Surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
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Contents:
Introduction
Historical aspect
Envelop of discrepancy
Recognition of deformity
Systemic evaluation of patient
Pre surgical orthodontics
Cephalometric evaluation
Prediction tracing
Mock surgery
Post surgical orthodontic management

"Beauty lies in the eyes of beholder" .
Margaret Hungerford.

Physically

attractive

people

are

generally

thought to be more Friendly, sensitive and
successful than others considering the face. As
a primary means of identification and a source
of non-verbal information, the psychological and
social implication of facial disfigurement should
not be underestimated.

Before advent of surgical procedures to correct
deficiencies of maxilla the only way the
orthodontists could treat patients presenting
with vertical maxillary excess was by dental
camouflaging the skeletal problems.


The term orthognathic surgery was coined by
Hullihen in 1849.
David Sarver will deserve much of the credit
for bringing about the computer simulations.
Previously cephalometric predictions of
treatment outcome were necessary, but
nowadays, computer imaging changed the
very focus of orthodontic and orthognathic
treatment.


A) Origin of surgical procedures
B) Pre/post surgical orthodontics


Of the current surgical techniques for
repositioning the facial bones, many were
pioneered in Europe to treat trauma and
gunshot wounds during 1st and 2nd world war
and to lesser extent in United States.


Rene Le Fort in 1901 noted that the midface
consistently sustained fractures at sites of weakness .
Edward Angle in 1901 Commented on the patient who
had treatment of this type, described how the result
could have been improved .
Van Eiselberg and Pehr Gadd in 1906 , were the first to
conceive the idea of surgically correcting a retruded
mandible by means of a step shaped osteotomy in the
body of mandible.

In

1907 Blair introduced the first ascending

ramus technique .
Limberg in 1928 modified Pehr Gadd's step
shaped sliding osteotomy operation by inserting
a pedunculated rib graft in surgically created
bony defect.


Wassmund in 1935 introduced a technique for
retruding the : anterior maxillary alveolus and
six anterior teeth.
Kazanjian in 1936 modified Blair's basic design
by performing an oblique sliding osteotomy.


Dingman performed an osteotomy in two stages.
First under local anesthesia and second under
general anesthesia and found that non-union and
parasthesia are common complications
Caldwell in 1954 adapted his vertical osteotomy
technique for correction of prognathism to the
correction of micrognathism.
Erich in1958 believed that retrognathism is best
corrected by means of overlay prosthesis on the
lower anterior teeth.

Trauner and Obwegeser introduced sagittal split
osteotomy in 1959 and it marked the beginning of
new era in orthognathic surgery. This technique
used an intraoral approach, which avoided the
necessity of potentially disfiguring skin incision.
Kole in 1959 introduced corticotomy as a surgical
adjunct to orthodontic therapy. Although the
foundations for present day procedures were laid
in Europe, the development and refinement of
orthognathic surgery occurred in United States.

PRE

AND

POST

SURGICAL

HISTORICAL

ASPECT:
William Bell

in 1966 discussed different

methods of orthodontic surgical correction of
mandibular retrognathism.
Peter B. Mills in 1969 discussed the role of
orthodontists in surgical correction of dentofacial
deformities.

Bell, Thomas and Creekmore in 1973 stated
that the goal of surgical orthodontic treatment of
mandibular prognathism is to correct the
malocclusion of the teeth and restore facial
balance and harmony.
Epker and Fish in 1978 stated that pre-surgical
orthodontics should be directed towards
removing the existing dental compensations.

Dale B. Wade in1980 used modules for
intermaxillary fixation. It was developed to help
the orthodontists prepare his patient for surgery
and provide the surgeon with the stable fixation
need for proper healing.


Legan, Hill and Sinn in 1981 discussed role of
orthodontist

in

diagnosis

and

treatment

planning in dentofacial deformity cases.
He suggested that the pre-surgical orthodontic
treatment carried out for them included leveling
of

mandibular

mandibular
rotations

occlusal

anterior
and

plane,

teeth,

angulation

coordination of arches.


upright

correct
problems

the

minor
and

Joe Jacobs in 1983 stated the principles of
orthodontic mechanics in orthognathic surgery.
Flanary, Barnwell and Alexander in 1985
investigated the pre-surgical concerns and
motivations, preoperative preparation for
surgery and perception of post surgical
outcome.


Fish and Epkar in 1987 discussed the prevention
of relapse after maxillary advancement. Suggested
that Post surgical orthodontics include, prevention
of relapse during inter-maxillary fixation where
surgical occlusal splint with bilateral infra-orbital
suspension wires attached.


ENVELOPE OF DISCREPANCY
The limits of correcting a malocclusion vary both
by the tooth movement that would be needed and
by the patient's age as quoted by William R.
proffit.


There are 3 possibilities of treatment;
Tooth movement by orthodontic treatment.
Tooth

movement

by

orthodontic

combined with growth modifications.
By orthognathic surgery.


treatment

The first envelope shows the amount of change
that could produced by orthodontic tooth
movement alone.
Second envelope of discrepancy indicates the
changes in the teeth movement can be achieved
orthodontically along with growth modification.
Third envelope shows, the changes can be
achieved by orthognathic surgery.

According to V. Mani (1995) the deformities
are classified as;
Maxillary prognathism - Skeletal
Dentoalveolar
]sMaxillary retrognathism- Skeletal
Dentoalveolar


Maxillary vertical deformity-Excess
Deficient
Maxillary transverse deformity-Broad
Narrow
 Mandibular prognathism- Skeletal
Dentoalveolar

ChinExcessive-Vertical,
Horizontal
Recessive-Horizontal
Vertical
Deep bite deformity

Open bite deformity or Apartognathia

Asymmetry


Maxillary deformity:

Epkar and Fish: Quoted that the deformities of
maxilla are of several types. The deformities are
either in the basal bone or in dentoalveolar
segment. The most common deformity encountered
can be horizontal, vertical or combined. The
deformity can be associated with deep bite or open
bite.


Schendel S.A. Quoted that in vertical excess, the
exposure of the upper anterior teeth is more than
3 mm in response 2) the upper lip may be short
or normal 3) the length of lower third of face is
more than the middle third of face.
Open bite can also occur as a result of deformity
in anterior or posterior region


Mandibular deformity: Mandibular deformity can
be present anywhere from the condyle to chin.
Ankylosis of TMJ jeopardize the mandibular
growth. Unilateral ankylosis causes hemi facial
deformity with the midline shifted to the affected
side.
Mandibular prognathism is mainly due to
horizontal excess. Of the body of the mandible as
quoted by Opdebeeck H and Bell W.H.

Chin deformity: The chin can be either recessive
or

excessive,

vertically

or

measurements are as follows
1) Facial axis
2) Facial depth angle


horizontally

The

Epkar and Fish Quoted that certain
examinations are necessary to evaluate the
individual with dentofacial deformities and to
plan treatment. These are;
A) General patient evaluation:
1) Medical history
2) Dental evaluation
a. Dental history
b. Dental health
B) Social psycologic evaluation

C) Esthetic facial evaluation
1. Front face analysis
2. Profile analysis
D) Cephalometric evaluation
1) Soft tissue
2)Skeletal
3) Dental


E) Panoramic
evaluation

or

full

mouth

F) Occlusal evaluation
1.     Functional
2.     Static
G) Masticatory and TMJ evaluation
   Masticatory muscles
Mandibular movements
TMJ symptoms
TMJ signs


periapical

Esthetic

facial

evaluation

(front

face):

The

esthetic facial evaluation is done directly on
patient, with the patient standing or seated
comfortably. The patient maintains head posture
with the Frankfort horizontal and interpupillary
lines parallel to the floor.


FRONT FACE ANALYSIS:
General facial characteristics:
David Sarver (1998) quoted that symmetry, balance
and morphology are important in production of good
front face esthetics.
A) Symmetry: No face is perfectly symmetric. The
absence of obvious asymmetry is necessary for good
esthetics.


Balance: The total face height is defined by the
distance from points trichion (Tr) to gnathion (Gn)
and divided into facial thirds by points glabella
(G) and Gnathion(Gn) . The upper, middle and
lower facial thirds may be defined as the distance
from trichion to glabella, glabella

to Subnasal

and Sub nasal to gnathion respectively. In normal
attractive person the ratio of these thirds is 0.30,
0.35 and 0.35 respectively.

Morphology : The morphology of any face is
determined by the distance between the points
fronto-temporale (Ft) - the slight elevation of the
linear temporalis on either side of forehead. The
width of middle third of face is defined by the
distance between the points zygion (Zy) - the most
lateral point of zygomatic arch.
The distance between gonion (Go) bilaterally
determines the width of the lower third of face.

Upper Third Face: Hairline to eyebrows (Tr-G)
It is affected by the hairline and hair style.
Morphology : It is quantified by calculating the
ratio of bitemporal width'(Ft-Ft) to the height of
the upper third face (Tr-G) the ratio in an
attractive individual is 2.20.


MIDDLE THIRD FACE: Morphology is quantified
by calculating the ratio of bi-zygomatic width (ZyZy) to the height of the middle third face (G-Sn).
The ratio in attractive individual is 2.20.
Eyes

and

orbits:

Examination

begins

with

measurement of intercanthal and interpupillary
distances.
Vertical symmetry of inner and outer canthi is
recorded.

NOSE: When deformity exists, then glabella,
dorsum tip and alar bases are noted.
CHEEK: includes sequential assessment of the
malar eminence, infraorbital rims and paranasal
areas for symmetry.
EARS : The ears are observed for symmetry level
and projection.


Lower Third Face: Subnasal to menton:
Morphology is quantified by calculating the ratio of
bigonial width (Go-Go) to the height of the lower
facial third(Sn-Gn). Normal ratio is1.3.
LIPS: Lips are important in overall esthetics of
face. At rest, the symmetry of lips relative to the
face and dentition is noted.
TEETH : Symmetry is single most important factor
in producing an esthetic smile. It includes the
symmetry of both lip movement and tooth
exposure.


CHIN : Often the chin may be more tapered or
square. Chin is evaluated for symmetry, vertical
relations and morphology and its relationship to
the mandibular angles and inferior border of
mandible.
Sub Mental and Neck Area:This is examined by
having the examiners and patients head at the
same level looking directly into one another's
eyes and check for any asymmetry.

PROFILE ANALYSIS: Overall facial profile is

evaluated in sagittal and vertical planes. It is
carried out in upper middle and lower third of face.
1) Upper third face: The projection of supraorbital rims is evaluated as they relate to globe.
They project 5-10 mm beyond the most anterior
projection of globe. Distinction is made between
frontal bossing and supra-orbital hypoplasia.
The glabellar angle is evaluated. This angle is
formed by the intersection of the lines glabella nasion and nasion - pronasale. Normal angle is
132 +- 5deg.This angle is judged as excessive,
normal or deficient.

Middle third face:
Eyes: The lateral orbital rim normally lies 8 to
12 mm behind the most anterior projection of
the globe while infra-orbital rim is normally 0
to 2 mm anterior to globe.
NOSE: The nasal bridge projects 5-8 mm
anteriorly to the globes. The nasal dorsum is
described as normal, convex and concave in
appearance. Differentiation is made between
the dorsal hump and down turned nasal tip.
Nasolabial angle is assessed.Normal 90-110°.

Lower third of face:
Lips: The protrusion or retrusion of the upper lip
is described as it relates to subnasal perpendicular
an

imaginary

line

through

subnasal

and

perpendicular to Frankfort horizontal. The most
prominent portion of the vermilion of the upper lip
should lie not more than 2 mm ahead or behind
the subnasale perpendicular.
Normally upper lip projects slightly (2 mm) anterior
to the lower lip.


CHIN PROJECTION: It relates to the nose and
subnasal perpendicular in the middle third face
and lips in the lower third face. It should lie 2 - 6
mm behind an imaginary subnasale perpendicular
line

assuming

normal

nasal

and

maxillary

prominence.
Submental and neck area: It is subdivided into;
Mandibular angle
Neck chin angle
Neck chin length.


PRE SURGICAL ORTHODONTICS
INTRA ARCH OBJECTIVES
In the initial stages of treatment, orthognathic
and conventional orthodontic mechanics have
some similar objectives, like to position the teeth
ideally relative to their apical bases through
establishment of correct torque, proper elimination
of rotations, flatness of the plane of occlusion and
eliminating tooth- arch length discrepancies.

NOTE
Here that these procedures may temporarily
accentuate the malocclusion, where
demonstrating the true magnitude of the Skeletal
problem.


Intra-arch mechanics in orthognathic cases
should be designed to achieve the ultimately
desired post surgical interdigitation and allow for
establishment of class I canine and molar
relationship after surgical treatment.
If extractions are necessary to accomplish the
desired objectives, then extraction sites should be
closed unless segmentalizcd surgical closure is
planned.
Even procedures like interdental enamel reduction
must be concluded prior to surgery.

SKELETAL

CLASS

compensations
mandibular

II

include

incisor

and

cases,
very
upright

dental

protrusive
maxillary

incisor.
SKELETAL CLASS III. Mandibular incisors are
often found

to be retroclined while maxillary

incisors are commonly flared forwards.


A patient with a class III skeletal malocclusion
may

have

dental

compensations

including

retroclined mandibular incisors and proclined
maxillary

incisors.

In

class

II,

division

2,malocclusion with a typical retroclination of
maxillary anterior teeth .
Likewise a patient with these malalignment will
respond to class II elastics for class III patients
class III elastics for class II patients before
surgery.

SEQUENCING OF ORTHODONTIC MECHANICS
PRIOR TO SURGERY:
1) Orthognathic surgery should not be performed
until the adolescent growth spurt is completed .
2) Surgical correction of maxillary and
mandibular deficiency and correction of vertical
maxillary excess can be carried out with a good
prognosis in most patients who are in their midteens.


3) However the initiation of orthodontic
treatment

often

helps

patients

tolerate

dentofacial deformity during their teen years
even if surgery is some time in the future. The
orthodontic appliance serves as a visible
symbol that the dentofacial correction is
being treated.


WHY EDGEWISE IS A CHOSEN APPLIANCE
FOR SURGICAL ORTHODONTICS ??
Fixed appliance used to stabilize the teeth and
the bone, at the time of surgery and during
healing.
Therefore, the appliance system must permit use
of

rectangular wire so as to achieve adequate

strength and stability.

Extraction pattern:
Camouflage: Extraction spaces are used for dental
compensations. For example - Mandibular deficiency with
class II malocclusion
1)    Extract upper 1 st premolar.
2)     Avoid extraction in the lower arch.
If surgery of mandibular advancement is planned for
above patients
1)   Extractions in the lower arch.
Only leveling and aligning in upper arch and if necessary
II premolars.

In classIII
CAMOUFLAGE:
Extractions of lower 1st premolar , Upper if
required the 2nd premolar
SURGERY:
Extractions

of

upper

1

st

premolar

necessary 2nd premolar in lower arch.

and

If

SEQUENCING

OF

OTHER

DENTAL

TREATMENT:
Dental and periodontal disease correction must
be considered prior to orthodontic surgical
correction has begun.


THREE MAIN CONSIDERATIONS:
Gingival grafting should be completed before
surgery, if attached gingiva is inadequate.
Removal of 3rd molars is desirable if the
surgeon anticipates using bone screws or rigid
fixation.
Patient with temperomandibular joint dysfunction
should be made aware that TMJ problem might
recur even after the surgical treatment.

Steps in orthodontic preparation:
1) Leveling of the maxillary and mandibular
arch.
2) Establishment of incisor position.


STABILIZING ARCH WIRES:
As presurgical phase is over, doing a model
surgery

is

a

must

to

check

for

occlusal

compatibility.
2nd molars banded to increase fixation stability.
Stabilizing arch wires is placed 6 weeks before
surgery so that they are passive when impression
is taken for surgical splint.

STABILIZING WIRES ARE;
1) 17 x 25 steel in 18-slot appliance.
2) 19 x 25 steel or TMA in 22-slot appliance.
Full slot withstands the forces resulting from
intermaxillary fixation.


BEFORE EVERY SURGICAL PROCEDURE:
1) Mark on the chart that he/she is a surgical
patient.
2)

VTO

clearly

illustrated

on

the

chart

determining.
a) Presurgical goals (anterior retraction, extraction
pattern etc.)
b) Anchorage requirements.
3. Step by step chart written for reference

RIGID FIXATION
In this the jaw movement post surgically is in
the anterior direction.
Splint causes retraction of upper anterior teeth
and flaring of the lower incisor.
Overcorrection

is

desired

orthodontics.


in

presurgical

CLASSII DIVISION 1
NORMAL OVERBITE:

DEFORMITY

WITH

Outline of treatment:
Presurgical
1. Consider extraction usually with 15, 25, 34
and 44.
2. Place lower appliances, utility arch and begin
lower canine retraction.
3. Place upper appliances, align and level,
begin upper Molar advancement.

4. Placement of class III elastics as necessary
5. Finish lower canine retraction.
6. Retract lower incisors.
7. Upper space closure.
8. Coordinate arches.
9. Impression to determine feasibility of
surgery.

DETAILS OF TREATMENT:
1)     Mark on the chart in a very conspicuous
manner that he/she is indicated for surgery.
2)     VTO are clearly illustrated on the chart,
which is determined through the prediction
tracing, which notes the presurgical goals and
anchorage requirements.
3)     Finally a step-by-step plan is written on the
chart
for
reference.
This is common for all presurgical cases. Here
the main goal is to place the teeth in their
normal relation to their respective basal bones.

Our main objective in this case is to remove dental
Compensations to the existing skeletal deformity that is
1) Up righting lower incisors.
2) Advancing upper molars Thus increasing the severity
of class II occlusion.
Note:
1)   Magnitude of class II should be same on either side.
2)   Dental midline should coincide with midline of face
to avoid the production of an asymmetric chin when
mandible is advanced.
3)   Consider extractions if necessary.

Leveling, aligning and arch coordination are
done before surgery by standard approaches
Generally class II division 1 patient require
extraction usually 15,25 and 34,44 so that we
can get the maxillary molars in to more class II
and mandibular incisor can be retracted to get
them upright.
Discussing the case the lower arch is
strapped up first after adequate separation

Stabilizing utility = 16 x 16 arch wire with a labial root
torque for incisors but without molar tip back used for
Incisor intrusion.
Elastic thread may be useful for correction of
rotations or in beginning the actual retraction of canine
teeth.
Now the appliance is placed in the upper arch.
Leveling and aligning of upper arch with 16 x
22multistranded stainless steel wire.
At this time lower sectionals are placed with retraction
sectionals.
Upper arch following aligning and leveling 16 x 22 boot
hook arch is placed and depending on anchorage
requirements the patient is instructed to wear class III
elastics.

In this case use of lingual class III elastics can be
done to prevent rotation of upper molar and lower
canine while space closure continues on the
buccal side.

Note: Upper second molar is not banded before
the complete space closure has occurred because
this allows efficient mesial movement of the 1 at
molar.


2nd molar may be banded only for leveling and
aligning and rotation correction. Once the lower
extraction space is closed, an ideal buccal
sectional is placed to begin the necessary root
paralleling 16 x 16 wire followed by 16 x 22
wire.
At

this

point

we

can

take

a

progress

cephalogram to determine the effectiveness of
the mechanics.
With root paralleling effective incisors retraction

Generally a round wire is used when lower
incisors are to be tipped lingually. Use of boot
hook utility arch allows the use of class I or class
III elastics to produce the lower incisor retraction
depending

on

anchorage

requirements

as

determined by the progress cephalogram.
After lower retraction is complete 16 x 16 wire is
placed as coordinated with upper arch. By now
even the upper extraction site is closed and no

decision for 2nd molar banding is taken.

Final

presurgical

forms.placing

phase

continuous,

is

to

coordinate

coordinated

arch

the

arch

wires

of

increasing size until desired arch form is achieved.
After the clinician feels that coordination is achieved,
impressions are taken and feasibility model surgery is
performed.
Note: It is not necessary for all teeth to fit one another
perfectly. Rather it is important to produce an occlusion at
surgery that can be easily finished by routine orthodontic
treatment.

Primary goals to achieve:
     Class I molar and canine relationship with
significant transverse or vertical problems.
     Once these goals have been achieved the
patient is ready for surgery.
    The arch wires are now tied with ligatures
wire to prevent inadvertent disengagement of
the wires and the patient is referred for surgery.

If these goals cannot be achieved ??
Tooth mass discrepancy.
Lower incisor angulation.
Transverse discrepancy.
Decision to proceed with surgery is made by 0btaining
new progress models and performing feasibility model
surgery on them t0 determine its plausibility. Proceed
only if model surgery permits.

Orthodontic Surgical maxillary expansion followed by
mandibular advancement
When mandibular advancement

surgery is planned for

patient when a transverse discrepancy of 6 mm or more
exists, combined orthodontic surgical expansion of maxilla
is recommended as a part of the treatment plan.
The need for this is determined by observation after placing
the models into the desired antero-posterior position .
When

the

transverse

discrepancy

is

truly

skeletal,

combined orthodontic surgical expansion of maxilla is
indicated.

But however there are 3 things that we should
remember regarding the appliance used:
Appliance is ideally a fixed appliance.
Appliance must be capable of achieving the
desired amount of expansion without need for
refabrication.
Appliance is preferably tooth borne both to
allow surgical access and to avoid possible
palatal soft tissue necrosis.

Factors affecting stability of treatment:
Appliance construction and cementation:
    Tightly fitting bands and well did solder
joints.
    Bands well cemented.
    Tooth borne.


Appliance activation:
1) Appliance activated 5 to 6 mm at surgery to
check that equal mobilization of both sides of the
maxilla is occurring.
2) Regular activation as indicated must be done
to avoid excess tissue tearing of palatal and
alveolar mucoperiosteum which otherwise may
cause a resultant periodontal or gingival defect
between the maxillary central incisors which is
clinically seen as loss of interdental papilla.

Appliance stabilization:

Stabilized

minimum

for

8

weeks

after

completion of expansion .
It is preferable to maintain the appliance is place
until the midline diastema is closed by the active
post surgical orthodontics


Maintenance of arch width:
Arch wires placed following expansion must be
careful made to confirm to the desired arch
width.
Either expansion appliance or a TPA can be used
to assure that the maxillary arch width is
maintained.


Anterior
Maxillary
Osteotomy
Augmentation Genioplasty:

With

    Seldom used in treatment of class II
dentofacial deformity. Since results in poor
esthetic results.
   Used when patients has a good functional
posterior occlusion.
    Prominent upper lip and teeth with acute
NLA.
    Lower arch well aligned and in proper
anteroposterior position.
Recessive chin can be corrected with
augmentation genioplasty.

Must be emphasized that this orthodontic

surgical approach does not produce the same
result as would be achieved by similar isolated
orthodontic
orthodontically,

treatment,
only

the

upper

because
teeth

are

retracted, with surgery the bone and teeth both
are retracted.


Pre surgical orthodontic goal:
Decision of extraction is to be taken and
alignment of teeth. If the crowding is severe
then the premolars are extracted.
While in case of severe anterior crowding
they are extracted prior to the treatment begins
so that the teeth can be aligned without moving
them farther anteriorly.
The upper arch is treated segmentally without
using a continuous arch wire before surgery.


After the final wires have become passive,
impressions are made and feasibility surgery
done on models.
Note: It is imperative, particularly for the patient
with deep bite, that adequate space exists
between the teeth for the surgeon to complete
the interdental osteotomies without damage to
the adjacent teeth.


Anterior maxillary osteotomy is done in two
pieces if there is large midline diastema or when
there is a transverse discrepancy of the canine
teeth.

It

is

often

preferable

to

correct

a

transverse' discrepancy in the canine area
surgically because by doing so; we Can prevent
the risk of periodontal dehiscence over the
canine tooth root.

Factors affecting the
orthodontic treatment:

stability

of

the

Adequate preparation of segments:
Proper torque.
Proper tooth-to-tooth relationship to allow
them to fit precisely over the lower arch.
The angulation of the tooth adjacent to the
ostectomy site should be erect so that adequate
surgical access and bone removal is possible to
allow proper positioning of the segments at
surgery

Maintaining
Surgery:

Space

Closure

Effected

at

When ostectomy is done interdentally and the
teeth surgically moved together, it is imperative
that the orthodontist closes any remaining
spaces immediately on release of fixation by
ligating the teeth together and keeping the space
closed from that time until retention.
Elimination of tooth mass discrepancy.
Lower incisor position should be optimally
within acceptable limits relative to the A-PO line
to promote a stable result.

AGE RELATED FACTORS:
Age of patient has no effect on the stability of
the anterior maxillary osteotomy, and this
procedure can be done successfully. For any
patient when the maxillary teeth are fully
erupted.


CLASS II DIVISION 1 DEFORMITY WITH
DEEP BITE:
Usual approach is mandibular advancement.
routinely again the outline of our treatment
will be
1.Place the appliance
2.Level and align
3.Coordinate arches
4.Class III elastics as necessary

Determine feasibility of surgery
Methods of deep bite correction are;
1) Leveling the arches to the molar incisor
occlusal plane and opening the bite surgically
by clockwise rotation of the distal segment
during advancement of the mandible.
2) Leveling the arches by intrusion of the
incisors

with

subsequent

advancement of the mandible.

straight

forward

NOTE:
When the face is symmetric at the beginning
of the treatment, it is important that the
magnitude of the class II occlusion is equal on
both

sides

and

the

dental

midline

are

coincident with the midline of the face to avoid
the production of asymmetric chin when the
mandible is advanced

LEVELING TO THE MOLAR INCISOR
OCCLUSAL PLANE:
Here there is little concern for how leveling is
done.
With this method of treatment the biggest
problem encountered is tendency for lower incisor
to flare (due to small round flexible wires used for
aligning). Therefore almost without exception, the
patient needs to wear class III elastics.
Excessive flaring must be avoided because it
diminishes the amount of advancement possible.

LEVELING TO THE FUNCTIONAL OCCLUSAL
PLANE: In class II division 1 deformity the deep
bite is carried by an increased curve of spee in
the lower arch while upper arch curve of spee is
within normal limits.Thus lower arch will take a
longer time and thus is begun first. Appliance is
first placed on the lower posterior teeth (second
molar through first premolar) and these segments
are leveled to define the functional occlusal plane.

Appliance is then placed on the lower incisors
and a 16 x 22 utility arch is placed to begin
incisor intrusion. This utility arch must have a
labial root torque across the incisor section to
keep the incisor roots away from the lingual
cortical plate during intrusion and have tip
back bends sufficient to produce 50-100 gm of
intrusive force across the incisor section.

After the lower incisor are leveled with the
posterior segments, a continuous 16 x 22" arch
wire is placed.

This wire steps down at the

canine teeth but otherwise ideal in shape.


Once the canine is at the desired level the upper
and lower arches are coordinated class III elastics
are

worn

until

the

desired

antero-posterior

relationship is achieved.
Class III elastics are avoided till this phase of
treatment because they will elevate the functional
plane by decreasing the anterior intrusion if used
before this time.

FACTORS
AFFECTING
TREATMENT:

STABILITY

OF

4 factors as discussed earlier.
Note: Relapse is not common in deep bite cases.
Note that the decision as to precisely how to
level the curve of spee is best predicted on the
esthetic objectives, that is, whether the optimal
movement of the mandible is to achieve maximal
projection of the chin or conversely minimal
chin projection with maximally increased lower
face height.

A DOUBLE PROTRUSION CAN BE EASILY PRODUCED:
In a patient with deep bite, when the. Mandibular
advancement surgery involves clockwise rotation of the
distal segment of the mandible, in this the teeth are
advanced more than A-pogonion line. As such, it is easy
to produce a BIMAXILLARY protrusion that may adversely
affect both the facial esthetics and maintenance of lower
incisor alignment following the removal of retention
appliance. This can be avoided by retraction of the upper
and lower incisors or the addition of an augmentation
genioplasty.


MANDIBULAR
ADVANCEMENT
WITH
ANTERIOR
MANDIBULAR
SUBAPICAL
OSTECTOMY
1.When lower curve of spee is extreme.
2.Maximum
desired.

advancement

of

bony

chin

is

3.Increase in face height is avoided.
Most useful when either the orthodontic
mechanics to level the excessive curve of spee
are problematic or significant reduction in the
treatment time will result from leveling the
curve of spee surgically

Disadvantages
However note that this procedure negates the
possibility of simultaneous horizontal osteotomy
for augmentation genioplasty .
It

also

increases

the

risk

of

periodontal

problems. Thus it is not a substitute for the
routine orthodontic leveling of the curve of spee.


DETAILS OF THE TREATMENT:
The upper arch is dealt with as previously
discussed if extraction or surgical orthodontic
maxillary expansions are to be done. But lower
arch is dealt in a totally different manner. The
anatomy of the lower curve of spee is important.
There are two general types:


1) The dual plane curve, in which the molars
and the premolars are essentially on one plane
while canines and incisor are elevated.
2) The rainbow curve - curve is continuous
from molars through central incisors which are
the highest points on the curve. When the
rainbow curve exists; it must be first converted
into a dual plane curve by orthodontic
treatment before surgically leveling is possible.
This is so because the teeth within the
segment are not properly related to one

FACTORS AFFECTING STABILITY
1) Adequate
surgery

room

to

perform

the

indicated

2) Improper positioning
3) Injury to adjacent roots
4) Teeth properly related within the subapical
segment i.e., dual plane curve of spee must be
created.
5) Proper arch shape.

6) Immediate post-fixation orthodontic control. It
is important to tie the teeth together on either
side of an ostectomy (close any space that may
remain open after surgery as rapidly as possible
to minimize the reopening during retention).
7)Age related factors as discussed earlier


MANDIBULAR ADVANCEMENT WITH REDUCTION
GENIOPLASTY:
1) Patients having class II dentofacial deformity there
exists adequate (normal) projection of the chin while
mandibular dento-alveolus is retruded.
2) In this case mandibular advancement will result in
excessive protrusion of chin.
3) However, the most important factor in making this
decision is the actual magnitude of the discrepancy
between the lower incisors and pogonion positions.
4) When the antero-posterior discrepancy is less than
5mm, good esthetics can generally be achieved with
routine mandibular advancement and properly done
reduction genioplasty.

Presurgical orthodontic treatment:
1)    These patients generally have mandibular retrusion.
3)    Surgical posterior repositioning of pogonion line
makes it possible for the lower incisors to be placed in
their optimal position without excessive advancement.
4)    Prediction tracing must be done to determine the
specific orthodontic mechanics and need for extraction.
5)    Frequently this patient may have a class II division
2 malocclusion.


TOTAL MANDIBULAR SUBAPICAL ADVANCEMENT:
Difference approaching 10 mm, poorer esthetics results
are achieved with reduction genioplasty because when
major posterior movement are done by this approach,
the labiomental fold is eliminated and a permanent
increased fullness is created in the submental area.
This is large discrepancy existing between the lower
incisor and pogonion position, the total subapical
mandibular advancement becomes the treatment of
choice.
When there is need for aligning by anterior subapical
procedure and a reduction genioplasty but as we know
this sound very unpractical, therefore total mandibular
subapical advancement is to be considered.

PRESURGICAL ORTHODONTICS:
1)

Done

without

augmentation

mandibular dentoalveolus.
2) Rest all is the same.
3) Create a dual plane curve of spee.


of

the

CLASS II DIVISION 2 DEFORMITY:
OUTLINE OF TREATMENT:
PRESURGICAL ORTHODONTIC TREATMENT:
1. Non -extraction.
2. Place upper appliances.
a. Maxillary expansion if necessary
b. Torque and intrude upper central incisor
3. Place lower appliances align and level upper and lower
arches.
4. Co-ordinate arches while using class III elastics as
necessary.
5. Impression for feasibility model surgery.

PRESURGLCAL ORTHODONTIC TREATMENT:
1) Aim at producing a class II division 1 malocclusion
so that the mandible can be advanced i.e.. create a.
positive overjet by intruding, advancing and torquing of
upper central incisors.
2) But this has very little effect on the upper lip drape
and esthetics because initially there is a void between
the lip and central incisors, which are supported by
the lateral incisors.
3)Expansion may or may not be
accommodate the advanced mandible).
4) Align and level lower arch.
5) Preferred method for leveling arches.

required

(to

A) If increase LFH is desired: Pogonion is
prominent, lower level face is short. Then,
minimally intrude anterior and instead, extrude
posterior i.e., leveling to molar incisor occlusal
plane.
Therefore on surgery increase lower face height
but

minimally

increase

chin

Appliance only in upper arch.


prominence.

If increase LFH is not desired then
1) Sectional arch wires from 2nd molars to 1 st
premolar and 16 x 22 utility arch is placed with
labial root torque and 80-100 Gms of intrusive
force for incisors.
2) Once the incisors are leveled with the posterior
teeth, a continuous stabilizing arch wire is placed
with the wire stepping down at the canine and
elastic thread used to intrude the canine to the
level desired.
3) An ideal, continuous lower arch wire is placed.

CLASS II DIVISION 2 WITH INFERIOR
REPOSITIONING OF THE MAXILLA WITH
MANDIBULAR ADVANCEMENT:
BASIC CONDITIONS:
    Upper incisors are buried superiorly beneath the
upper lip and are perhaps not even visible upon smiling.
    Extreme reverse curve of spee exists in the maxillary
occlusal plane.
   A very short lower third face height.
    Patient requires an improvement in facial balance and
in upper tooth to lip esthetics.

Just level and align and coordinate the arches, as
surgery will place the maxilla correctly in both
vertical and antero-posterior position and
occlusion is corrected by advancing the mandible.
In transverse discrepancy maxilla can be
expanded or constricted at time of surgery.
Thus while doing this treatment our main concern
is:
    Tooth mass discrepancy.
     Torque of upper incisor.

     A-P position of the lower incisor.

MECHANICS:
1)    Appliances placed on the upper arch.
2)    Sectionals arch wires placed from molar to
1 st premolar (or 1 anteriorly to where reverse
curve begins).
3)     A Utility arch is placed on the anterior
teeth usually canine to canine, to torque and
advance them into proper antero-posteriorposition.
This utility arch will need to have extrusive force
on canine area to offset the intrusive effect
produced by the overly upright central incisors.

TPA may be given for better control.
Advancing utility may also be given.
Molar and premolars at that time are tied
together to prevent the spaces from opening up.
Once room is made for lower incisor bracket
the lower appliance is placed and leveling is
begun.
When lower curve of spee is biplanar or very
extreme, it may be leveled segmentally and
these segments leveled surgically by a lower
subapical procedure or body osteotomies when increased LFH desired.

FACTORS AFFECTING STABILITY:
When segmental surgery is done, several
unique situations occur and hence must be
understood.
1) Interdental surgical osteotomies and
ostectomies.
2) Proper relation of the teeth within these
segments.
3) Immediate post surgical orthodontic
control of these areas.

AS DISCUSSED EARLIER;
1) Enough room to do the proposed surgery.
2) Relation of the teeth- within the segments:
Surgically moved segments must fit well during
surgery.
3) Immediate post surgical orthodontic control
following release of fixation.
The teeth adjacent to the osteotomy to be
tightly ligated together to prevent the formation
of fibrous tissue in this area thus preventing
the spaces from opening up later on.

VERTICAL

MAXILLARY

EXCESS

WITHOUT

OPEN BITE:
Lefort I superior repositioning of the maxilla with
1.Place the appliances, align and level.
2.Coordinate arch forms.
3.Elastics as necessary to place lower incisors in
the proper antero-posterior position.

Details of treatment:
Presurgical orthodontics required.
Can have orthodontic appliances placed and
can immediately go for surgery.
Either single piece or a segmentalized procedure.
With

or

without

extraction

of

upper

1st

premolar.
Lower arch may need to be set up presurgically

The A-P and transverse positions of the lower
teeth at the time of surgery are critical because
they determine the upper tooth to lip relationship
both antero-posteriorly and symmetry.
Extraction decision in lower arch depends on the
prediction tracing.
Non-extraction - Both the arches are aligned and
leveled independently.
Class III elastic may be used if necessary.
Extractions - Mechanics is same, for maximal
retraction of
anterior.

TAKE CARE
   Lower midline must coincide with the facial
midline.
    Lower canines must be equal in their anteroposterior position (otherwise may lead to
asymmetry).
    Hence it is very important to correct the
mandibular asymmetry - (consider unilateral
extraction or elastic therapy) .


Arch

coordination

and

need

for

segmentalization.
Usually for people with vertical maxillary
excess - V- shaped maxillary arch and Ushaped mandibular arch.
Maxillary arch shape is best changed with
surgery and segmental mechanics are used.

FACTORS

AFFECTING

STABILITY

OF

TREATMENT:
INAPPROPRIATE VERTICAL MECHANICS :
Extrusion of anterior and intrusion of posterior
teeth" must be avoided.
Presurgical orthodontic expansion of maxilla is
contraindicated

SUPERIOR REPOSITIONING OF THE MAXILLA WITH
MANDIBULAR ADVANCEMENT:
IN MOST CLASSII
Vertical maxillary excess dentofacial deformities
maxillary superior repositioning is not sufficient to
correct class II occlusion by solely autorotation of the
mandible.
it may be necessary to reposition the maxilla both
superiorly and posteriorly. But when esthetics does not
permit posterior positioning of maxilla (an obtuse NLA,
recessive paranasal areas ) in this case superior or
supero-anterior
repositioning
of
maxilla
and
simultaneous
mandibular
advancement
may
be
indicated.

1) Primary emphasis on lower arch, because
if mandibular teeth are properly related to the
mandible, and maxilla positioned in relation to
them then the esthetic result will be good.
2) The general treatment sequence is same
as described earlier.
Note: No pre-surgical orthodontic maxillary
expansion is indicated best produced during
surgery.

FACTORS TO SUMMARIZE:
1. Avoid inappropriate
mechanics.

use

of

vertical

2. Maxillary expansion for adults is done
surgically.
3. Make occlusion more class II before surgery.
4. Properly managed tooth mass discrepancies
before surgery.
5. Adequately level both upper and lower
arches or segments.

CLASS II DEFORMITY WITH OPEN BITE:
Segmental total subapical superior maxillary
repositioning augmentation genioplasty.
OUTLINE OF TREATMENT:
1.Extract lower first premolars
2. Place lower appliance.
3. Retract lower canines

4. Begin lower incisor retraction, extract upper
1 st premolar
5. Place upper appliance; align and level
segmentally.
6. Ideal lower arch and ideal upper sectional
arches
7. Impressions for feasibility model surgery.

BASIC GOALS:
Symmetrically place the lower dentition in the
proper anteroposterior and transverse
position with respect to the mandible such that
when maxilla is surgically repositioned all the
teeth will be in
proper antero-posterior,
vertical and transverse relations.
Symmetry of lower arch is important because it
will dictate the symmetry of upper arch.
Any orthodontic procedures that tend to open
the bite need to be done presurgically like
molar uprighting, rotations.

Teeth are aligned so that no cross bites will
need to be corrected following surgery.
.Any mechanics that are expressly intended to
close the bite are avoided during the presurgical
orthodontic treatment.
Vertical

elastics,

high

pull

headgear

with

facebow, vertical pull headgear to a chin cup or
any other device used in an attempt to close the
w
bite is inadvisable.ww.indiandentalacademy.com

Actual treatment:
   Begin 1 at in lower arch.


superior

repositioning

of

maxilla

with

   Mostly extraction of upper and lower 1st
premolar is indicated.
Appliance placed in lower arch.


NOTE : Lower brackets are bonded 1 mm lower
than usual so that brackets do not interfere
with production of the desired overbite at time
of surgery
1) Lower arch - Maximal anchorage case usually
lingual arch is placed.
2) Stabilize utility arch with retraction sectional
arches to the lower canines are used.

When canines are excessively labial - it is often
helpful to have, the elastic thread tied to the
lingual arch to supply a lingual vector during
retraction and help the canines move out of the
labial cortical plate and minimize strain on
anchorage.
In critical anchorage cases banding of upper
arch is done earlier so it would be useful to use
of class III elastics to back up the lower
anchorage.

Once lower canines retracted, 16x22 sectional

arch wire are placed to upright the canines and
lower retraction is begun. Lingually tipping of
incisors as said earlier is done with a boot hook
utility arch made from 0.018 round wire and
intra-arch elastics traction.
Upper arch extraction.
Appliance is placed and segmental arch wires
are placed in the upper arch.

TPA for rotating and torquing the upper

molars.

Also

helps

stabilizing

surgically

produced expansion.
Sectional mechanics are used in the upper
arch to maintain the dual occlusal plane usually
found in class II open bite dentofacial deformity.


NOTE:
When upper canines are excessively constricted relative
to the lower canines and premolars then it is desirable
to split the anterior segment into 2 segments and
produce the desired canine expansion surgically,
widening both the teeth and bone (rather than risk
periodontal problems).
A potential problem faced is the insufficient space
through which to do the surgical ostectomies.
Orthodontist therefore must intentionally tip canine
root mesially and premolar root distally

CLASSIII DEFORMITIES
Mandibular prognathism
The usual orthodontic approach that we have is:
Mandibular setback or with simultaneous adjunctive
surgical procedures.
1) Reduction genioplasty:
A) Vertical reduction genioplasty: When the chin is
vertically Long, (i.e.., when the distance from the lower
lip to menton is excessive).
Note : In excessively long chin the reduction genioplasty
helps as much as the mandibular setback.

B) A-P, reduction genioplasty: When there is
excessive projection of pogonion (i.e.., increased
distance between point Band Pog).
C) Both vertical and A-P reduction genioplasty.


AUGMENTATION GENIOPLASTY: Class III
malocclusion and normal A-P chin position
and a normal neck chin angle and length.
Correction of malocclusion by a mandibular
setback

will

often

compromise

the

facial

esthetics by producing an unaesthetic chin,
one that is retrusive and lacks good neck chin
definition.


PARANASAL AUGMENTATIONS:
A) Class III malocclusion with narrow alar base
and some paranasal deficiency exists in profile.
B) Not indicated in major class III dentofacial
deformity (I.e., greater than 10-12 mm which
true

maxillary

deficiency

and

prognathism exist).

mandibular

Midsymphisis osteotomy or ostectomy:
In the class III prognathic dentofacial deformity it
is not unusual that occlusal

discrepancy exists

(i.e. posterior Crossbite) when teeth are positioned
into the proper class I relation. The actual
magnitude of this discrepancy is best determined
before beginning orthodontic treatment so that a
deliberate decision can be made regarding the
optimal method by which to correct it.

Options in the adult patients are ??
Orthodontically moving the upper posterior teeth
buccally and lower posterior teeth
lingually(less than5mm discrepancy) .
Combined orthodontic - surgical expansion of the
maxilla when the transverse discrepancy is greater
than 5mm.
Surgical

narrowing

of

the

mandibular

simultaneously with mandibular setback.

arch

When there exists both a significant anterior
tooth mass discrepancy (4mm or more) and a
minor transverse discrepancy (5mm or less), the
treatment of choice may be bilateral ramus
osteotomies to set the mandible back and a
lower midline body ostectomy with extraction of
a lower incisor to narrow the mandible an hold,
simultaneously correct the anterior tooth mass
discrepancy.
Helpful when transverse discrepancy is in
canine area.
. Eliminates the time consuming orthodontic
closure of the lower incisor extraction space
while increasing stability of the result.

MANDIBULAR BODY OSTECTOMIES:
Mandibular prognathism with an acceptable
class III posterior occlusion or one that can be
made

acceptable

by

routine

orthodontic

treatment. This most basically is a class III molar
occlusion without a cross bite.


There are two specific situations that may be
best treated by body ostectomies:
When posterior edentulous spaces exists then
body ostectomies may be done to. Close the
spaces or shorter the Span of the needed
prosthetic replacement.
Considerable linguoversion of the lower anterior
teeth and yet no crowding is present. In this
situation the dental compensations may be
eliminated by orthodontically opening spaces,
usually between the first premolars and the
canines

Orthodontic treatment objectives:
Proclination of lower incisors.
Retraction of upper incisors.
May be expansion of upper arches.
Few vertical consideration because upper and
lower arches are in level.


Extractions

may

be

considered

from

a

prediction tracing usually 14, 24, 35, 45.
Usually

a

non-extraction

approach

is

considered.
Expansion Transverse discrepancy more than
5 mm and age 18 years above - surgical
orthodontic expansion is considered.

Proclination of lower incisors ???
How to get the desired A-P positions ???
Minor problem encountered ???


Maxillary deficiency:
Usual

surgical

approach

is

maxillary

advancements .
Other option is
1) Inferior repositioning of the maxilla:
Class III dentofacial deformity with short lower
third face with maxillary incisors being vertically
located several mm above the upper lip line www.indiandentalacademy.com

vertical maxillary deficiency.

Overclosed appearance - short upper lip, acute
NLA and prominent chin. However in position of
rest of mandible - Upper lip normal in length,
NLA normal and chin is normal. Increased free
way space of 5-15 mm.
May

usually

appear

a

dentofacial deformity.
Treatment is similar.

secondary

cleft

True midface dentofacial deformity:
Those

individuals who exhibit

retrusion

or

hypoplasia of the midface without clinically
significant cranial vault deformities.
. Maxillary molar retrusion or deficiency.
.Maxillary nasal retrusion or deficiency.
.Maxillary molar - Nasal retrusion or deficiency

Cephalometry is an excellent tool for
quantifying, classifying and communicating
patient data.
It is useful as a treatment-planning tool through
the construction of prediction tracings to study
profile changes and to allow the planning of
extractions and orthodontic mechanics to meet
the treatment objectives.

The shape of the face depends mostly on the
basic

skeletal

analysis

is

architecture.

mandatory

for

Thus

skeletal

identifying

and

classifying any deformity. Innumerable analysis
has

been

proposed

to

study

the

skeletal

relations. Among them some are;
Burstone's analysis( cogs for both hard and soft
tissue)
Dipaolo's (quadrilateral analysis)
Grummons analysis

Cephalometrics for orthognathic surgery
. Charles J Burstone, DDS, MS; Randal B.
James, DDS; H. Legan, DDS; G. A. Murphy,
DDS; and Louis A. Norton, DMD,Farmington,
Conn


Successful treatment of the orthognathic surgical
patient is dependent on careful diagnosis.
Cephalometric analysis can be an aid in the diagnosis of
skeletal and dental problems and a tool for simulating
surgery and orthodontics by the use of acetate overlays.
Cephalometric analysis also allows the clinician to
evaluate changes after surgery.
The first step in the diagnosis of the orthognathic
surgical patient is to determine the nature of the dental
and skeletal defects

Patients who require orthognathic surgery usually have
facial bones as well as tooth positions that must be
modified by a combined orthodontic and surgical
treatment. For this reason, a specialized cephalometric
appraisal system, called Cephalometrics for Orthognathic
Surgery (COGS), was developed at the University of
Connecticut. This appraisal is based on a system of
cephalometric analysis that was developed at Indiana
University, with the addition of clinically significant new
measurements.

The COGS system describes the horizontal and
vertical position of facial bones by use of a constant
coordinate system; the sizes of bones are represented
by linear dimensions and their shapes, by angular
measurements.
The standards are based on a sample obtained from
the Child Research Council of university of Colorado
School of Medicine. Although the sample of 16 females
and 14 males is small, the mean measurement values
closely correspond with those of other northern
European populations.
This longitudinal sample was selected to ensure
consistent standards by age and rate of growth.

Cephalometric Analysis
Sella (S), the center of the pituitary fossa.
Nasion (N), the most anterior point of the nasofrontal
suture in the midsagittal plane
Articulare (Ar), the intersection of basisphenoid and
the posterior border of the condyle mandibularis.
Pterygomaxillary fissure (PTM), the most posterior
point on the anterior contour of the maxillary
tuberosity
Subspinale (A), the deepest point in the midsagittal
plane between the anterior nasal spine and prosthion,
usually around the level of and ante-rior to the apex
of the maxillary central incisors.-Pogonion (Pg), the
most anterior point in the midsagittal plane of the
contour of the chin www.indiandentalacademy.com

Supramentale (B), the deepest point in the midsagittal
plane between infradentale and Pg, usually anterior to
and slightly below the apices of the mandibular incisors.
Anterior nasal spine (ANS), the most anterior point of
the nasal floor; the tip of the premaxilla in the
midsagittal plane. -Menton (Me), the lowest point of the
contour of the mandibular symphysis
Gnathion (Gn), the midpoint between Pg and Me,
located by bisecting the facial line N-Pg and the
mandibular plane (lower border).
Posterior nasal spine (PNS), the most posterior point
on the contour of the palate.
Mandibular plane (MP), a plane constructed from Me to
the angle of the mandible (Go).
Nasal floor (NF), a plane constructed from PNS to ANS.
-Gonion (Go), located by bisecting the posterior
ramal plane and the www.indiandentalacademy.com
mandibular plane angle.

The baseline for comparison of most of the data in this
analysis is a constructed plane called the horizontal
plane (HP), which is a surrogate Frankfort plane,
constructed by drawing a line 7° from the line S to N.
Most measurements will be made from projections
either parallel to HP (11 HP) or perpendicular to HP ( 1
HP).


CRANIAL BASE
First, it is necessary to establish the length of the
cranial base, which is a measurement parallel to
HP from Ar to N. This measurement should not be
considered an absolute value but a skeletal
baseline to be correlated to other measurements,
such as maxillary and mandibular length, to
obtain a diagnosis of proportional dysplasia.


Ar-pterygomaxillary fissure (Ar-PTM) is
measured parallel to HP to determine the
horizontal distance between the posterior
aspects of the mandible and maxilla. 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 causal factor for
prognathism or retrognathism can be evaluated
by this measurement of the cranial base.

HORIZONTAL SKELETAL PROFILE
A few simple measurements should be made on the skeletal
profile to assess the amount of disharmony. We call this
the horizontal skeletal profile analysis because all the
measurements are made parallel to HP. This is very
practical because most surgical corrections. primarily made
in the anteroposterior direction.
The first measurement quantitatively describes
the degree of skeletal convexity in the patient. The angle
of skeletal facial convexity is measured by the angle formed
by the line N-A and a line A to Pg. The N-A-Pg (angle) gives
an indication of the overall facial convexity, but not a
specific diagnosis of which is at fault -the maxilla or
mandible

A perpendicular line from HP is dropped through N and
the inferior anatomic point is horizontally measured in
relation to the superior structures
The horizontal position of A is measured to this
perpendicular line (N-A). This measurement describes the
apical base of the maxilla in relation to N and enables the
clinician to determine if the anterior part of the maxilla is
protrusive or retrusive.
The measurement and related measurements are
important in the planning of treatment of anterior
maxillary horizontal advancement or reduction, and of
total maxillary horizontal advancement or reduction.
Point B and PG[ pogonion ] are measured in the same
way.


VERTICAL SKELETAL AND DENTAL
A vertical skeletal discrepancy may reflect an anterior,
posterior, or complex dysplasia of the face. Therefore,
the vertical skeletal cephalometric measurements are
divided into anterior and posterior components.


MAXILLA AND MANDIBLE
The total effective length of the maxilla is the distance from
PNS-ANS that is projected on a line parallel to the HP. The
ANS-PNS distance, with the previous measurements N-ANS
and PNS-N, give a quantitative description of the maxilla in
the skull complex.
Four measurements relate to the mandible
Ar to Go
Go-Pg
Go angle [represents the relationship between the ramal
plane and MP]
B-Pg, [Distance from B point to a line perpendicular to MP
through Pg.]


DENTAL
In the assessment of dental anomalies cephalometrically,
one must attempt to relate the teeth to each other
through a common plane, such as the occlusal plane (OP)
or to a plane in each jaw, the MP, or the NF plane.


Table


Discussion:
A cephalometric appraisal is only one step in diagnosis and
planning of treatment. It gives the clinician insight into the
quantitative nature of the skeletal-dental dysplasia.
If surgery' is planned to produce cephalometric changes
that make the face approach the normative standards,
usually a more typical and desirable face is produced. It is
a mistake, however, to treat to a standard that avoids other
considerations.
The soft tissues can and do mask the underlying bone and
teeth; therefore one must compensate for this variations.

ADVANTAGES:
A cephalometric analysis for patients who have
orthognathic surgery
It is based on the landmarks that can be altered by
various surgical procedures.
These rectilinear measurements examine critical
facial components that can be readily transferred to
acetate overlays and study casts for detailed
planning of treatment and post surgical evaluation.

SOFT

TISSUE

CEPHALOMETRIC

ANALYSIS

FOR

ORTHOGNATHIC SURGERY:
Treatment planning for patients who require orthognathic
surgery should include both a hard tissue and soft tissue
cephalometric analysis.
The hard tissue will show the nature of the existing skeletal
discrepancy, it is incomplete
in providing the information concerning the facial form and
proportions of patient. The soft tissue covering the teeth
and bone is highly variable in its thickness and this

variation may be greater.

In

planning

surgery

on

patients

with

vertical

discrepancies, lip length is an important factor. Sometime
lips may be short,allowing the patient to close with great
difficulty. Amount of incisor exposure will be more during
speaking.

Therefore,

the

diagnosis

of

vertical

discrepancies will be depend upon both soft and hard
tissues factor.
Therefore, Charles J. Burstone in 1980 developed a soft
tissue cephalometric analysis for orthognathic surgery.

Cephalometric landmarks:
Soft tissue landmarks used are;
Glabella (G) : The most prominent
midsagittal plane of the forehead.

point

in

the

Columella point (Cm) : The most anterior point on the
columella of nose.
Subnasale (Sn) : The point at which the nasal septum
merges with the upper cutaneous lip in the midsagittal
plane.
Labrale superiors (Ls) : A point
mucocutaneous border of upper lip.


indicating

the

Stomion superius (Stms) : Lower most point on the
vermilion of the lower lip.
Labrale inferius (stml) : The upper most point on the
vermilion of the lower lip.
Labrale

inferius

(Li):

A

point

indicating

the

mucocutaneous border of lower lip.
Mentolabial sulcus (Si) : The point of greatest concavity
in the midline between the lower lip and chin.
Soft tissue pogonion (Pg) : The most anterior point on
soft tissue chin

soft tissue gnathion (Gn) : The constructed midpoint
between soft tissue pogonion and soft tissue menton.

Soft tissue menton (me) : Lowest point on the soft tissue
chin, found by dropping a perpendicular from horizontal
plane through menton.
Cervical

point

(C):

Innermost

point

between

the

submental area and neck located at the intersection of
lines drawn tangent to neck and submental areas.
Horizontal reference plane (HP): Constructed by drawing
a line through nasion 7° up from sella - nasion line.

Facial form
To describe the soft tissue profile of patient angle of
facial convexity, or facial contour angle, G - Sn - Pg is
evaluated.
G-Sn - Pg : 12°+/- 4°
A line perpendicular to horizontal plane (HP) is dropped
from glabella and the relationship of the maxilla and
mandible is related to it to determine if the problem is
maxillary or mandibular.

G-Sn (Hp): The distance from subnasal (Sn) to
vertical line parallel to the horizontal plane is
measured
maxillary

which

describes

protrusion

or

the

amount

retrusion

of
in

anteroposterior dimension.
Negative number is maxillary retrusion, large
positive number,is maxillary procumbency.
G - Sn - (HP): 0 +/- 3 mm

G- Pg (HP) : The position of pogonion is
measured parallel to HP from the Perpendicular
line dropped from glabella. This measurement
gives an indication of maxillary prognathism or
retrognathism.
G - Pg : 0 +/- 4 mm


Vertical height ratio - G - Sn / Sn - Me (HP):
In

vertical

dimension,

anterior

facial

proportionality is assessed by taking the ratio of
middle third facial height to lower third facial
height measured perpendicular to HP. The ratio
less than 1 to 1 connote a disproportionality
large lower third of face .
Normal: 1 mm


Lower face - throat angle (Sn - Gn - C): It is
formed by intersection of the lines Sn - Gn and
Gn - C. an obtuse lower face neck angle warns the
clinician not to use procedures that reduce the
prominence of chin.


Nasolabial angle (Cm - Sn - Ls) : 4 +/- 2mm
It is important in assessing antero-posterior
maxillary dysplasia. An acute nasolabial angle
will often allow us to surgically retract the
maxilla or retract the maxillary incisors.
Obtuse nasolabial angle suggests a degree of
maxillary hypoplasia.
Cm - Sn - Ls: 102° +/- 8°

Upper lip protrusion Ls to (Sn - Pg) : 3 +-1 mm
Lower lip protrusion Li to (Sn - Pg) : 2+- 1 mm
It is evaluated by drawing a line from subnasal to soft
tissue pogonion and amount of lip protrusion or
retrusion is measured by perpendicular linear distance
from this line to the most prominent point of both lips.
Labio-mental sulcus Si to (Li – Pg) 4 +/- 2 mm
It

is

measured

from

the

depth

of

the

sulcus

perpendicular to Li- Pg line. Sulcus of about 4 mm is
average in pleasing lower lip t0 chin contour.

Vertical lip chin ratio - Sn - Stms / Stms - Me: 0.5 mm:
Lower third of face (Sn - Me) is divided into length of upper
Sn - Stms. It should be approximately 1/ 3rd the total and
distance Stms - Me is about 2/3rd.
Sn - Stms/Stms - Me should be 1: 2 ratio becomes smaller
than one half- vertical reduction genioplasty considered.
Distance of upper lip to the maxillary incisor (Stms - 1) is
key factor in determining the vertical position of maxilla.
Patient with vertical maxillary excess tend to show a large
amount of upper incisors with the lip in response.

Interlabial gap - 3 mm:
Vertical distance between the upper lip and
lower lip with then lip in rest position is
normally 3mm. If vertical maxillary excess tend
to have large Interlabial gap, lip In competency.


ORTHODONTIC SURGICAL CEPHALOMETRIC
PREDICTION TRACING (Epkar and Fish, 1994):
one of the most Important planning tools in
surgical cases is the cephalometric prediction
tracing. Once the problem is recognized .
The type of surgery provisionally decided,
prediction tracing is done accordingly

Types of prediction tracings ;
1) Orthodontic surgical
2) Surgical
Orthodontic

surgical

tracing

is

used

for

overall

treatment planning and illustrates the effect of both
orthodontic tooth movements and surgical skeletal
changes.
surgical tracing is done as a part of two patient
concept.

The orthodontic surgical tracing is done for the fallowing
reasons .
To assess accurately the profile esthetic results of the
proposed surgery and orthodontics.
Determine desirability the of
procedures such as genioplasty.
To help determine the
orthodontics.

adjunctive

surgical

sequencing of surgery and

To help decide if extractions are necessary.
To determine which teeth to extract if extraction
treatment is required.
To determine the anchorage requirements.

Esthetics directly depends on the soft tissue
morphology and harmony. So, it is important to know
the soft tissue change associated with the surgical
procedure.
Certain points to be kept in mind during prediction
tracing are;
With the antero-posterior movement of the incisors,
60-70% change is seen in lips. With the vertical
movement of incisors, associated with soft tissue
changes are minimal but lip rotation is almost equal to
the rotation of mandible.
In mandibular advancement, lip movement is 60-70%,
but the soft tissue chin movement is almost as equal to
the base movement.

In maxillary advancement, the nose tip is slightly
elevated, but the change is usually temporary. In
maxillary retro positioning, the movement of the
base of the upper lip is only 20% of that of point A.
The lower lip rotates along with the mandibular
rotation.
In surgery of chin, the soft tissue reacts about 6070%to forward advancement.

currently, there are three methods of prediction
tracing.
A)

It involves repositioning acetate tracing. of the

various bony and skeletal segments over the original
tracing to duplicate the movement of potential treatment
procedures. The post treatment soft tissue outline is
established by considering the ratio of soft tissue to hard
tissue change.


In Second technique appropriate landmarks from the
cephalometric tracing are digitized and entered into a
computer using commercial programs clinician can
simulate surgical movements on screen and rapidly
compare several possible options using computer is no
more accurate than doing prediction by hand.
The third method involves overlying the digitized image of
the lateral cephalometric tracing on to a video image of
patient. The surgical predictions produced from the
digitized cephalometric tracing can be integrated with
the video image so that the prediction includes not only a
line drawing but also a corresponding facial image.

The available surgical prediction programs include
Dentofacial planner plus
Quick Ceph and
Prescription Planner / Portrait, OTP, TOMAC, Dr. Ceph
etc


Mandibular advancement:
First the bony and soft tissue landmarks are
traced. Frankfort horizontal plane is drawn and
then a line is passed from nasion through point A
and extending inferiorly. Point A is frequently in
its normal relation (90deg maxillary depth).
Begin the prediction by tracing the distal portion
of the mandible, the soft tissue chin, and the
occlusal plane on clean acetate paper. A lightly
dotted line is used for soft tissue chin and the
corresponding part of mandible. It makes easier to
add genioplasty whenever required.

In deep bite cases, occlusal plane is made
between functional plane and molar incisor
occlusal planes. The choice must be made
carefully as it affects the esthetics the amount
and direction of advancement and the necessary
orthodontic treatment.
Functional occlusal plane
Wolford L.M., Chemello B.D. and Hilliard F.
(1994) quoted that deep bite frequently
associated with excessive curve of spee in lower
arch and a reverse curve of spee in the upper
arch

Molar incisor occlusal plane:
The patient with deep bite has two divergent molar
incisor occlusal planes. One from maxillary incisor to
maxillary molar and another from mandibular molars to
mandibular incisors.
If mandible has to be advanced along these divergent
planes, then rotate clockwise the distal of mandible, so
that both planes get coincide. The teeth are advanced
more than pogonion and lower face height is increased by
the amount of excessive overbite.

After tracing the fixed structures, draw A - Po
line and the facial axis on the prediction. This
line is used to place the teeth in their ideal
position.
Ideal position of lower incisor determined by
Rickets, is with the incisal edge 1 mm ahead of
the A - Po line and the long axis at 22° to A - Po
line.

The single most common problem encountered in doing a
cephalometric

Prediction

tracing

for

mandibular

advancement is the inability to produce the desired lower
incisor tooth movements because the total arch length
discrepancy is greater than the width of two premolars.
Then start soft tissue profile prediction superimpose the
prediction on the tracing. As the position of upper incisor
was changed the upper lip vermilion will change in the
same direction but about half as much. Draw appropriate
lip in the new appropriate position and connect it to
subnasale by a smooth curve .

Lower lip frequently not only supported by lower
incisor but also everted by the upper incisors.
Generally lower lip thickness is equal from point B
superiorly and usually the same thickness in
upper lip. The lay the prediction on tracing,
touches upper lip, incisal edge of upper incisor
and .labial surface of lower incisor on the
prediction trace the vermilion portion of the lip.
Finally, connect the lip to the soft tissue chin with
a smooth curve to produce completed prediction
tracing

SUPERIOR REPOSITIONING OF THE MAXILLA AND
ADVANCEMENT GENIOPLASTY:
Routine tracing of pretreatment cephalogram with
skeletal, dental and soft tissue landmarks done.
Then to start with prediction - fresh tracing of the
patients

cephalogram

without

analysis

line

made.

Construct subnasal perpendicular this tracing to allow
assessment of changes in chin and lip position. For soft
tissue chin and mandible use dotted lines, as it is easier
to add genioplasty.

Note : Accurate tracing of condyle is important as
it serves as center of rotation for mandible,
Functional occlusal plane ( molar-premolar) is
used.
Then the prediction is rotated counterclockwise
around the condyle keeping the condyle in fossa,
until the functional occlusal plane is 1-3mm
below the upper lip on tracing .Where to place
the occlusal plane is based on the amount of
upper tooth exposed before treatment,

Then hold the prediction and draw the fixed
structures,observe the anteroposterior position of
chin. The soft tissue chin optimally lies 2 - 6 mm
behind the subnasale perpendicular on tracing.
If chin is deficient at this time augmentation
genioplasty done. There the bone to soft tissue
ratio is 1 : 0.7.


For augmentation genioplasty, draw a horizontal
line parallel to FH plane on symphysis. Then
superimpose the tracing on prediction. Slide the
prediction until the bony chin of the tracing
projects anteriorly. Then hold the prediction and
draw the new chin position, relative to both
subnasale perpendicular and the forehead and
nose. Then draw A - Po line should be coincident
with A – Po line Place the teeth in their ideal
position. Superimpose the Prediction on tracing
and soft tissue can be compared.

TWO JAW SURGERY (MAXILLARY SUPERIOR
REPOSITIONING AND MANDIBULAR
ADVANCEMENT)


MODEL SURGERY :
Model surgery simulates the actual surgery, in
the dental arch model of the patient
It gives a three dimensional uerstanding of the
postoperative relationship of the jaws.
Why Model surgery is performed ???


The basic reason to perform the model surgery is
1) To determine if the indicated surgical procedure will
produce an occlusion that can be simply and safely
perfected by subsequent orthodontic treatment.
2) To get a definite idea about the extent of bone / arch
advancement or reduction required in the surgery.
3) To get a postoperative relationship of the jaws,
dentition and occlusion.
4) To decide
treatment.

about

the

post

surgical

orthodontic

5) As a vehicle for fabrication of splints for stabilization
after surgery


There are two basic types of feasibility model surgery.
Whole arch
Segmental
Whole arch feasibility model surgery is done by hand
articulating

dental

models

into

the

best

possible

occlusion.
Segmental feasibility model surgery is done by sawing
the upper lower or both dental models into the dentoosseous segments to be produced at surgery and reassembling them into the best possible occlusion while
using any simple hinge type articulator to help hold the
model bases.


Technique:
The models are duplicated, trimmed to simulate the
anatomy and arbitrarily mounted on an articulator using
a wax bite to ensure proper occlusion. The roots of the
teeth adjacent to planned interdental osteotomies or
osteoctomies are drawn on cast.
The teeth and the alveolus are sectioned from the upper
model base along a reference line made approximately 5
mm above the tooth root apices. Then the maxilla is
sectioned into the appropriate segments taking care not to

cut through the tooth roots.

The anterior segments are placed into its best
occlusal relationship with the lower teeth and
held in this position with soft Wax. The
objective is to establish a class I canine
occlusion with -normal overbite and overjet.
Sometimes, it is necessary to section the
anterior segment between the central incisors
to increase or decrease inter-canine width,
close the midline diastema etc.

In Lefort I osteotomy, models are articulated in
an

anatomical

articulator

with

face

bow

transfer. An anatomical articulator is necessary
because the repositioning of maxilla always
result in some rotatory movement of mandible in
Toto.


POST SURGICAL ORTHODONTICS AND RETENTION:
Orthodontic objectives following surgery are generally
similar to those considered in finishing a conventional
orthodontic case. Final tooth alignment maximum
interdigitation, finalizing torque and artistic positioning
are all completed at this time.
Establishment of correct root parallelism is important,
particularly in segmental cases where the roots of the
teeth adjacent to the osteotomy sites should have been
kept divergent so as to provide additional lnteradental

space for the surgical cuts.

The post surgical treatment time needed to reach such
objective varies according to type of patient, minimum 34 months required for post surgical treatment
Post-surgical orthodontic consideration (Bell and
Jacobes, 1981; Epkar and Fish, 1994):
1)Immediate post surgical control:
After the release of fixation, is the important time under
the orthodontists control. During this time orthodontist
can produce rapid and drastic changes that will
profoundly affect the final result with regard to stability
and function.


Appliance repair:
All the arch wires are removed and the fixed appliance is
checked for damage. Any bands or bonded attachment that
have become loose, bent or other wise damaged are
replaced.
Arch wires:
After surgery, arch wires that were removed are placed
back in the mouth unless either they were damaged that
they require replacement.


Appointment frequency:
Patients are seen more frequently for the first
month or 30 after release of fixation. Patient is
seen on 3-4th day after surgery to check if
he/she is having any problem. If all is well,
second appointment in I week, then in 2nd week
and then routing 4 week.


Finishing
It is the most important part of post surgical
orthodontics and is deliberate attempt to achieve.
A. Compatibility between centric occlusion and centric
relation
b. Canine protection
c. Incisal guidance
d. Root parallelism
e. Pleasing appearance

After completing finishing the patient is placed
in passive arch wire and if good stability is
demonstrated in absence of any mechanics, the
appliance is removed.
Retention:
For retention. conventional retention appliances
are given or the appliance is placed as it is for
few months.

Class I dentofacial deformities:
Today, clinicians tend to focus on the fact that
the patient population has a class I occlusion and
ignore the totality of the patient’s skeletal,
functional

and

esthetic

problems.

Class

deformities include;
a. Vertical maxillary excess
b. Vertical maxillary excess with open bite

I

.Orthodontic

factors:

Specific

orthodontic

factors that directly and most commonly
contribute to relapse in the correction of
patients with class I VME.
a. in appropriate vertical mechanics:
b. Expansion of maxilla

CLASS II DENTOFACIAL DEFORMITIES SECONDARY
TO MANDIBULAR DEFICIENCY (Arnett, 1993; Epkar
and Fish, 1994):
Post-surgical orthodontic treatment:
First appointment within 48 hour of patient release.
Both the upper and lower arch wires are removed
checked for damage and adjusted or replaced. Loose
appliance re-cemented, occlusion is checked. The elastics
are reviewed. In the next appointment, complications are
noted

Mechanical principles used;
1.If equal movement is desired then either no arch wire is
placed or same size arch wire is placed in both arches.
2.If more movement of teeth in one arch required, either
no arch wire is placed in arch to be moved farthest or
larger archwire is placed in the arch to be moved the least.


Factors affecting the stability of treatment:
1) Orthodontic factors:
a. Removal of dental compensations
b. Correction of tooth mass discrepancies
c. Leveling of both arches
d. Correction of transverse discrepancy
e. Production of a double protrusion


2. Surgical factors:
a Soft tissue mobilization
b. Distraction of the condyle from fossa
c. Method of fixation


MANDIBULAR
GENIOPLASTY

ADVANCEMENT

WITH

REDUCTION

Factors affecting stability of treatment
Orthodontic factors:
Very little effect on orthodontic stability, except to
anteroposterior relationship to be normalized without
excessive flaring of lower incisors.
The factors are;
1.Making the occlusion more class II before surgery.
2.Properly managing tooth mass discrepancies before
surgery.
3.Adequately leveling upper and lower arches before
surgery.
4.Properly managing any transverse discrepancy before
surgery.
5.Being aware that deep-bite relapse is not uncommon.

Surgical factor:
Skeletal stability is excellent, if it is done as a free bone
segment, The primary factor in obtaining the optimal
soft tissue esthetic result is related to removing minimal
soft tissue from the inferior (mobilized) segment. If the
inferior chin segment is not degloved, the skeletal
movement of the symphysis carries the soft tissue with
1: 1 ratio.
Age related factors:
The addition of reduction genioplasty will have no effect
on subsequent growth.

MAXILLARY

EXPANSION

FOLLOWED

BY

MANDIBULAR ADVANCEMENT :
Following surgery, the patient is informed about the
appliance activation. Two-one quarter turns per days.
The patient is seen 2-5 days following surgery to check
his/her understanding about activation. The patient is
seen at appropriate intervals until the desired expansion
has been achieved. After expansion, the diastema occurs
and bone has formed between them in 8-10 weeks after
surgery.

FACTORS AFFECTING STABILITY OF TREATMENT:
1.Appliance construction and cementation
2.Appliance activation
3.Maintenance of arch width


MANDIBULAR

ADVANCEMENT

WITH

ANTERIOR

MANDIBULAR SUBAPICAL OSTECTOMY
The lower arch is usually 16 x 22 T' loop arch wire with
loop being placed at the osteotomy sites. Use of light,
flexible wires such us Nitinol is not recommended. If loops
are avoided the stiff Segmental wires are maintained and
light flexible wires are placed over them. Upper and lower
arch wires should be coordinated.


FACTORS AFFECTING STABILITY:
1.Adequate room to perform the surgery
2.Teeth properly related within the subapical segment
Surgical factors:
1.Inadequate ostectomies
2.Excessive ostectomies


CLASS II DEFORMITIES SECONDARY TO VERTICAL
MAXILLARY EXCESS:
Post-surgical orthodontic treatment:
The arch wire is usually 16 X 22 with 'T' loops at the site
of any osteotomy, when there is no problem with bracket
alignment on either side of an osteotomy; the 'T' loops
are not necessary.
Another option is to maintain the sectional archwires
placed before surgery and place over these in piggyback
fashion, a light flexible archwire.

Factors affecting stability:
Orthodontic factors
1.Avoid inappropriate use of vertical mechanics.
2.Maxillary expansion for the adult is done surgically.
3.Make the occlusion more class II before surgery.
4.Properly manage tooth mass discrepancies before
surgery


5.Adequately level both upper and lower arches or
segments.
6.Appropriately coordinate the lower arch and upper arch
segment.
Surgical factors:
Two problems are encountered
1) The maxilla is expanded and poor bone contact exists
posteriorly.
2.The posterior bone is thin and structurally does not

produce a stable interface.

CLASS III DENTOFACIAL DEFORMITIES
It is multifactorial in its developmental nature, large
mandibles, small maxillae, and both midface deficiency
and open-bite. Optimal esthetic results can only be
achieved if the skeletal correction is done in the proper
jaw.
1.Sagittal

split

ramus

osteotomy

setback and
2.Mandibular body ostectomies .

with

mandibular

1. Orthodontic factors:
Room to do the proposed surgery
Proper arch shape


CLASS III DENTOFACIAL DEFORMITIES SECONDARY
TO MAXILLARY DEFICIENCY:
1.Anteroposterior,

vertical

and

transverse

maxillary

deficiency:
In the first post surgical visit, orthodontist removes
splint. Check the appliance for damage. Damaged or
loose appliance is replaced. When maxilla is surgically
expanded, then Continuous upper arch wire is placed
with careful coordination with lower wire.
Since intentional anteroposterior over correction of 1-3
mm is usually done at the time of surgery, a small class II
occlusal discrepancy www.indiandentalacademy.com present.
will generally be

CLASS III DENTOFACIAL DEFORMITY WITH OPEN
BITE:
In such cases, post surgical orthodontic visit is
optimally within 48 hours of removal of surgical splint.
The arch wires are removed and appliance is checked for
damage and necessary adjustments are made. When
maxillary segmentalization is done, the teeth on either,
side of the osteotomy (ostectomy) are tightly ligated
together with a figure of 8 wire around orthodontic
brackets and new upper archwire is placed.

Surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

Surgical orthodontics /certified fixed orthodontic courses by Indian dental academy

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