Orthognathic surgery

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Definition
The simplest definition of orthognathic surgery is the alignment of the jaws to
normalize the relationship between the jaws themselves and the rest of the
craniofacial complex.
Causes of dentofacial deformities
The development of proper craniofacial form and function is a complex process.
Some parts of the craniofacial complex have their own intrinsic growth potential,
including the spheno-occipital and sphenoethmoidal synchondroses and the nasal
septum.
The majority of the growth of the bones of the face occurs in response to
adjacent soft tissue and the functional demands placed on underlying bone
including the nasal, oral, and hypopharyngeal airway; facial muscles; and muscles
of mastication.
The general direction of normal growth of the face is downward and forward with
lateral expansion. The maxilla and the mandible grow by remodeling or
differential apposition and resorption of bone, producing changes in three
dimensions.
Alterations in the pattern of growth or in the rate at which this growth occurs
may result in abnormal skeletal morphology of the face and an accompanying
malocclusion.
Malocclusion and associated abnormalities of the skeletal components of the face
can occur as a result of a variety of factors:
1. Inherited tendencies; such as a familial tendency toward a prognathic or
deficient mandible, racial characteristics (anterior bimaxillary protrusion in
black Africans and Chinese or zygomatico-maxillary hypoplasia in Asians),

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 congenital abnormalities and syndromes, cleft lip and palate and
craniosynostosis which is the premature fusions of craniofacial sutures.
2. Prenatal problems; such as intrauterine molding of the developing fetal head
may result in a severe mandibular deficiency.
3. Systemic conditions that occur during growth; such as fetal alcohol syndrome,
which may result in hypoplasia of midface structures.
4. Trauma; such as trauma to the temporomandibular joint in a growing child
may result in alteration of growth causing deficient or asymmetric mandibular
growth.
5. Environmental influences; such as abnormal function after birth including
abnormal tongue position and size, respiratory difficulty, mouth breathing, and
abnormal lip postures.
Treatment objectives
The main objectives of orthognathic surgery are:
1. Obtain functional occlusion with teeth in the most ideal position.
2. Correct underlying skeletal disharmony.
3. Obtain maximum esthetic results
4. Skeletal stability.

Evaluation of patients with dentofacial deformities

Management of patients with dentofacial deformities requires integration
between orthodontics and surgery. Treatment by orthodontics alone may result
in an acceptable occlusion but a compromise in facial esthetics. While treatment
by surgery without orthodontics may result in improved facial aesthetics but a
less than ideal occlusion. In addition to orthodontic and surgical needs, these
patients often have many other problems requiring periodontic, endodontic,
complex restorative, and prosthetic considerations.
Assessment of orthognathic patients should be carried out systematically to have
a complete understanding of the presenting dentofacial deformity. This
assessment includes:

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General assessment

 Patient’s perception of the problems and the goals of any possible treatment.
Patient concerns generally fall into two main categories; functional and
esthetic problems. Functional problems could be related to difficulty in biting
and chewing, discomfort due to malocclusion, TMJ dysfunction, or speech
difficulties, whereas esthetic problems could be related to facial or dental
appearance or due to gingival display.
 The patient’s current health status and any medical or psychological problems
that may affect treatment.
 History of dentofacial deformity and its progression; the main points are
whether the anomaly is congenital or acquired, familial traits, or racial
characteristics.
Facial assessment
The patients should be evaluated in natural head position, or when the Frankfort
plane is parallel to the floor, any habitual tilting should be avoided.
Evaluation of facial esthetics in the frontal view should assess the presence of
asymmetries and evaluate overall facial balance:

 Vertical and transverse proportions; normally proportioned face is divided into

equal thirds. Lower anterior facial height is reduced in short-faced patients and
increased in long-faced patients. Transversely the face can be divided into
equal fifths; the middle fifth should equal the width of the alar base and
intercanthal distance.
 Vertical and transverse asymmetries; vertical symmetry is evaluated in
reference to inter-pupillary line, canting of the maxillary occlusal plane by
placing a wooden tongue spatula across the premolars and relating it to the
inter-pupillary line. Transverse symmetry is evaluated by an imaginary facial
midline perpendicular to the inter-pupillary line, only significant asymmetries
need assessment. The dental midline and chin position should be assessed in
relation to the facial midline.
 Ear shape and position.

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 Scleral show and eyelid position; the lower eyelid should rest at the inferior
border of the iris with no scleral show.
 Upper incisor show; this should be done with the lips fully relaxed and in full
smile. Normally only 2-3 mm of the central incisors should show in relaxed lips.
 Lip form and symmetry.
The profile evaluation allows an assessment of the anteroposterior and vertical
relationships of all components of the face including Jaw relationship and facial
convexity, forehead, infraorbital rims, nose, paranasal regions, upper lip, lower lip
and chin, lower lip to submental plane angle, and mandibular plane angle.
Intraoral assessment

 Assessment of dental arch form, symmetry, tooth alignment, and occlusal

abnormalities in the transverse, anteroposterior, and vertical dimensions.
 Dental problems: missing teeth, severe caries, extensive dental restorations, or
root resorption, must be identified because they may influence treatment
design.
 Periodontal status: preexisting periodontal pathologies could be exacerbated
during orthodontic and orthognathic surgical treatments.
 Tongue assessment: an enlarged tongue (macroglossia) can cause
dentoskeletal deformities and instability of orthodontic and orthognathic
surgical treatments and create masticatory, speech, and airway management
problems.
The muscles of mastication and TMJ function should also be evaluated.
Impressions and a bite registration for dental cast construction and evaluation
should also be obtained. The study models are either physical plaster models or
digital e-models. The plaster models should be orthodontically trimmed with
accurate occlusal registration with monitoring of occlusal changes.

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Radiographic evaluation
Panoramic and lateral cephalometric radiographs are routinely used in patient
evaluation and are an important part of the initial assessment.
The panoramic radiographs assess dental-related pathology, and mandibular
morphology including the condylar head and neck, the ramus, the antegonial
angle, the body, the inferior alveolar canal, the shape and extent of the maxillary
sinus and the maxillary alveolar process.
Lateral cephalometric radiograph is usually used for quantitative analysis using
numerous landmarks, lines, and angles to measure different aspects of
dentofacial complex, the values obtained are compared with the normal values. It
can also be used for qualitative analysis using average templates from normal
population, or superimposition to identify differences between 2 cephalometrics
to assess growth, treatment changes or relapse.
Currently, cone-beam computerized tomography (CBCT) has become the state of
the art for most radiographic examinations of facial bones to plan orthognathic
surgery. Cephalometric and panoramic views can be reconstructed from the
CBCT. Its applications are:

 Assessment and diagnosis of complex dentofacial problems

 3D orthognathic prediction planning.
 Anatomical information; position of nerves and teeth and orientation of
mandibular rami.
 Fabrication of 3D models.
 Postsurgical evaluation.
Other useful diagnostic records include clinical photographs, 3D images
(stereophotogrammetry), facial animation, and 4D imaging (3D with movement).

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Skeletal classification
The original Angle’s classification of Class I, Class II, and Class III described dental
malocclusion, over the years it also became a way of classifying skeletal
relationships of the maxilla and mandible with corresponding Class I, Class II, and
Class III. Specifically, these classifications are:

 Class I skeletal: The maxillary base is in a normal anteroposterior relationship

to the mandibular base.
 Class II skeletal: The mandibular base is posterior to the maxillary base
because of maxillary prognathism, mandibular retrognathism, or both.
 Class III skeletal: The mandibular base is anterior to the maxillary base because
of maxillary retrognathism, mandibular prognathism, or both.
These correlations between dental occlusion and the skeletal pattern do not
always exist. A Class II molar occlusion can coexist with a Class I canine
relationship within a Class I skeletal pattern with a premolar extraction. Thus
when using Angle’s original terminology one must be careful as to its reference:
molar, canine, or skeleton.
Furthermore, it is an inadequate classification system for the description of
dentofacial skeletal deformities. For instance, a Class III skeletal relationship can
be a result of either solely the maxilla, solely the mandible, or a combination.
Although it may give a visual description, it is not sufficiently specific to indicate
which element requires correction.
Pre-surgical treatment phase
Periodontal considerations: oral hygiene instruction, scaling, and root planing; in
certain instances, flap surgery to gain access for root planing may be necessary to
provide proper tissue health. Soft tissue grafting to provide a zone of attached
keratinized tissue that is more resistant to potential orthodontic and surgical
trauma should also be accomplished during this phase of therapy.
Restorative considerations: all carious lesions must be restored early in the pre-
surgical treatment phase. In some cases, the final restorative treatment is delayed

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until the proper skeletal relationships are achieved and the finishing orthodontics
is completed.
Orthodontic considerations: pre-surgical orthodontics aims to correct
compensatory tooth movement and arch malalignment, recreating the primary
malocclusion and allowing balanced surgical correction of the skeletal bases. In
general, these corrections will make the malocclusion look worse pre-surgically,
but it will show the true magnitude of the skeletal problem thus allowing an
optimal surgical correction. The objectives of pre-surgical orthodontics are:

 Decompensation of dentition; it is aimed at improving the angulation of teeth

over underlying bone, after which skeletal problems are corrected.
Undesirable angulation of the anterior teeth occurs as a compensatory
response to a developing dentofacial deformity. Dental compensations for the
skeletal deformity are corrected before surgery by orthodontically
repositioning teeth properly over the underlying skeletal component, without
consideration for the bite relationship to the opposing arch.
 Alignment of arches: gross crowding, spaces, or rotations are corrected.
 Coordinate arches: the shape and dimensions of the maxillary and mandibular
arches are made compatible so that they will occlude reasonably following
surgery.
 Leveling of arches.
Treatment Timing
Treatment of the stable adult deformity can be started without delay, however,
questions often arise about how best to manage the growing child who is
identified as having a developing dentofacial deformity.
Orthognathic surgery may be undertaken:

 During growth; considered as interceptive surgery indicated to restrict an

unfavorable growth to minimize the degree of subsequent dentofacial
deformity. Functional appliance therapy may be the preferred approach for a
growing patient. As a general guideline, orthognathic surgery should be
delayed until growth is complete in patients who have problems of excess

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 growth, although surgery can be considered earlier for patients with growth
deficiencies.
 After growth cessation; considered as definitive surgery.
Treatment planning
The ideal orthognathic planning should achieve the following objectives:
1. Determine the final post-surgical dental occlusion.
2. Demonstrate the post-surgical soft tissue facial appearance.
3. Determine the magnitude of skeletal hard tissue movement necessary at the
time of surgery.
These objectives can be met by the following methods:
Model planning; this is based on surgical procedures performed on study models
(mock surgery) to determine the direction and distance of surgical movement
necessary to achieve desired postoperative occlusion and facial aesthetics. The
pre-surgical models, centric relation bite registration, and face-bow recording for
model mounting are completed. The casts are mounted on a semi-adjustable
articulator and are sectioned and mobilized to achieve normal occlusion.
Intraocclusal wafers are constructed on this final occlusal setup for use at the
time of surgery to align osteotomies and dental segments into the desired
postsurgical position. The limitation of this procedure is that it provides no
information about soft tissue changes.

Two-dimensional (2D) soft tissue profile prediction planning; the change in facial
appearance can be demonstrated with the use of computer technology by
superimposing digital images of the patient’s profile over bone landmarks
obtained from the cephalometric radiograph. The bone structures are then
manipulated to duplicate the bone movements desired at the time of surgery.
The computer can then produce a digital image that represents the facial esthetic
result produced by the associated facial skeletal change.

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Advantages of using this type of technology:

 The ability to predict the facial changes that may result from a particular
surgical correction.
 The facial images are also more easily evaluated by patients, allowing them to
assess the predicted results and provide input into the surgical treatment plan.
Disadvantages of this technology:

 The predictions are limited to 2D predictions showing only the lateral profile.
 The inability of the computer to predict accurately every type of surgical
change for every patient.
Three-dimensional (3D) computerized surgical planning
Recent advances in imaging technology and 3D computer planning have improved
the precision of surgical correction of dentofacial deformities.
Using surgical planning software systems to produce a computerized model of the
skeletal and occlusal abnormalities where the planned osteotomies can then be
designed and surgical movements created to reposition the skeletal and occlusal
components into the corrected positions. It requires CT acquisition, 3D imaging,
or laser scanning. Digital photographs are superimposed on the 3D CT data and a
virtual model of the face is constructed. Movement of the skeletal components
produces soft tissue changes that can then be visualized in three dimensions. The
splint can also be designed using 3D computer technology with splint construction
completed using computer-aided design and computer-aided manufacturing
(CAD-CAM) rapid prototyping.

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