2/12/2019

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Aya Khamaiseh

Aya Khamaiseh
Dr. fadi jarrab

Orthognathic surgery – part 3 -

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‫يُطلب من جمعية التصوير الطبية‬
 Orthognathic surgery - part 3 -
 orthognathic surgery is done when the problem can’t be fixed dentally or by
orthodontic treatment because the problem is in the base ( which holds the
teeth ) that’s why it requires surgical correction .

 example : a 9 or 10 year old patient comes in with a prominent lower jaw :

 since the patient is still a grower , he’s not suitable for orthognathic surgery.
 orthognathic surgery is done after the growth is completed
 Boys ( minimum 18 years old ) ( its known that boys keep growing 
longer than girl )
 Girls ( minimum 16 years old ) ( some say they keep growing till 21 )

o when the patient is still a grower there are other treatment options such as
functional appliances where an orthodontist would be consulted .

o but later on after the growth is completed , we can go for orthognathic surgery .

 as we said earlier the aetiology of skeletal disproportion could be :

1. Genetic pattern ( most common cause ) :
 for example class 3 , 2 runs in families .

2. Embryonic disturbance of growth :

 for example ( cleft lip and palate / hemifacial microsomia )
 hemifacial microsomia is caused by the haemorrhage of the stapedial
artery which causes malformation of the 1st and the 2ndbranchial arches
therefor effecting the structures supplied by it ( OMENS ) .

3. postnatal damage .
4. abnormal regulation of growth :
 for example ( condylar hyperplasia ) .

 in cases of gummy smiles :

- we use a ruler to measure :
1. the upper lip .
To know if the
2. the central incisors .
gummy smile is
3. the incisal show at rest .
muscular or bony
4. the incisal show when smiling .

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  the profile view is very important :
o for example in this picture the patient complains from a protruded lower jaw,
but when looking at the profile view we can see that the maxilla is the deficient
( retrognathic ) jaw , ( maybe the mandible is slightly prognathic, but the
maxilla is definitely the problem ) .

o its very important to use the profile view when diagnosing especially certain
angles such as the nasolabial angle ( 90 – 100 ) and the paranasal area ( if its
supported or depressed ) .

o those angles will prevent you from being mislead by the mandible in certain cases .

o we should asses the relationship of the maxilla to the face and then the
mandible will follow according to the occlusion .

 in the previous lecture we talked about wafers :

1. we take an impression of the upper and lower jaws .
2. we take a facebow record ( in order to relate the maxilla to the base of the
skull ) followed by articulation .
3. based on the clinical and radiographic examination I’m planning on advancing
the maxilla 3 mm and setting back the mandible 2 mm .
4. in the lab ( on the articulated casts ) I cut the maxilla using a saw and advance
it 3mm on the articulator , then ill set it with gypsum to secure it which leads
to a new occlusion .
5. using acryl we make an acrylic wafer ( the intermediate wafer ) to create a
new relation that I want to achieve in the patient , where the maxilla is
advanced 3mm . ( this is not the final relation ; we still have to set back the
mandible )
6. during the surgery I advance the maxilla 3mm and make sure its adapted to the
intermediate wafer we created .

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7. now for the mandible , in the lab I cut the mandible and set it back 2mm and
make another acrylic wafer ( the final wafer ) ( where both the maxilla and
mandible are in the goal position ) .
8. during surgery we set back the mandible 2mm and make sure its adapted to
the final wafer . ( the is the final relation )
9. now we place plates ( 2 plates on each side ) on the newly created occlusion.

An acrylic wafer registers the relation between the maxilla and the mandible
and has indentations on both sides from the upper and lower teeth .

CONDYLAR HYPERPLASIA
o The most common developmental cause of facial asymmetry is condylar
hyperplasia .
 Developmental : means that it happens after birth ( by itself / on its own )

o where suddenly the condyle is activated then overgrowth happens leading to CH .

o Its more common in young females ( also occurs in males but less )
o It starts at the age of 16 – 17 years where the patient comes in complaining of
facial changes ( asymmetry ) .
 Definition : An excessive unilateral growth of the mandibular condyle which
elicits facial asymmetry and occlusal alterations ( malocclusion ) .
o There will be an open bite on the affected side ( the side with overgrowth ) .
o It’s a Self-limiting condition :
 but while it remains active  asymmetry and malocclusion will remain
progressive.

o Before I start treating any case of CH I must know if it’s still active ( growing ) or
if its ceased ( stopped growing ) .
o Etiology remains uncertain / unknown .
 some say that it might be a previous trauma that predisposed to CH but its
still uncertain .

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 Obwegeser and Makek classified CH associated facial asymmetries into three categories:

1. Hemi-mandibular hyperplasia : which causes asymmetry in the vertical plane .

 where the face appears longer on one side than the other side .
 with an open bite on the effected side .

2. Hemimandibular elongation : which causes asymmetry in the transverse plane .

 where one side of the face elongates and deviates to the other side ( the
non-effected side ) .

3. A combination of the previous two entities.

 in most cases .

 Important points :
 Hemimandibular hyperplasia is a type of condylar hyperplasia .
 Hemimandibular hypertrophy is a separate thing that effects the soft tissues
only ( thickening of the soft tissues on one side more than the other side ) .
 The most common type of CH is the combination type .

 Hemimandibular elongation ( transverse plane )

 we look at the chin point and how its deviated to
the other side .
 you can see there’s a crossbite and a scissor bite .
 there’s no open bite ( which is only in
hemimandibular hyperplasia ) .

 Hemimandibular hyperplasia ( vertical plane )

 as you can see there’s an open bite .

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  combination type ( HM hyperplasia + HM elongation ) .

 in those cases there’s a midline shift .

 we depend on the chin for diagnosis more than the teeth

 because we don’t know if any of the dental problems were present before
or after the CH .

 condylar hyperplasia ( diagnosis ) :

1. OPG
 the condyles either look big or small .
 in cases of HM elongation the condyle appears small and slender( even
though the activity is higher,but itdoesn’t get enlarged ) .
2. Models
 where we take an impression and monitor the patient over a period of 2-3
months to make sure if the problem is progressing or not and if the
occlusion is changing or not .
3. Photos
4. radioisotopic bone scan
 the most important diagnostic tool for CH ( the first thing we think of when
presented with such cases )
 this investigation is usually done for cancer patients ( to see if the cancer
metastasized to a certain part of the body ) .
 this type of scan is sensitive but not specific ( its shows if there’s overactivity in
certain areas but not the type of activity , if its cancer or growth or anything else ) .
 in cases of CH when taking this scan = if there’s overactivity in the condyle
this means that the disease is still active , at that point the DR will decide to
treat or not to treat .
5. CT scan
 very important especially if I decided to do surgery .
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 we need a good CT scan prior to surgery because behind the condyle is the
maxillary artery and we have to avoid any damage to it .
 OPG

Always compare the right and left

sides in those scans

RADIOISOTOPIC
bone scan

 Condylar hyperplasia ( treatment ) :

1. Consider evidence of neoplasia :

 chondrosarcoma or osteosarcoma ……
 we should take a biopsy and send it to histopathology to rule out the
possibility of neoplasia especially if the plan is to perform surgery .

2. Consider evidence of continued growth :

 there are 2 schools for this :
 1st school says : let the growth finish and whatever deformity arises after it
we can treat it if the patient is willing ( because some patients get used to
the asymmetry ) .
 2nd school says : from the beginning we have to stop the disease process
and any deformity that arises after it will be easier to treat ( with less
psychological effect on the patient ) .
 whatever school you are doesn’t matter as long as you know what the
disease is, and the patient should be entirely involved in the process .
 the patient has to know that this disease (CH) is active for 2-3 years
and then stops , so in order to stop the disease process , the
patient has to go through surgery ( which is not easy ) and there
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might be a second surgery too .
 If the growth has not ceased ( stopped ) :
 high condylar shaving or condylectomy followed by correction of the deformity .
what happens during condylar shaving ?
 a preauricular incision ( Infront of the ear ) is done to reach the TMJ .
 we cut the uppermost part of the condyle ( where the activity is higher ) .
 roundation .
 follow up for 6 months to make sure the activity has ceased and see if
the patient wants to correct the facial deformity ( by genioplasty or
BSSO .. ) because sometimes patients with minor facial deformity refuse
further treatment ( so it depends on the patient’s choice ) .

o high condylar shaving is done when most of the activity is in the

uppermost part of the condyle .
o condylectomy is done when the entire condyle is overactive , so we
remove the entire condyle .

 If the growth has ceased ( stopped ) :

 orthognathic surgery .
 surgical camouflage .
 For example the patients chin is deviated to the left ; we can do neoplasty and
repair the deformity instead of removing the entire thing (camouflage) .

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  the process of condylar shaving :

This is
the head
of the
condyle

- one of the most important things about the facial

nerve during condylar shaving or other surgeries
close it , is to know in which level you are .

in the face and the neck we have something This is

known as THE SMAS LAYER: the pre-
auricular
o which is a superficial muscular aponeurotic incision
system .
o the facial nerve is just below this layer .
o in order to know in which level we are , we
have a reference point which is the
temporalis muscle.
o when we expose the temporalis muscle
we’ll see the temporal fascia ( blistering /
white / very noticeable ) and at this point This is
the
we can go deeper in the preauricular area
temporal
and raise the flap to reach the TMJ
fascia
knowing that the facial nerve is in the flap
that was raised ( protected ) .

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 possible drawbacks of condylar shaving ?
 hypermobility
 popping sounds
 shortening
 malocclusion ( which is compensated by overeruption of certain teeth )

 when shaving the condyle there’s a risk of ankylosis .

 there’s always a risk of ankylosis in every TMJ surgery .

HEMIFACIAL MICROSOMIA
o definition : (HFM) is a deficiency in the amount of hard and soft tissues on one
side of the face. It is primarily a syndrome of first and second branchial arches
involving underdevelopment of the temporomandibular joint, mandibular ramus,
masticatory muscles, ears and occasionally defects in facial nerve and muscles .

o OMENS classification is very important in HFM Because it represents the

structures that are affected by HFM .

 O : orbit / M : mandible / E : ear / N : nerves / S : soft tissue .

The stapedial
o the cause of HFM : when the stapedial artery hemorrhages it will artery supplies
cause malformation of the 1st and 2nd branchial arches which will the 1st and
2ndbranchial
affect the structuressupplied by them ( OMENS ) .
arches .

o HFM is the most frequently encountered form of isolated facial asymmetry.

o HFM is the second most common congenital facial anomaly after cleft lip and
palate with a reported incidence between1 : 5000 and 1 : 5600 live births.
o Males appear to be more frequently affected than females (3 : 2).
o The right side is affected more often than the left side.
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o It is usually unilateral (70%) and always asymmetrical. HFM is always
o it is always asymmetrical if it exhibits bilaterally . asymmetrical
o Although “hemifacial” refers to one half of the face, the
condition is bilateral in 10-31% of cases, with one side being more affected
than the other.

o In 48% of cases, the condition is part of a larger syndrome such as Goldenhar

syndrome .
 So every patient that presents with asymmetry has to be sent to an
internalist ( internal medicine / internist ) to rule out the possibility of other
syndromes .

o The OMENS classification (O – orbital distortion;M – mandibular hypoplasia; E

– ear anomaly; N – nerve involvement; and S – soft-tissue deficiency) is the
most comprehensive and therefore, one of the most commonly used systems .

 The OMENS classification represents the effected structures , but when it

comes to the management of the disease, we use another classification called
Pruzansky’s and Kaban’s classification .

 Pruzansky came up with type l , ll , lll .

 Kaban made a modification of Pruzansky’s classification .

 Pruzansky’s classification :
 type l : all structures present ( mandible , condyle , ramus , glenoid fossa ) but
hypoplastic( a bit smaller than the other side ) .
 type ll : mandible has a functioning TMJ with a misshapen condyle (smaller)
and a ramus that is short and abnormally shaped.
 type lll : absence of the mandibular condyle and the glenoid fossa.

 In the Pruzansky’s system, the distortion of the adjacent facial skeleton is

directly related to the degree of mandibular deformity .

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  Kaban’s modification of Pruzansky’s :
o Type IIA : the TMJ, ramus and glenoid fossa are hypoplastic, malformed and
malpositioned, but the deformed joint is adequately positioned for symmetric
opening of the mandible.( hypoplastic more than type l ) and ( the TMJ is still
functioning , can open and close ) .
o Type llB : Type IIB the joint is malpositioned inferiorly and medially and will not
function as a TMJ for adequate symmetric opening of the mandible . ( the
TMJ is not functioning , can’t open and close )

 In the type IIA, the degree of hypoplasia of the mandibular musculature is

closer to normal than in the type IIB.
 type llA is closer to type l .
 type llB is closer to type lll .

What determines if we can treat HFM or not ?

 if there’s enough function in the TMJ or not .

o we don’t treat : type l , type llA

o we treat : type llB , type lll
( in order to restore function )

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  HFM ( treatment ) :
 There are essentially two approaches:
 An early approach:
 a costo-chondral bone graft.
 Distraction osteogenesis.
 A late approach :
 A classical osteotomy (i.e. bimax surgery with canting themaxilla in
combination with advancement of the mandible and lengthening the
ramus)
 A bimaxillary distraction osteogenesis .

 when there’s no function ( types llB , lll ) we perform surgery .

 sometimes if the pt. needs a new jaw we can ( take a graft from the ribs ) or ( use
prosthetic joints )

DISTRACTION OSTEOGENESIS

o we use this concept for bone development ( correction ) .

o there’re some problems that we might face in orthognathic surgery such as :
 advancing the mandible more than 8 mm ( as we know we can advance
the mandible up to 7-8 mm not more than that ) .
 a patient with a cleft palate that underwent a palatal surgery will have a
palate full of scars ( as we said in the previous lecture that we depend on
the palatal artery for the maxillary blood supply ) because of the scars , the
blood supply may become less ( lower ) and the movement of the maxilla
becomes harder .
o that’s why they came up with the concept of DO .

 the process of DO :
1. I have a piece of bone that ill break into 2 pieces and place a plate on each of the
pieces with a special device ( distraction appliance ) that separates the 2 plates .
2. I start to increase the distance between the 2 bones by 0.5 mm everyday .
3. the space that’s created between the 2 bones ( chamber ) will undergo bone formation .
4. with time we’re able to restore the bone without compromising anything
because it allows incremental bone formation , therefor the soft tissue will be
able to adapt to these changes . 12
 From Slides

o When correcting deformities, the conventional osteotomy techniques have

several potential limitations .
o When large skeletal movements are required, the associated soft tissue often
cannot adapt to the acute changes and stretching that result from the surgical
repositioning of bone segments. This failure of tissue adaptation results in
several problems, including surgical relapse, potential excessive loading of the
TMJ structures, and increased severity of neurosensory loss as a result of
stretching of nerves.
o DO involves cutting an osteotomy to separate segments of bone and the
application of an appliance that will facilitate the gradual and incremental
separation of bone segments .
o The gradual tension placed on the distracting bone interface produces
continuous bone formation. Additionally, surrounding tissue appears to adapt
to this gradual tension, producing adaptive changes in all surrounding tissues,
including muscles and tendons, nerves, cartilage, blood vessels, and skin.
o A Russian surgeon, Gavril Ilizarov, developed the current concept of correcting
bone deficiencies in the 1950s.

 DO involves several phases :

 the surgical / osteotomy phase :
 an osteotomy is completed, and the distraction appliance is secured(
without activation of the appliance )

 the latency phase :

 very early stages of bone healing begin to take place at the osteotomy–bone
interface. ( soft tissue and bone healing ) .
 The latency phase lasts generally 7 days ( 1 week ) ,
during which the appliance is not activated.

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  the distraction phase :
 begins at a rate of 1 mm per day: This distraction rate is usually applied by
opening or activating the appliance 0.5 mm twice each dayor 0.25 mm 4
times each day . ( depends on the case ).
 The amount of activation per day is termed rate of distraction.
 The timing of appliance activation each day is termed rhythm.
 During the distraction phase, the new immature bone that forms is called
regenerate bone .

 the consolidation phase :

 Once the appropriate amount of distraction has been achieved, the appliance
remains in place ( without activation ) during the consolidation phase .
 allowing for mineralization of the regenerate bone.
how long does the consolidation period take ?
 it depends on the amount of time the distraction phase took X2
(multiplied by 2 ).
 for example if the distraction phase took 2 months then the
consolidation phase takes 4 months after it . ( distraction 3 months
consolidation 6 months …. )

 the appliance removal phase :

 the appliance is removed at the correct time .

 the remodeling phase :

 the period from the application of normal functional loads to the complete
maturation of the boneis termed the remodeling period.

question :
when the goal amount of
distraction is reached , do
we immediately remove
the appliance ?
 NO we don’t , because we
have to wait for the
consolidation phase
*question :
when we need to advance the mandible more
than 8mm what do we start with ?
 we can do DO .
Or
 we can do DO and let the patient wait for a year
until the bone is completely healed and then we
can carry on with BSSO or any other surgery .
( we cannot do BSSO then DO )

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  Possible advantages of DO include :
 the ability to produce larger skeletal movements .
 elimination of the need for bone grafts and the associated secondary surgical site .
 better long-term stability .
 less trauma to the TMJ .
 decreased neurosensory loss.

 DO also has certain disadvantages:

 The placement and positioning of the appliance to produce the desired vector
of bone movement is technique sensitive and sometimes results in less than
ideal occlusal positioning, resulting in discrepancies such as small open bites
or asymmetries .
 The need for two procedures:
1. placement .
2. removal of the distractors.
 increased cost and longer treatment time, with more frequent
appointments.

** One of the earliest uses of the DO concept in orthognathic surgery

involved widening of the maxilla with a technique termed surgical-assisted
rapid palatal expansion.

Good Luck

If you found any

mistake or something
missing from the
script please add it to
the correction zone .

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