Orthodontics and orthognathic surgery Dr. Maher Fouda

1. Orthodontics and orthognathic
surgery
Professor Dr. maher Fouda
Faculty Of Dentistry –Mansoua University
Martyn T Cobourne. Handbook of Orthodontics , 2ed
(2016) Elsevier Ltd.

2. Treatment steps with orthognathic surgery
1- orthodontic decompensation. (orthodontist)
2- analytic model planning (mockup surgery)
3- surgical operation. (maxillofacial surgeon)
4- case finishing. (orthodontist)

3. A malocclusion associated with any significant discrepancy in the
dentofacial skeleton of an adult will often require a combination of
orthodontics and surgical repositioning of the jaws for definitive
correction. Orthodontic camouflage may be possible in some cases, but
this approach can be a compromise and limited by the extent of the
skeletal discrepancy.

4. Growth modification is not possible in an adult, but many of these
malocclusions are amenable to attempts at treatment with a functional
appliance if diagnosed in a growing child or adolescent. However, these
more severe forms of skeletal discrepancy are often the ones least likely to
respond to attempts at growth modification and often end up requiring a
surgical approach once growth has ceased

5. Common facial deformities
• The range of facial deformity that is seen can have almost infinite
variation, but in the simplest terms, will often include (Fig. 12.1): •
Anteroposterior disproportion associated with the size or position of
the maxilla and mandible in class II and class III cases; • Vertical
disproportion, associated with excessive or reduced maxillary incisor
tooth show, increased overbite or open bite; • Transverse anomalies;
and • Asymmetries of the face and jaws.
Correcting an Open Bite: Some of the bone in the upper
tooth-bearing portion of the jaw is removed. The upper
jaw is then secured in position with plates and screws.

8. Orthognathic surgery to correct these discrepancies can involve a range
of surgical movements, which achieve repositioning of the maxilla or
mandible within the facial skeleton . Surgery of this kind does not affect
any inherent growth capacity that may reside in the jaws and for this
reason it is only carried out once skeletal growth has ceased, in the
adult. This is particularly important for class III cases with mandibular
excess, where continued forwards growth of the mandible after
backwards surgical repositioning can lead to the reappearance of a
reverse overjet if the surgery is carried out before growth has ceased.
Correcting a Protruding
Lower Jaw: The bone in the
rear portion of the jaw is
separated from the front
portion and modified so that
the tooth-bearing portion of
the lower jaw can be moved
back for proper alignment

9. Patients presenting for orthognathic surgery
An adult patient will ultimately be advised that they require orthodontics
and orthognathic surgery if the discrepancy in their skeletal base
relationship is so severe that orthodontic camouflage either is not possible
or would significantly compromise facial aesthetics. • Many are unhappy
with the way they look and achieving a normal facial appearance is often a
key motivation (Stirling et al, 2007); • Some are more concerned with
functional difficulties associated with their malocclusion, such as eating or,
more rarely, speaking; and • Others are simply unhappy with the
appearance of their teeth.
Correcting a Receding Lower Jaw or
“Weak Chin”: The bone in the lower
portion of the jaw is separated from its
base and modified. The tooth-bearing
portion of the lower jaw and a portion
of the chin are repositioned forward

10. It can often come as something of a shock to a patient who is primarily
concerned with the appearance of their teeth to be told that not only do
they need orthodontic treatment to correct their position, but facial
surgery as well. In these instances surgical intervention may be declined
and orthodontic treatment limited to tooth alignment alone, with the
patient and orthodontist accepting the underlying skeletal discrepancy.

11. Range of surgical
movements. (1) The maxilla can
be moved forward, upwards and
downwards. (2) The mandible can
be moved forwards or backwards.
(3) The chin can be moved
forwards, backwards, upwards
and downwards.

12. A minority of patients may exhibit a significant preoccupation with an
imagined, relatively minor or nonexistent defect in their facial appearance:
a condition known as body dysmorphic disorder (Cunningham &
Feinmann, 1998). Any suspicion of this should elicit referral for a more
formal psychiatric assessment prior to embarking on any combined
treatment .

13. Body dysmorphic disorder and the orthodontist
Body dysmorphic disorder is a psychological condition characterized by a
significant preoccupation with an imagined or slight defect in appearance.
Affected individuals often seek cosmetic treatment, with both orthodontics and
orthognathic surgery featuring amongst the most commonly requested
procedures. Indeed, up to 7.5% of an orthodontic sample may have body
dysmorphic disorder compared to 2.9% of the general population (•Hepburn &
Cunningham, 2006).

14. Body dysmorphic disorder and the orthodontist
Importantly, affected individuals are rarely satisfied with the outcome of
any treatment and it is important that any patient suspected of having
body dysmorphic disorder is referred to a psychiatrist for definitive
diagnosis and management before any orthodontic intervention is
considered (Polo, 2011).

15. Body dysmorphic disorder and the orthodontist
The main diagnostic criteria for body dysmorphic disorder include: (1) a
preoccupation with an imagined defect in appearance; (2) excessive
concern with a slight physical anomaly; (3) the preoccupation causing
clinically significant distress or impairment in social, occupational or other
areas of functioning; (4) the preoccupation is not better accounted for by
another psychological disorder. Management of these individuals includes
pharmacological and behavioural therapy, combined with any orthodontic
intervention.

16. Index of orthognathic functional treatment need
The use of indices to prioritize treatment for those most in need
is increasingly being seen within statefunded healthcare systems.
In the UK, the Index of Orthodontic.

17. In the united kingdom ,the index of treatment need currently defines those
malocclusions that should be treated within the National Health Service
(Brook & Shaw, 1989), but it is difficult to apply constructively to cases that
require a combination of orthodontics and surgery. A number of functional
indications for combined treatment are absent from the Index of
Orthodontic Treatment Need, such as the presence of excessive maxillary
incisor show at rest, whilst in the aesthetic component there are no class II
division 2 or class III cases.

18. In an attempt to overcome these limitations, an Index of
Orthognathic Functional Treatment Need has been designed
and validated to help prioritize the treatment of combined
cases (Ireland et al, 2014) .

19. Assessment of patients for combined treatment
The acquisition of records and principles of treatment
planning for adults with marked skeletal discrepancies
follows the same essential sequence as for any other
patient. The primary objective is to position a well-aligned
class I occlusion within a balanced and proportional facial
skeleton.

24. A fundamental difference between planning for surgical correction of a
skeletal discrepancy and conventional orthodontic growth modification or
camouflage is the extent of predictable change that can be brought about.
Jaw movements of up to 1 cm can be achieved by the surgeon, which, in
combination with fixed appliance systems that allow precise tooth
positioning, means that significant malocclusions can be corrected with
great accuracy.

25. Patients should be assessed within the environment of a joint clinic that
involves both maxillofacial surgeon and orthodontist. Definitive records
are required for this consultation, which should include study models,
radiographs, cephalometric analysis and both intraoral and facial
photographs.

26. In combination with the clinical examination, these records allow a
detailed evaluation of where the discrepancy lies and the formulation of a
preliminary plan regarding the essential surgical movements that will be
required. It is particularly important that the patient understands the
potential risks and complications of undergoing orthognathic surgery. This
consultation should give them the opportunity to ask any questions and
come to an informed decision with regard to undertaking such treatment.

27. Soft tissue cephalometric analysis for facial
deformity
William Arnett has described a comprehensive method of
evaluating cephalometric lateral skull radiographs as part of the
facial diagnosis and treatment planning for patients with
dentofacial deformity (Arnett & Gunson, 2004). The mean values
and standard deviations for this analysis were based upon those
of 46 adult Caucasian patients (split into males and females) with
untreated class I occlusions and good facial balance.

28. The cephalometric radiograph is taken in natural head posture
with metallic markers placed to mark five right sided soft tissue
landmarks (cheekbone, orbital rim, nasal base, subpupil, neck–
throat junction). A true vertical line (TVL) is then constructed
through subnasale (or 3 mm in advance of subnasale in the
presence of maxillary deficiency).
Natural Head Position
NHP is a standardized and
reproducible orientation
of the head in space when
one is focusing on a
distant point at eye level.
Natural head posture is
preferred because of its
demonstrated accuracy over
intracranial landmarks. Natural
head posture has a 2° standard
deviation compared with a 4°
to 6° standard deviation for the
various intracranial landmarks
in use.

29. True Vertical Line ( TVL ) It is a Vertical line passing through the
Subnasale with natural head posture. It may be used to quantify
favorable or unfavourable change in the profile after overjet reduction
and has a potential role in post treatment
analysis and research

30. The analysis is then divided into five key areas (dentoskeletal, soft tissue,
facial heights and lengths, TVL projections and facial harmony) using 46
different measurements (some of which are repeated in different areas of
the analysis) (Fig. 12.3).

31. Dentoskeletal factors
A total of nine dentoskeletal measurements are made:
1- Maxillary central incisor tip projection to TVL
2- Maxillary central incisor inclination to the occlusal plane;
3- Overjet;
4- Mandibular central incisor tip projection to TVL;
5- Mandibular central incisor
inclination to the occlusal plane;
6- Maxillary central incisor vertical
exposure to the upper lip;
7- Overbite;
8- Mandibular anterior height
9- Maxillary occlusal plane angle
to the TVL.

32. Dentoskeletal factors
1. Mx1 to TVL (-9.2 to -12.1 mm)
2. Mx1 to Mx occlusal plane (56.8–57.8°)
3. Overjet (3 mm)
4. Md1 to TVL (-12.4 to -15.4 mm)
5. Md1 to Md occlusal plane (66.3–64°)
6. Mx1 exposure to Ulip (4.7–3.9 mm)
7. Overbite (3 mm)
8. Md anterior height (48.6–56°)
9. Mx occlusal plane TVL angle (95.6–95°)

33. Soft tissue components
A total of four soft tissue measurements are made:
• Upper lip thickness;
• Lower lip thickness;
• Soft tissue pogonion thickness;
• Soft tissue menton thickness

34. Soft tissue components
10. Upper lip thickness (12.6–14.8 mm)
11. Lower lip thickness (13.6–15.1 mm)
12. ST pogonion thickness (11.8–13.5 mm)
13. ST menton thickness (7.4–8.8 mm)

35. Facial heights and lengths
The facial heights and lengths are divided into six soft and four hard tissue
measurements. For the soft tissues, the following are considered:
14- Upper lip length;
15- Interlabial gap;
16- Upper incisor exposure;
17- Lower lip length;
18- Lower third anterior face height;
19- Total anterior face height.

36. Hard tissue measurements include:
20- Maxillary height;
21- Overbite;
22- Mandibular height;
23- Maxillary occlusal plane angle to the TVL.

38. True vertical line projections
The following 16 horizontal distances are measured in
relation to the TVL:
• Within the high midface (glabella, orbital rim,
cheekbone, subpupil).
• Within the maxilla (nasal projection, nasal base,
subnasale, soft tissue Apoint, upper lip, upper lip
angle, nasolabial angle).
• Within the mandible (lower incisor, lower lip, soft
tissue B-point, soft tissue pogonion, throat length).

40. Facial harmony values
The facial harmony values are designed to give information on the balance between
different parts of the face and all relate to the TVL. They consist of 11 measurements
divided into four groups:
40- Total facial harmony (facial angle, forehead to maxilla, forehead to mandible);
41- Orbit to jaw harmony (maxilla, mandible);
42- Maxilla to mandible harmony (nasal base to chin, maxilla to mandible, lip to lip)
43- Mandibular harmony (lower incisor tip to chin, lower lip anterior to chin, chin
contour).

41. Harmony values
Total facial harmony
40. Facial angle (169.3–169.4°)
41. Forehead to Mx (8.4–7.8 mm)
42. Forehead to Md (5.9–4.6 mm) Orbital rim to jaw
43. Mx (18.5–22.1 mm) 44. Md (16–18.9 mm)
Maxilla to mandible
45. Nasal base to chin (3.2–4.0 mm)
46. Mx base to Md base (5.2–6.8 mm)
47. Lip to lip (1.8–2.3 mm) Intra-mandibular
48. Md1 to chin (9.8–11.9 mm)
49. Llip to chin (4.5–4.4 mm)
50. Chin contour (2.7–3.6 mm)
Redrawn from Arnett, G.W., McLaughlin, R.P., 2004. Facial and Dental Planning for Orthodontists and Oral
Surgeons. Mosby, Edinburgh.)

42. The numerical values are placed directly on the tracing and colourcoded
black, green, blue or red, depending upon whether they lie within 1, 2, 3 or
4 standard deviations from the mean, respectively. Although complex, this
analysis provides a detailed overview of soft tissue facial proportions and
harmony.
Arnett soft tissue cephalometric analysis. There is
a large nose (20, blue), flat upper lip (0, red; −10,
red), excess upper incisor exposure (7, green),
steep occlusal plane (104, red) and mandibular
retrusion (−20 red).

43. The further these figures are from the ideal (black) the greater the need for
surgical correction of the malocclusion, to avoid compromising the facial
appearance (facial decline).
Arnett soft tissue cephalometric analysis. There is a
large nose (20, blue), flat upper lip (0, red; −10, red),
excess upper incisor exposure (7, green), steep
occlusal plane (104, red) and mandibular retrusion
(−20 red).

44. The process of combined orthodontic surgical treatment
Having fully assessed the patient and established a treatment plan through the joint
clinic, the care pathway for combined orthodontic and surgical correction of a
malocclusion is divided into three main stages, with fixed appliances in place
throughout: • Presurgical orthodontics to correct abnormal tooth position and
prepare the patient for surgery;
• Surgery to correct the jaw position; and • Postsurgical orthodontic treatment to detail
tooth position prior to removal of the fixed appliances

45. The orthodontist plays a predominant role in preparing a patient for
orthognathic surgery. Once it is felt that the teeth are in a position to allow
the required surgical movements to take place, the patient returns to the
joint clinic and orthodontist and surgeon definitively plan the necessary
surgical movements.

46. Orthodontic and orthognathic combined treatment minimum
dataset A recommended minimum dataset was formulated by the British
Orthodontic Society (BOS) and British Association of Oral and Maxillofacial
Surgeons (BOAMS) in 2004 for patients undergoing orthodontics and
orthognathic surgery. This provides comprehensive data on the presenting
jaw discrepancy and malocclusion, treatment carried out and outcome,
including followup at 2 years. Patient feedback is also required in the form
of a questionnaire that is completed prior to, immediately after and at 2
years following treatment.

47. In addition to the baseline radiographs that are required for definitive diagnosis and
surgical planning, a number of radiographic investigations are also required at specific
time points within the pathway: • An immediate postsurgery panoramic radiograph
(the responsibility of the surgeon); • A cephalometric lateral skull radiograph 1–3 weeks
postsurgery (the responsibility of the orthodontist); • A predebond cephalometric
lateral skull radiograph where postsurgical orthodontics has exceeded 6 months; and •
A cephalometric lateral skull radiograph at 2 years followup. This dataset facilitates
appropriate audit and prospective research into the effectiveness of combined
treatment.

48. Presurgical orthodontic treatment
There are two principal aims of presurgical orthodontic treatment:
• Eliminate any natural dentoalveolar compensation that might exist for a
skeletal discrepancy and therefore allow complete surgical correction;
and • Coordinate the dental arches to produce a well interdigitated,
functional and stable occlusion in the final postsurgical position.

49. These aims are achieved within a number of overlapping phases, primarily
during presurgical treatment and through orthodontic tooth movement.
Occasionally, surgical intervention is required during this phase to assist in
achieving necessary expansion of the maxillary arch. Surgically assisted
rapid palatal expansion (SARPE) is therefore carried out before the
definitive osteotomy. This is in contrast to surgically assisted levelling,
which usually takes place as part of the definitive osteotomy.

51. Some controversy exists regarding the amount of orthodontic treatment that should be
completed prior to surgery (Box 12.2), but conventional planning usually requires full
decompensation and dental arches that have been set up to articulate very closely to
the proposed final postsurgical position.

52. How much orthodontic treatment is required prior to surgery?
There are different schools of thought regarding the amount of orthodontic treatment
that should be carried out prior to surgical jaw correction. Conventionally, most tooth
movement is achieved before surgery: • Allowing accurate and maximal correction of
the skeletal problem; and • Requiring only a short period of postsurgical orthodontic
treatment to detail the occlusion.

53. An alternative philosophy advocates completing only minimal tooth movement before
carrying out the surgery as early as possible. The advantages of this approach include
the following: • Improved facial aesthetics are achieved earlier in treatment; •
Subsequent tooth movement is more predictable and achievable within a class I
skeletal environment; • Local metabolic changes associated with postsurgical healing
facilitate more effective tooth movement; and • Surgical repositioning is rarely
completely accurate and therefore the sooner postsurgical orthodontic treatment can
be instigated, the better.

54. While these arguments and proposed advantages have some validity they are marginal
and conventional wisdom would suggest achieving maximal occlusal decompensation
prior to surgery.

55. Alignment of the dental arches Orthodontic alignment of the dental arches will be
necessary. Space requirements will need to be assessed and if these are high, tooth
extraction may be needed (Box 12.3). However, in surgical cases the planned
anteroposterior and vertical position of the upper and lower incisors can significantly
influence space requirements.

56. Archwire Coordination
• It is important throughout treatment. • Most critical with heavier
round wires and . 019x.025 SS. • Arch form templates can be used
for coordination. • The upper wire should superimpose
approximately 3mm outside lower wire. • This is representative of
overlap of the upper teeth relative to the lower teeth.

57. Extractions and orthognathic surgery
Extractions may be required to provide space for tooth alignment and
levelling, incisor decompensation or access for segmental osteotomy cuts.
However, it is important to note that tooth movements required for
orthodontic camouflage are often directly opposite to those necessary for
decompensation prior to surgery, and extractionbased camouflage
treatment should be approached with some caution in individuals with
significant skeletal discrepancy.

58. A good illustration is extraction of premolars in the mandibular arch of a class III case.
These will often be required to provide space for retroclination of the lower incisors if
orthodontic camouflage is planned; however, if this treatment proves to be
unsuccessful and surgical decompensation is subsequently required, the lower incisors
will need to be proclined

60. If premolars have previously been extracted, this will lead to considerable
space opening up in the buccal segments. For this reason, particularly in
class III cases, if there is any suspicion that orthognathic surgery may be
required, mandibular premolar extractions should be avoided and any
treatment decisions delayed until facial growth has ceased.

61. Class II cases may require extraction in the mandibular arch if there is any degree of
crowding, particularly if this is combined with a requirement to upright or intrude the
incisors. Proclination of the mandibular incisors is usually undesirable because it will
reduce the amount of potential forward surgical movement of the mandible

62. . In the maxillary arch of class II cases, crowding is generally less common,
incisor movement rarely requires significant space (quite the contrary in a
class II division 2 malocclusion) and some arch expansion is often
desirable; therefore extractions are rarer. If the incisors are retroclined,
space will be generated as they are moved forwards to create an overjet
necessary to facilitate mandibular advancement .

63. • Class III cases do not usually require extractions in the mandibular arch,
crowding is generally rare because of the increased arch length associated
with an enlarged mandible and space is often generated as a result of the
incisor proclination required for decompensation.

64. In contrast, space is often at a premium in the maxilla, arch length can
be reduced because of a small and narrow upper jaw and there is
commonly crowding. To make matters worse, the incisors often require
some retroclination, which requires space, and therefore premolar
extractions are commonly required (Fig. 12.5).

65. A class III case treated with a maxillary
advancement and mandibular setback. Maxillary
first premolars were extracted as part of the
orthodontic decompensation, largely to provide
space for alignment of the upper labial segment
and some presurgical centreline correction

66. Altering the labiolingual position of the incisors
The final labiolingual position of the incisor teeth is important because it
will dictate the amount of surgical movement that can take place in the
anteroposterior dimension. Any existing dentoalveolar compensation that
would restrict this movement needs to be corrected prior to surgery.
Inevitably, these incisor movements can lead to considerable worsening of
the malocclusion during this period and the patient should be made
aware of this before treatment begins (Fig. 12.6).
Orthodontic decompensation will create an overjet in a
class II division 2 malocclusion (upper) and increase a
reverse overjet in a class III malocclusion (lower

68. • Class II cases often require maximal forwards movement of the mandible
and this is achieved by ensuring an overjet is present. Retroclination of
lower and occasionally some proclination of the upper incisors can be
required in class II division 1 cases, while in class II division 2 cases a
significant amount of upper incisor proclination is usually needed.

69. • Class III cases are often associated with the opposite situation. The upper
incisors are proclined, while the lowers are retroclined, and presurgical
orthodontic treatment mechanics are required to reverse these positions
and produce a reverse overjet.

70. Arch levelling
An excessive or reduced curve of Spee in either the maxillary or
mandibular arch will require levelling if good interdigitation of the teeth is
to be achieved in the final occlusion. This can take place at one of three
time points during treatment and the choice of mechanics will be dictated
by the method of levelling employed.

71. (a and b) Bilateral sagittal split osteotomy (c) Vertical augmentation
geneoplasty. (d) Panoramic radiograph after 2 weeks of surgery

73. Arch levelling prior to surgery
A decision to level the arches using orthodontic treatment mechanics
prior to surgical repositioning of the jaws usually takes place in the
absence of severe discrepancies in either of the occlusal planes. Levelling
can be achieved with incisor intrusion, molar extrusion, a combination of
these two movements or, more rarely, incisor proclination.

74. • With mandibular surgery alone, levelling a curve of Spee with incisor
intrusion will result in the lower face height being maintained following
surgery and is usually planned for patients with acceptable vertical
proportions .

75. • In the patient requiring posterior impaction of the maxilla to correct an
open bite, care should be taken if orthodontic levelling of a reduced
curve of Spee in the maxillary arch will involve excessive extrusion of the
incisors. Following surgery, any vertical relapse of these teeth will result in
a tendency toward reopening of the open bite.

76. Initially, the maxillary right canine and the left first premolar were
extracted followed by placement of fixed appliances up to the
second molars

77. Arch levelling during segmental surgery
Occasionally, the vertical discrepancy is so severe that segmental jaw
surgery is indicated to achieve arch levelling. This is more common in the
maxilla in association with a markedly increased curve of Spee and
anterior open bite.
Segmental arch mechanics prior to maxillary
segmental surgery to correct an anterior open
bite (upper panel presurgery and lower panel
following surgery and appliance removal).

78. If a decision is made to correct this with segmental surgery, the
orthodontist will use segmented archwires to level the teeth within
segments and ensure that the vertical discrepancy is maintained prior to
surgery. Space will be required between teeth adjacent to the planned
segments to allow for vertical osteotomy cuts and premolar extractions
are often required to create this .
Segmental arch mechanics prior to maxillary segmental surgery
to correct an anterior open bite (upper panel presurgery and
lower panel following surgery and appliance removal).

79. Arch levelling following surgery
Arch levelling following surgery Class II cases with a reduced lower
anterior face height are often associated with an increased curve of Spee
in the mandibular arch. It is desirable to increase the lower face height in
these cases as the mandible is advanced and this is achieved by
maintaining the curve of Spee prior to surgical movement.
A three point landing maintains a curve of Spee in the
mandibular arch and allows an increase in face height as
the mandible is advanced. The posterior open bites are
closed down after surgery with extrusion of the
posterior teeth

80. The lower incisor position ensures an increase in face height as the
mandible is advanced and the arch is subsequently levelled by extrusion of
posterior teeth during the postsurgical period. This technique is known as
a ‘threepoint landing’ because in the initial postsurgical position there is
only tooth contact between the incisors and posterior molars. Clearly, in
these cases it is important that the orthodontist maintains the curve of
Spee in the mandible prior to surgical repositioning.
A threepoint landing maintains a curve of Spee in the mandibular arch and allows an increase in face
height as the mandible is advanced. The posterior open bites are closed down after surgery with
extrusion of the posterior teeth.

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