ramus osteotomy?

A

Advantages: Fast procedure, no hardware, decreased risk to IAN, good for rotational asymmetries

Disadvantages: IMF required, possibility of condylar sag, difficulty applying rigid fixation, decreased bony contact, not good for open bites

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24
Q

Describe the technique for an intraoral vertical ramus osteotomy.

A

-Ramus exposing incision
-Strip lateral ramus
-Place retractor in sigmoid notch, inferior border
-Bicortical osteotomy with oscillating saw
-Lateralize proximal segment
-IMF
-Close
-IMF x4 weeks

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25
Q

What are complications of an intraoral vertical ramus osteotomy?

A

-Bleeding (high in notch masseteric artery, ramus inferior alveolar
-Proximal segment too small (subcondylar fx)
-Cut too far forward (may include coronoid and need to perform coronectomy)
-Cut too ffar forward in ramus (transect IAN)

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26
Q

What is the technique for a genioplasty?

A

-Vestibular incision
-Identify mental nerve
-Midline and lateral reference marks
-Osteotomy 5 mm below tooth roots and mental nerve
-Complete osteotomy/downfracture
-Fixation (plate with bicortical screws)
-Layered closure (mentalis)

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27
Q

What are complications with a genioplasty?

A

-Bone resorption
-Paresthesia
-Lower lip ptosis (poor mentalis reapproximation)

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28
Q

What increases the risk of avascular necrosis in Lefort I?

A
  • More than 2 segments
  • Move >10 mm
  • Large transverse/expansion movements
  • Palatal mucosal tears
  • Smoking
  • Very lengthy surgery
  • Avoid palatal coverage splints
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29
Q

What is your technique for Lefort I?

A

-Circumvestibular incision 3-5 mm above mucogingival line to mesial 1st molar
-Expose maxilla (piriform, infraorbital foramina, zygomatic buttresses, pterygomaxillary fissure, nasal floor, caudal septum, lateral nasal wall)
-Horizontal cut
-Lateral nasal walls (DPA 34 mm from piriform rim)
-Nasal septum
-Pterygoid plates (chisel anterior, inferior, medial)
-Downfracture
-Mobilize maxilla (segment if necessary). Clip DPA if necessary
-Splint, IMF
-Remove interferences
-Plate (4 miniplates, 1.5 mm screws)
-Check occlusion
-Close (alar cinch, V-Y closure)

30
Q

What are complications with Lefort I?

A

-Bleeding
- Pterygoid muscles at posterior maxilla common cause: treat with surgicel or fibrin sealants
- Venous pterygoid venous plexus: treat with local and packing
-Arterial- Descending palatine, PSA, sphenopalatine artery. Treat with anterior and posterior nasal packs, vessel clip if possible. Consider embolization if uncontrolled

-Trigeminal cardiac reflex (hypotension/bradycardia possible asystole). Treat with stop stretching maxilla, atropine, ACLS if necessary

-Unable to mobilize maxilla: Usually in clefts, excessive palatal scarring or pharyngeal flap or due to perpendicular plate of palatine bone

-Improper maxillary position: Inadequate trimming of posterior maxilla (unable to seat condyle), deviated septum (failure to trim cartilage during impaction), chronic sinusitis (too much impaction blocking osteum)

-Avascular necrosis (less than 1%). Monitor, consider hyperbaric oxygen, possible debridement.

31
Q

What are the most stable orthognathic surgeries?

A

-Maxillary impaciton
-Mandibular advancement
-Genioplasty

32
Q

What are the stable orthognathic surgeries?

A

-Maxillary advancement
-Maxillary impaction/mandibular advancement
- Maxillary advancement/mandibular setback

33
Q

What are the less stable orthognathic surgeries?

A

-Isolated mandibular setback
-Maxillary downward repositioning
-Maxillary posterior widening

34
Q

What are the soft tissue changes seen in mandibular advancement?

A

-Increased neck chin definition
-Slight increase in lower third facial height
-Decrease in labio-mental fold

35
Q

What are the soft tissue changes seen in mandibular setback?

A

-Decreases chin prominence
-Shortens chin neck definition
-Decreases lower third facial height

36
Q

What are the soft tissue changes seen in a maxillary advancement?

A

-Widens alar base
-0.9:1 hard tissue:soft tissue change
-Incisor display ~0.6:1

37
Q

What are the soft tissue changes seen in maxillary impaction?

A

-Widen alar base
-Elevate nasal tip
-Decrease in nasolabial angle
-Reduces lower third facial height due to autorotation
-Increases chin prominence

38
Q

What are the soft tissue changes in maxillary downgraft?

A

-Loss of nasal tip support
-Downward repositioning of columella and alar base
-Increased nasolabial angle
-Lengthening and thinning of upper lip

39
Q

What are the extraction patterns for class 2 and class 3 patients?

A

Class 2: Extract upper 2nds and lower 1sts

Class 3: Extract upper 1sts and lower 2nds

40
Q

What is Holdaway ratio?

A

-Draw a line that crosses N and B
-Measure distance from NB to incisal edge of mandibular incisor and to Pog (AP direction)
-Ratio (incisal/Pog) is 1:1 in males and 0.5:1 in females

41
Q

Describe SARPE expansion

A

-Latency for 5-7 days, then can activate
-Can expand 0.5 mm/day (one 0.25 mm turn twice a day)
-Overexpand for relapse

42
Q

What are the best scenerios to complete a SSO, VRO, inverted L osteotomy

A

Sagittal split: Correction of deformities that affect the size, position, orientation and shape of mandible

Vertical ramus osteotomy: Correct mandibular prognathism

Inverted L osteotomy: Correct severe deformities that effect the size, position, orientation and shape of mandible

43
Q

Describe Vertical ramus osteotomy (why use, advantages/disadvantages, technique)

A

-Correct mandibular prognathism
-Advantage: IAN injury very rare, not associated with TMJ disc displacement/condylar degeneration
-Disadvantage: Requires MMF, possible condylar sag, can’t use for retrognathia, micrognathia, anterior open bite

-Expose ramus, inferior border of mandible. Complete vertical cut to sigmoid notch to angle of mandible behind mandibular foramen (masseteric artery 8 mm above sigmoid notch). Mobilize proximal segment laterally, minimal lateral pterygoid dissection to prevent condylar sagging. 6 weeks MMF

44
Q

Describe Inverted L osteotomy (why use, advantages/disadvantages, technique)

A

-Correct severe deformities (BSSO ~15 mm limit)
-Bone graft and extra-oral approach is required for advancement

-Expose ramus and inferior border of mandible. Horizontal cut: Above the lingula; from anterior border of the ramus to just behind mandibular foramen. Vertical from the posterior limit of the horizontal cut to the inferior border of mandible in front of angle. Plate with recon plate/bone graft if needed.

-Risks: Proximal segment fracture at corner of L. Similar risks as BSSO

45
Q

What is sleep apnea?

A

A syndrome characterized by repetitive upper airway collapse during sleep. These episodes can cause sleep fragmentation, hypoxemia, hypercapnia, impaired cognition

46
Q

How is sleep apnea diagnosed and what are common symptoms?

A

-Diagnosis: 5 or more obstructive events per hour and prescence of symptoms, fifteen or more events w/o symptoms

-Symptoms: Loud snoring, witnessed breathing interruptions, waking up unrefreshed, daytime sleepiness

47
Q

What are potential findings in a polysommography?

A

-Obstructive events: Apnea (interruption of breathing >10s). Hypopnea (50% decrease in nasal airflow with 3% decrease in oxygen, respiratory arousal)

-AHI: apnea-hypopnea index (add apneas and hypopneas per hour)
-RDI: respiratory disturbance index (apneas, hypopneas, RERA per hour)

-Oxygen saturation nadir (lowest oxygen sat)
-Total time of hypoxia

48
Q

What is your cephalometric evaluation on an OSA patient?

A

-Soft palate length (PNS to uvula tip 35 mm)
-Posterior airway space (Smallest AP distance between base of tongue and posterior pharyngeal wall 11 mm)
-Hyoid to mandibular plane distance (Ideal is less than 15 mm)

49
Q

Describe sleep endoscopy.

A

DISE: Drug induced sleep endoscopy

VOTE: Measures amount of collapse (0: no obstruction, 2: complete obstruction) velum, oropharynx, tongue, epiglottis

Lateral pharyngeal wall and concentric velum collapse best predictors of MMA

50
Q

What is the OSA classification system?

A

Fujita Classification

-Type I: Narrow oropharynx, large tonsils, uvula, and pillar webbing
-Type II: Oral and hypopharyngeal obstruction (retropalatal and retrolingual), low palate and large tongue
-Type III: Hypopharyngeal obstruction, retrognathia, floppy epiglottis

Most have a combined schedule

51
Q

How is OSA treated?

A

Medical: Behavior, weight loss, exercise, oral appliances, CPAP

Surgical: Bariatric surgery (morbid obesity), nasal surgery (helps with CPAP compliance), MMA

Tracheostomy: 100% curative

52
Q

What is the epidemiology of Cleft lip w/ or w/o palate

A

1:700

Ethnic:
Native American- 3.6:1000
Asians (Japanese): 2.1:1000
Asians (Chinese): 1.7 1000
Caucasians: 1:1000
African: 0.3:1000

46% of oral clefts are cleft lip w/ palate

Males>Females

Unilateral>Bilateral

L>R

10% associated with syndrome

53
Q

What syndromes are associated with cleft lip/palate?

A

Van der Woude syndrome
Treacher Collins
Down syndrome
Fetal Alcohol Syndrome
Oro-facial Digital Syndrome

54
Q

What are the percentages of clefts are cleft lip only, CL/P vs cleft palate only

A

Cleft lip with palate: 46%
Cleft palate only: 33%
Cleft lip only: 21%

55
Q

What genes play a role in CL/P?

A

3-14 genes

-Nonsyndromic on 1, 2, 4, 6, 11, 14, 17, 19
-Nonsyndromic: IRF6 and MSX-1
-Syndromic: TBX22, FGFR1, P63

56
Q

What is epidemiology of cleft palate only?

A

1:2000

-Genetically different than CL/P

-Female>Male
-50% associated with syndrome

57
Q

What syndromes are associated with cleft palate only?

A

-Pierre Robin Sequence (may require mandibular DO)
-Stickler’s syndrome (hearing loss, retinal detachment)
-Velo-Cario-Facial syndrome (Chromosome 22), cardiac anomalies

58
Q

What gene associated with Cleft palate only?

A

TGF-B3

59
Q

What are factors that contribute to etiology of clefts?

A

-Smoking
-Folic acid deficiency in periconception period
-Exposure to alcohol, retinoids, anticonvulsants, corticosteroids
-First releative 3.3% CL/P 2% isolated CP (suggest genetic counseling)
-Risk of 2nd child with cleft 2-5%
-After 2 children affected, risk increases to 9-12%

60
Q

What is the embryology of a CL/P?

A

Any failure of the fusion of the lateral nasal and median maxillary process at 6 weeks gestation

-Controlled by FGF, SHH (sonic hedgehog), BMP, TGF-B

-Bilateral maxillary palatal shelves ascend and fuse to form primary palate at 8-12th week

61
Q

What are the CL/P classification systems?

A

-Veau classification
Group 1: Soft palate cleft
Group 2: Cleft of the hard and soft palate up to the incisive foramen
Group 3: Complete unilateral cleft and palate
Group 4: Complete bilateral cleft lip and palate

Kernahan’s striped-Y classification

62
Q

Who are the memebers of the craniofacial team?

A

OMS, ENT, Plastics, Pediatric dentistry, Orthodontist, Speech pathologist, geneticist, audiologist, social worker, psychologist, pediatrician

63
Q

What is the management sequence of a CL/P patient?

A

-Dentofacial orthopedics: at first few weeks of life if needed (taping or splint)

-Lip adhesion: before definitive lip repair, may not be done due to scarring (for wide clefts)

-Cleft lip repair (Nasolabial repair): Done at 10-12 weeks (10 weeks age, 10 g/dL hemoglobin, 10 lb)

-Cleft palate repair: 9-18 months (before progression of natural speech)

-Correction of Velopharyngeal insufficiency: 18-24 months with pharyngeal flap

-Nasolabial Revision: 3-5 years once nasal growth is completed if needed

-Phase I Ortho: Before alveolar grafting, minimal maxillary expansion, don’t rotate teeth into cleft

-Alveolar grafting: 8-12 years: When canine root is 1/2 to 1/3 formed and not fallen into cleft

-Phase II ortho: Permanent dentition

-Orthognathic surgery: After completion of growth, correct maxillary hypoplasia

-Rhinoplasty: 6-12 months after orthognathic surgery

64
Q

How is a unilateral cleft lip repaired?

A

Millard rotational-advancement (modified Z-plasty)

-Goal is to create 3 layered closure of skin, muscle and mucosa that approximates normal tissue and excises hypoplastic tissue at cleft margins
-Obicularis oris muscle is adapted to form a continuous sphincter
-Incision lines fall within natural contours of the lip and nose on closure to promote natural symmetry
-Columella can be lengthened

65
Q

How is a bilateral cleft lip repaired?

A

-Very difficult due to lack of quality tissue, shortened columella and rotation of premaxillary segment
-Short term result are good but worsen overtime due to progression of natural growth process
-Goal is to reconstruct the nasal floor, obicularis oris muscle, central red lip and vestibule

66
Q

How is a cleft palate repaired?

A

-Water tight closure of the entire communication of the hard and soft palate
-Anatomic repair of the musculature of the soft palate which is crucial for the creation of normal speech
-Attempt to release abnormal muscle insertions of the tensor and levator palatini and uvularis muscles to ultimately have them rejoin at the midline and insert at the posterior edge of the hard palate
-Repair is usually between 9-18 months to correlate with development of speech
-Repair before 9 months associated with greater incidence of severe growth restriction

-Mobilize multilayered flaps to close defect created due to failed fusion of palatal shelves.
-Nasal mucosa is closed
-Reconstruction of levator and tensor palatini muscles with removal of aberrant insertions along hard palate and reconstructed to join at midline
-Velopharyngeal mechanism are reconstructed to allow soft palate to close the space between the nasopharynx and oropharynx to create certain sounds
-Closure of oral mucosa

67
Q

What are the types of palatal reconstruction?

A

Bardach: Creation of 2 full thickness flaps containing palatal neurovascular bundle which is in each pedicle, flaps brought to midline

Von Lagenbeck: Similar to Bardach, but preserves anterior pedicle, long lateral releasing incisions made at border of the palatal and alveolar bone to allow mobilization

Furlow: Double opposing Z-plasty one on oral mucosa and one in reverse orientation on nasal mucosa, can lengthen palate

68
Q

How is an alveolar cleft repaired?

A

-Sulcular incision made on buccal site of the cleft with horizontal extension superior to the mucogingival junction and carried posteriorly to tuberosity

-Incision on the palatal side of the cleft with sharp dissection used to separate palatal mucosa from the nasal mucosa

-Nasal mucosa reflected from the bony walls of the cleft
-Nasal mucosa closed in water tight manner
-Palatal mucosa closed

-Bone packed in site to reconstitute maxilla

-Releasing incisions made in posterior to allow for full advancement, periosteum scored
-Labial flaps advanced and closed over graft site in tension free manner

-Treat openings post-op conservatively with gentle debridement of loose particles of graft and irrigation. Don’t try to re-close

69
Q

Describe Velopharyngeal Insufficiency management.

A

-Diagnosis: Formal eval by speech pathologist, direct visualization using nasopharyngoscopy or videofluoroscopy

-Goal is to improve hypernasality and speech intelligibilitu

-Re-repair of the palate (lengthen palate or reconstruct levator veli palatini)

-Superiorly based pharyngeal flap: Standard approach to repair, high success rate but may contribute to OSA, hyponasality, difficulty advancing maxilla

-Sphincter pharyngoplasty: Creates single port, increases scarring along tonsillar pillars

-Palatal augmentation: Unpredictable outcomes

70
Q
A

Oral Board Flashcards (9 decks)

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