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Orthodontic‑orthognathic interventions in orthognathic surgical cases:

“Paper surgery” and “model surgery” concepts in surgical orthodontics
Narayan H. Gandedkar, Chai Kiat Chng, Vincent Kok Leng Yeow

Abstract
Thorough planning and execution is the key for successful treatment of dentofacial deformity involving surgical orthodontics.
Presurgical planning (paper surgery and model surgery) are the most essential prerequisites of orthognathic surgery, and
orthodontist is the one who carries out this procedure by evaluating diagnostic aids such as crucial clinical findings and radiographic
assessments. However, literature pertaining to step‑by‑step orthognathic surgical guidelines is limited. Hence, this article makes
an attempt to provide an insight and nuances involved in the planning and execution. The diagnostic information revealed from
clinical findings and radiographic assessments is integrated in the “paper surgery” to establish “surgical‑plan.” Furthermore,
the “paper surgery” is emulated in “model surgery” such that surgical bite‑wafers are created, which aid surgeon to preview the
final outcome and make surgical movements that are deemed essential for the desired skeletal and dental outcomes. Skeletal
complexities are corrected by performing “paper surgery” and an occlusion is set up during “model surgery” for the fabrication
of surgical bite‑wafers. Further, orthodontics is carried out for the proper settling and finishing of occlusion. Article describes
the nuances involved in the treatment of Class III skeletal deformity individuals treated with orthognathic surgical approach and
illustrates orthodontic‑orthognathic step‑by‑step procedures from “treatment planning” to “execution” for successful management
of aforementioned dentofacial deformity.

Keywords: Model surgery, presurgical orthodontics, surgical wafers, surgical orthodontics

Introduction surgery” to establish a “surgical‑plan.” Further, the “paper

Surgical orthodontics is one of the most challenging fields
in orthodontics which involves meticulous treatment
planning and execution engaging a multidisciplinary team.
In a multidisciplinary team, orthodontists play a vital role
in patient evaluation, data collection (photographs, study
models, and radiographs), and also, in performing the “paper
surgery” and “model surgery,” such that a “surgical wafer”
is created which facilitate surgeon to emulate the plan.
Presurgical planning (paper surgery and model surgery) is
the most essential prerequisite of orthognathic surgery.
The diagnostic information revealed from clinical findings
and radiographic assessments is integrated in the “paper
Department of Plastic, Reconstructive, and Aesthetic Surgery, KK
Women’s and Children’s Hospital, 229899 Singapore
Correspondence: Dr. Narayan H. Gandedkar,
Department of Plastic, Reconstructive, and Aesthetic Surgery,
Cleft and Craniofacial Centre and Dental Service,
KK Women’s and Children’s Hospital, 100 Bukit Timah Road,
229899 Singapore.
E‑mail: gandedkar.naru@gmail.com
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surgery” is emulated in “model surgery” such that surgical
bite‑wafers are created, which aid the surgeon to preview the
final outcome and make surgical movements that are deemed
essential for the desired skeletal and dental outcomes. We
describe a step‑by‑step procedure of “paper surgery” and
“model surgery” technique for successful orthognathic
surgery.
Our treatment plan is essentially a composite of clinical
evaluation and cephalometric (both lateral and postero‑antero
cephalograph) assessment. A. M. Schwarz was one of the
pioneers who used “facial profile” for the clinical assessment
of face with little or no use of cephalographs. Schwarz’s
“Gnathic profile field (GPF)” is a simple yet efficient clinical
appraisal of a patient’s maxillofacial profile pattern by
observing patient’s in profile view.[1‑4] Moreover, “rule of
thirds” is also applied for the evaluation and correction of
face. “Rule of thirds” is face horizontally divided into thirds
with lines drawn at hairline, eyebrows, and base of nose and
chin[5‑8] [Figure 1a and b].
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as the
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How to cite this article: Gandedkar NH, Chng CK, Yeow VK. Orthodontic-
DOI: orthognathic interventions in orthognathic surgical cases: “Paper surgery”
10.4103/0976-237X.188575 and “model surgery” concepts in surgical orthodontics. Contemp Clin
Dent 2016;7:386-90.

© 2016 Contemporary Clinical Dentistry | Published by Wolters Kluwer - Medknow 386

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Gandedkar, et al.: Paper and model surgery concepts in orthognathic surgery
Skeletal movements of orthognathic surgery are planned by
analyzing certain soft tissues landmarks. Although Schwarz
used these landmarks for photographic or clinical assessment,
we have adapted them to lateral cephalogram for the
planning of orthognathic surgery. Moreover, posteroanterior
(PA) cephalographs are used to assess and plan orthognathic
surgery for the correction of skeletal asymmetry.
GPF essentially involves certain landmarks which are
enumerated below [Figure 1a]:
• Nasion (Na): The junction of nasal and frontal bones at
the most posterior point on the curvature of the bridge
of the nose
• Orbitale (Or): A point midway between the lowest point
on the inferior margin of the two orbits
• Pogonion (Pg): The most anterior point on the contour
of the chin
• Porion (Po): The midpoint of the upper contour of the
external auditory canal (anatomic porion) or a point
midway between the top of the image of the left and
right ear‑rods of the cephalostat (Machine Porion)
• Subnasale (Sn): It is the transition point between the
nose and the upper lip. It is the projection of hard tissue
A point
• Frankfort horizontal plane: A line connecting Po to Or
• Orbitale vertical line
• Nasion vertical line.
Orthognathic surgical planning by applying the principles
of “paper surgery” and “model surgery” is described in the
following case.
Case Report
A 19‑year‑old female presented with chief complaints of
forwardly placed lower front teeth and a large lower jaw.
On examination, extraorally, she showed concave profile,
increased lower anterior face height, mild hypoplastic
maxilla, positive lip step, incompetent lips, hyperdivergent
growth pattern, and chin deviation to the left side by 4 mm
a b
Figure 1: (a and b) Showing gnathic profile field and “rule of
thirds”
387
[Figure 2a‑d]. Intraorally, she showed Class III molar and
canine relation, severe crowding of upper and lower anterior
teeth, reverse overjet of 2 mm, and occlusal canting with
3 mm upward movement of cant on the left side on smiling
[Figure 3a‑e]. Lateral cephalograph and orthopantomograph
confirmed the clinical findings [Figure 4a and b].
Treatment plan
From the clinical presentation and cephalometric evaluation,
it was apparent that the mandible was excessively large and
Class III deformity was a combination of prognathic mandible
in both vertical and anteroposterior planes and a deficient
maxilla. In addition, mandible deviated to 4 mm to left side.
Surgical orthodontics was planned for the correction of
largely deviated mandible and deficient maxilla.
Surgical treatment plan
The decision was made to commence presurgical orthodontic
treatment with extraction of all first premolars such that
severe crowding would be alleviated. Once the crowding is
resolved, clinical measurements and cephalographs will be
taken for surgical planning.
Treatment progress
All teeth were bonded with 0.022″ preadjusted brackets
(Smartclip®, 3M Unitek, St Paul, MN, USA) and all teeth
were ligated with 0.010 stainless steel ligature wire.
0.014″ Ni–Ti wires were placed in the upper and lower
arches were placed as initial archwires, and subsequently,
wires were changed to 0.016 × 0.022 Ni–Ti archwires and
were reached to 0.017 × 0.025″ stainless steel. Once the
crowding was alleviated, presurgical records were taken
(clinical measurement, photographs, study models, and
cephalographs) [Figures 5a and b].
Clinical measurements
Measurements which are more relevant to assess the extent
of asymmetries are taken into account, such as canine tip to
eye canthus (right and left side), chin midline, incisor show
a b
c d
Figure 2: (a-d) Pretreatment extraoral photos
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Gandedkar, et al.: Paper and model surgery concepts in orthognathic surgery
a b c the lateral cephalometric tracing and templates are cut
d e
Figure 3: (a-e) Pretreatment intraoral photos
a plane is to be applied with prudence as the canine tooth
b plane using lateral cephalograph tracing.[9,10]
Figure 4: (a and b) Pretreatment lateral cephalograph and
orthopantomograph images
a b
Figure 5: (a and b) Presurgical lateral cephalograph and
orthopantomograph
(at rest and at smile), and dental midline. In the present case,
the left canine tip to left canthus distance is shorter than the
right canine tip to right canthus by 3 mm, chin is deviated to
the left by 4 mm, incisor show at rest is 6 mm and at smile
is 11 mm, upper midline is on, and lower midline is shifted
to 4 mm to the left side.
Paper‑surgery planning and execution
Lateral and PA cephalographs are traced with acetate
matte paper. Maxilla and mandible templates are cut out
from both lateral and PA cephalographs tracings using
different colors in order to differentiate various movements
[Figures 6‑8].
Contemporary Clinical Dentistry | Jul-Sep 2016 | Vol 7 | Issue 3
Measurement planes and templates
Four measurement planes (three horizontal and one vertical)
are drawn on the PA tracing and one maxillary plane on
out. Planes such as greater wing‑superior orbital (GWSO)
plane, orbital plane, maxillary canine plane, maxillary plane
(autonomic nervous system peripheral nervous system), and
a vertical plane formed by the line passing through crista
galli perpendicular to the GWSO plane[9,10] were selected
as reference planes. The vertical plane running from crista
galli intersecting GWSO represents maxillary and mandibular
asymmetry in the transverse dimension and ascertains the
degree of mandibular and maxillary skeletal and dental
midline shifts in relation to stable skeletal structure of
the cranium. Orbital plane could also be used to ascertain
the maxillomandibular complex’s transverse asymmetry
provided the orbital plane is symmetrical. Maxillary canine
plane represents the vertical discrepancy of the maxilla while
taking maxillary canine into account. The maxillary canine
morphology may influence the maxillary canine plane. If the
canine tooth has anatomical aberrancies, such aberrancy must
be taken into consideration before using the maxillary canine
plane. Furthermore, the maxillary plane is used to ascertain
maxillary skeletal discrepancy in both sagittal and vertical
Five templates essentially lay down the surgical planning in
the sagittal and vertical plane. Surgical planning is further
explained in Figures 6 and 7. Once the surgical plan is
ascertained, maxilla and mandible models are mounted on the
articulator, and models are moved according to the planned
“paper surgery” such that surgical wafer is fabricated.
Results
Posttreatment images and lateral cephalographs show the
planned paper and model surgery is achieved, and also, show
the fulfillment of “GPF” and “rule of thirds” [Figures 9‑12].
The treatment resulted in a symmetrical facial form with
correction of largely deviated mandible and hypoplastic
maxilla to a more orthognathic facial profile. The facial
midline was in line with the dental midline with achievement
of proper overjet and overbite.
Discussion
This paper describes the GPF and “rule of thirds”
[Figure 1a and b] application in the planning of “paper and
model surgery.” “GPF” and “rule of thirds” provide a simple
and practical method of clinical evaluation of the soft‑tissues
relationship. The surgical wafers produced using this method
is precise and involves the orthodontist in every single step
of wafer fabrication, such that the orthodontist can control
all the variables. Although using three‑dimensional (3D)
virtual setup, some of the steps can be commuted from
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Gandedkar, et al.: Paper and model surgery concepts in orthognathic surgery

manual to computerized method, however, 3D has several

shortcomings, such as:
• 3D visualization and assessment is expensive in nature which
invariably requires computed tomography (CT) scanned
images which might add an additional financial burden[11]

a b
Figure 6: (a) Surgical planning is done in both sagittal and
vertical planes by placing maxilla template on the original
tracing. In vertical plane, the maxilla is impacted for 3 mm
and in sagittal plane, the maxilla is advanced for 3 mm both
at autonomic nervous system and peripheral nervous system.
Once the advancement and impaction is done, the maxillary
template is fixed. (b) The mandible autorotates upward and
forward due to maxillary impaction (big arrow). This autorotation
has to be taken into account while setting back the mandible.
The pivotal point for the autorotation of the mandible is at the Figure 7: The mandible is set back for 6 mm such that mandible
glenoid fossa (small arrow) is within the gnathic profile field

a b
Figure 8: (a) The maxillary deviation in the vertical plane is
corrected by pivoting the maxilla at the right canine tip such
that the right side is moved upward and left side is moved
downward. Once this movement is achieved, the maxillary
template is fixed. (b) Mandibular template is adjusted such Figure 9: Comparison of profile images of pretreatment,
that mandibular deviation is corrected in the transverse plane presurgical, paper surgery prediction, and postsurgery

a b c

d e
Figure 10: (a-e) Posttreatment intraoral photos

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Gandedkar, et al.: Paper and model surgery concepts in orthognathic surgery
a b
c d
Figure 11: (a-d) Posttreatment extraoral photos
• Stereolithography for the wafer fabrication is a must[9,10]
• 3D internal reference system is unreliable as it is difficult
to define and can be distorted by craniofacial deformity,
and also lack normative data[9,10]
• Additional set of skills in 3D assessment and planning is
required with expensive inventory[11,12]
• Soft‑tissues evaluation is not possible as the soft tissues
analog of CT images is unreliable due to the dearth of
reference and normative data[9,10]
• Superimposition of scanned digital cast model on the
CT image is cumbersome as artifacts incorporation may
lead to misalignment[12-14]
• Unclear reference landmarks on the 3D digital cast model
during transfer of initial cast model from optical scanner
might lead to inherent errors.[8,9,15-19]
Conclusion
Paper and model surgery provides a simple and efficient way
of assessing a dentofacial deformity with routinely available
chair‑side tools of evaluation. Through this case report, we
have shown that careful evaluation of some specific landmarks
and planes can lead to efficient planning and execution leading
to the correction of complex dentofacial deformity.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Contemporary Clinical Dentistry | Jul-Sep 2016 | Vol 7 | Issue 3
b
a
Figure 12: (a and b) Posttreatment lateral cephalograph and
orthopantomograph images
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