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Cirugia de Modelos Ellis
Cirugia de Modelos Ellis
4&1161-1167,199O
Mock surgery on dental casts is a routine proce- during bimaxillary surgery. In the usual sequence of
dure for purposes of both diagnosis and treatment steps performed during bimaxillary model surgery,
planning in patients with dentofacial deformities. the first is repositioning the maxilla. After section-
The technical details of model surgery have ap- ing the maxilla, repositioning it in all three planes of
peared in the clinical literature for years, with little space to the desired location is extremely difficult.
difference in their content.lm5 However, all tech- In isolated maxillary model surgery, the mandible
niques described contain potential errors that serves to determine the proper anteroposterior and
lead to inaccuracy and difficulties. These can be transverse position of the maxilla once the proper
summarized as 1) improper mounting of the casts; vertical dimension has been attained. In contrast,
2) errors in the placement of reference lines on the during bimaxillary model surgery the mandible can-
casts; and 3) errors in measuring the surgical dis- not be used as a guide for maxillary repositioning
placement of segments. because it will also undergo changes in position.
The most difficult aspect in performing model The necessity of holding the maxillary cast on the
surgery is in the repositioning of the maxillary cast articulator against the pull of gravity adds to the
difficulty; frequently, it becomes displaced before it
can be secured.
* Associate Professor, Oral and Maxillofacial Surgery, The Because surgical splints are made from the repo-
University of Texas Southwestern Medical School, Dallas.
This research was supported in part by a grant from the sitioned models, it is important that model surgery
Chalmers J. Lyons Academy-James R. Hayward Research be performed accurately as errors will be trans-
Fund. posed to the patient. To date, no studies have been
Address correspondence and reprint requests to Dr Ellis: Di-
vision of Oral and Maxillofacial Surgery, The University of performed that determine the accuracy of maxillary
Texas Southwestern Medical School, 5323 Harry Hines Blvd. model repositioning during bimaxillary model sur-
Dallas. TX 75235. gery. The purpose of this investigation was to de-
0 1990 American Association of Oral and Maxillofacial Sur- termine how accurately 4th-year residents can per-
geons form maxillary model repositioning during bimaxil-
0278-2391/90/4811-0005$3.00/0 lary cases.
1161
1162 ACCURACYOFMODELSURGERY
Methods
FIGURE 4. Method of measuring the anteroposterior position FIGURE 6. Method of measuring the mediolateral position of
of the maxillary incisor. The model-block is simply turned on its the posterior maxillary dental arch. The caliper is brought in
side (heel) and a measurement is taken to the facial surface of the contact with the facial surface of the first (or second) molar or
incisors. orthodontic tube.
ring for determination of the vertical position of the direction. Thus, mean error values reported repre-
maxilla. Once the resident felt that the maxillary sent total variance from the planned value, not di-
model was in its proper postsurgical position, it was rection of movement. Comparison between the
returned to the model-block for repeated measure- planned and actual movements for each variable
ments by the author to determine the actual changes were made using the paired t test. Pearson’s corre-
induced by model surgery. lation coefficients were calculated to determine the
The planned and actual values for the change in significance of interactions between variables.
anteroposterior and vertical position of the incisor,
the vertical position of the molars, the position of Results
the dental midlines, and the mediolateral position of
the dental arch at the first molars were tabulated. The data for each of the 20 cases are presented in
All measures were converted to positive numbers Table I. The anteroposterior position of the central
for statistical analysis to factor out differences in incisor in the twenty cases had a mean deviation of
1.2 mm (SD, 0.9) from the planned value. This was
a statistically significant difference (P < 301). The
1 vertical position of the central incisor had a mean
deviation of 1.1 mm (SD, 1.2; P < .OOl) from the
planned value. The vertical position of the right and
left molars had mean deviations of 1.1 mm (SD, 0.9;
P < 301) and 1.2 mm (SD, 1,l; P < .OOl), respec-
tively, from planned values. The mediolateral
change in position of the maxillary midline varied
0.9 mm (SD, 0.5; P < 301) from the plan. The
mediolateral change in position of the first molar
(posterior dental arch) varied 1.9 mm (SD, 0.7; P <
401). Thus, the mean movements of the maxilla for
all variables were significantly different from the
planned movements at greater than the .OOl level of
confidence. This statistical test, in effect, analyzed
the mean difference between the planned and actual
positioning of the maxilla to determine if they were
FIGURE 5. Method of measuring the mediolateral position of
the maxillary dental (incisor) midline. This is performed by tum-
significantly different from 0, which they were. The
ing the model-block on its side and sliding the caliper to the data were also subjected to the paired t test to de-
interdental space between the incisors. termine the significance of differences between the
1164 ACCURACY OF MODEL SURGERY
Table 1. Predicted and Actual Measures of Maxillary Position After Model Surgery
A-P Ul v UI VU6R v U6 L ML M-L U6
Case P A P A P A P A P A P A
1 + 3.0 + 0.8 0.0 J 2.2 t 6.0 t 5.4 t 6.0 t5.1 0.0 0.4R 0.0 2.lR
(error) 3.8 2.2 0.4 2.1
2 -+ 5.0 -+ 4.4 t 6.0 t 5.0 t 6.0 t::: t 6.0 t::; 2.OR 1.6R 0.0 1.4R
(error) 0.6 0.3 0.4 1.4
3 + 7.0 -+ 7.1 0.0 1::: 0.0 7::; 0.0 t 1.3 0.0 0.6L 0.0 2.2L
(error) 0.1 0.7 0.6 2.2
4 0.0 +- 2.4 t 2.0 r::: t 7.0 f 6.8 t 7.0 t::: 1.5L 1.8L 0.0 2.6L
(error) 2.4 1.3 0.4 0.3 2.6
5 + 4.0 + 4.7 4 3.0 4 2.1 J 3.0 r::: 4 3.0 i 2.9 0.0 1.4L 0.0 3.lL
(error) 0.7 1.4 3.1
6 + 2.0 + 2.1 t 2.0 7;:: t 2.0 r::: t 2.0 r;:: 2.OL 1.5L 0.0 0.9L
(error) 0.1 0.2 0.5 0.9
7 + 3.0 -+ 2.1 J 3.0 r::: 4 4.0 r::; J 4.0 J 7.0 2.OR 2.5R 0.0 l.lR
(error) 0.9 0.1 3.0 0.5 1.1
8 + 5.0 + 5.8 0.0 J 0.8 0.0 1;:: 0.0 J 1.3 0.0 1.7L 0.0 2.8L
(error) 0.8 1.0 1.3 1.7 2.8
9 -+ 2.0 + 1.1 13.0 i;:: J 4.0 13.0 0.0 J 0‘7 2.OL 0.9L 0.0 2.4L
(error) 0.9 0.9 1.0 0.7 1.1 2.4
10 + 5.0 + 4.7 J 4.0 J 3.5 5_4.0 12.5 4 4.0 J 3.9 0.0 2.lR 0.0 2.lR
(error) 0.3 0.5 1.5 2.1 2.1
11 0.0 + 0.8 0.0 J 5.5 t 3.0 t 1.6 t 3.0 r::: 0.0 1.4L 0.0 2.5L
(error) 0.8 1.2 1.4 2.5
12 + 4.0 + 3.3 4 2.0 $:Z t 3.0 t::: t 3.0 t 2.9 0.0 1.8R 0.0 1.7R
(error) 0.7 1.8 1.7
13 + 5.0 -+ 2.4 t 4.5 ts:; t 6.0 7;:: T 6.0 t;:t 1.OL 0.2R 0.0 2.lR
(error) 2.6 1.5 2.2 2.9 1.2 2.1
14 + 2.0 + 3.8 t 7.0 t 8.1 t 7.0 T 6.7 t 7.0 16.7 2.OR O.9R 0.0 1.8R
(error) 1.8 1.1 0.3 1.1 1.8
15 0.0 + 0.8 t 3.5 t 4.0 13.5 7 1.9 t 3.5 T;:: 0.0 0.6 0.0 I .8R
(error) 0.8 0.5 1.6 0.6 1.8
16 -+ 2.0 --+ 1.3 J 3.5 J 3.5 -13.5 J 4.0 4 3.5 I::: 0.0 0.8L 0.0 1.5L
(error) 0.7 0.8 1.5
17 -+ 5.0 -+ 5.6 t 1.0 r::; t 1.0 t;:; t 1.0 r;:: 0.0 0.7R 0.0 1.3R
(error) 0.6 1.1 0.5 0.7 1.3
18 0.0 + 1.9 t 2.0 t;:; t 1.0 t4.6 t 1.0 $ 1.6 1.OR 0.4R 0.0 0.8R
(error) 1.9 0.3 0.6 0.8
19 + 10.0 + 12.0 0.0 to.2 0.0 4;:; 0.0 $ 0.0 0.8R 0.0 2.4R
(error) 2.0 1.5 0.8 2.4
20 0.0 --f 1.2 t 1.0 t::‘6 t 2.0 4::; t 2.0 12.1 0.0 0.4R 0.0 0.9R
(error) 1.2 0.4 3.2 4.1 0.4 0.9
Abbreviations: A, actual; A-P Ul, anteroposterior position of the maxillary central incisor; L, left; ML, maxillary dental midline (right
c) left); M-L U6, mediolateral position of maxillary first molar (either); P, predicted; R, right; V Ul, vertical position of the maxillary
central incisor(s); V U6 L, vertical position of the maxillary left first molar; V U6 R, vertical position of the maxillary right first molar;
+ , anteriorly; + , posteriorly; t , superiorly; J , inferiorly.
planned and actual maxillary movements greater tion noted was between the error in positioning the
than 1 mm. When the data were analyzed in this maxillary midlines and the error in mediolateral po-
manner, the only variable that still showed a signif- sitioning of the maxillary molar (r = .47; P < 0.05).
icant difference was the mediolateral position of the This showed that when there was an error in posi-
maxillary molars (P < .OOl). tioning of the maxillary midline, there was also an
Pearson’s correlation coefftcients showed that error in the mediolateral positioning of the posterior
there was a significant correlation between the error maxilla, and vice versa.
in vertical positioning of the right and left maxillary
molars (r = 31; P < .OOl). Thus, when the maxilla Discussion
was improperly positioned vertically on one side,
the other side also was improperly positioned in the The results of this investigation suggest that max-
same direction. The only other significant correla- illary model surgery performed in the classic man-
EDWARD ELLIS III 1165
in mediolateral positioning of the posterior maxil- to one side in the posterior area and the occlusion is
lary dental arch was 1.9 mm when measured at the correct, the mandible will also be skewed the same
first molar (P < .OOl). Seventeen of the 20 cases had direction, resulting in facial asymmetry.
greater than 1 mm, 10 had greater than 2 mm, and 1 An advantage to the use of the Erickson Model
had greater than 3 mm of change in the mediolateral Surgery Platform for performing maxillary model
position of the posterior maxilla that was not surgery in bimaxillary cases is that preexisting
planned. When this occurred, it usually accompa- asymmetries can be easily identified before model
nied movements in the dental midline to the same surgery so that they can be corrected during model
side (r = 47; P < .05). Although minor maxillary surgery. An asymmetry readily identifiable with
arch asymmetries may seem inconsequential, one this instrument is the one described above, ie, me-
must remember that the maxilla, once secured in its diolateral asymmetries of the posterior maxilla.
planned position, serves as the target for mandibu- These are difficult to determine any other way and
lar repositioning during bimaxillary surgery. There- readily lend themselves to correction during bimax-
fore, any asymmetry in the position of the maxilla illary surgery.
will be magnified in the mandible, especially at the Another common asymmetry one finds is differ-
gonial angles, as these are a greater distance from ence in the vertical position of the maxillary molars
the axis of the asymmetry. from one side to the other, ie, the “cant” of the
Those surgeons who look critically at their pa- maxilla. These are usually small; when larger than 1
tients may have noticed an occasional patient who to 2 mm, they can also be seen on an accurate ceph-
appears asymmetric after bimaxillary surgery to alogram and identified clinically with careful mea-
correct a symmetrical deformity. Most commonly, surements between the canines and the medial can-
one side of the face appears more prominent than thi using a caliper. Note in Table 1 that only one
the other, especially along the lateral surface of the case (case 9) had differential vertical movements of
rami. An examination of the dental midlines may the posterior maxilla planned. Of interest, however,
show alignment with the facial midline. However, is that 13 cases had greater than 1 mm, 5 had greater
alignment of the dental and facial midlines should than 2 mm, and case 9 had greater than 3 mm
not lull the clinician into a false sense of security of vertical difference from one side to the other
that the surgery has been performed correctly, for present before model surgery. This does not mean
the posterior maxilla may be asymmetrical, ie, that a cant was present in every case, as an asym-
skewed to one side (Fig 8). If the maxilla is skewed metry in the position of the auditory canals may
also have been present, distorting the face-bow
mounting. However, only case 9 was planned for
correction of this discrepancy. If minor cants were
diagnosed either clinically, radiographically, or on
the model platform, they could have easily been
eliminated with bimaxillary surgery.
Because of the difficulties performing maxillary
model surgery for bimaxillary cases on the articu-
lator, the author and associates have used the
model surgery platform for over 5 years. We have
found it simpler and more rapid than performing
maxillary model surgery on an articulator. Because
the maxillary model surgery is not performed on the
articulator, but on the model-block, ie, “upside-
down,” gravity works to the advantage of the sur-
geon and greatly facilitates repositioning of the
model. Any point on the cast is measured by simply
sliding the caliper to the point on the cast being
measured. These points may be dental, skeletal, or
soft tissue. Measurements along the dentition pro-
FIGURE 8. Illustration demonstrating how a facial asymmetry vide information on the location of the teeth before
can be present even while the maxillary dental midlines are co- and after model surgery. Measurements can also be
incident with the facial midline. If the posterior maxilla is rotated
recorded at any level along the proposed osteotomy
to one side or the other during maxillary surgery, the mandible
will follow because it will be occluded with the maxilla during side if one desires to determine the osseous changes
mandibular surgery. at that level.
EDWARD ELLIS III 1167
Using the model surgery platform, we have 3. Epker BN. Fish LC: Surgical-orthodontic correction of
open-bite deformity. Am J Orthod 71:278, 1977
learned that minor malpositions, so easily intro-
4. Hohl TA: Use of an adjustable (anatomic) articulator for
duced when performing model surgery on an artic-
case prediction in segmental surgery, in Bell WH, Profftt
ulator, are eliminated, resulting in more precise re- WR. White RP (eds): Sureical Correction of Dentofacial
positioning of the maxillary dental cast. The making Deformities. Philadelphia: PA, Saunders, 1980, pp 169-
177
of measurements directly to the teeth (and bones as
5. Hill SC: Cephalometric planning and mode1 surgery. In Bell
desired) assures that no surprises will result during WH (ed): Surgical Correction of Dentofacial Deformi-
and after surgery. ties-New Concepts. Philadelphia, PA, Saunders, 1985,
pp 217-226
References 6. Ellis E, Gal10 WJ: A method of accurately positioning the
maxillary incisor position in two-jaw surgery. J Oral Max-
illofac Surg 42402, 1984
1. Bell WH: Correction of the short-face syndrome-vertical
maxillary deficiency: A preliminary report. J Oral Surg 7. Stanchina R, Ellis E, Gal10 WJ, et al: A comparison of two
35:110, 1977 measures for repositioning the maxilla during orthog-
2. Bell WH, Creekmore TD, Alexander RG: Surgical correc- nathic surgery. Int J Adult Ortho Orthogn Surg 3:149.
tion of the long face syndrome. Am J Orthod 7140, 1977 1988