The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
4. Envelope of discrepancy
3 ranges of correction for any kind of
malocclusion
• Orthodontic tooth movement alone
• Tooth movement plus functional or
orthopedic treatment
• Surgical orthodontics
www.indiandentalacadem
y.com
4
6. Indications
A skeletal or dento-facial
deformity is so severe that the magnitude of
the problem lies outside the envelope of
possible correction by orthodontics alone
proffit
www.indiandentalacadem
y.com
6
12. Collection of records
Interview data
• Patient’s chief complaint
• Interview related to the patient’s social
psychological status
• Information related to the patient’s
physical status
www.indiandentalacadem
y.com
12
13. Collection of records
Patient’s chief complaint
2 groups
1. who are concerned about their
appearance, oral function
2. Older patients concerned about some
specific health related problems
www.indiandentalacadem
y.com
13
14. Collection of records
Social psychological status
An extension of chief complaint
• Motivation
• Expectation
personality
exceptional
Personality
inadequate
no problem
pathologic
personality
www.indiandentalacadem
y.com
14
15. Psychological considerations in
orthognathic surgery
“The area around mouth is both emotionally
charged and strongly connected with one’s self image”
- MACGREGOR
The face is the area of one’s body that produces the greatest
concern regarding physical attraction
A survey of over 100 adults ( Berschied et al )
- The people who are satisfied with their facial features
expressed greater self confidence
www.indiandentalacadem
y.com
15
16. Psychological considerations in
orthognathic surgery
Dento- facial defects are extremely prominent
Study done by Richardson (a normal child, a child with
crutches and a brace on the legs, 1 child with hand
missing, a child in a wheel chair, a child with a
facial deformity and an obese child)
It is impossible and foolish to treat the patient’s
physical condition without adequate understanding
and regard for the emotional frame work
www.indiandentalacadem
y.com
16
17. Psychological considerations in
orthognathic surgery
CONCEPT OF BODY IMAGE
( Individual’s self concept )
2 COMPONENTS
• BODY SENSE
– The actual appearance the
person sees when viewing himself in a mirror /
photograph
- SCHILDER & SCHONFELD
• BODY CONCEPT
- The internal process of how the
patient feels about his appearance
www.indiandentalacadem
y.com
17
18. Psychological considerations in
orthognathic surgery
• Internal motivation – originating within the patient
• External motivation - a desire to overcome others
The patient motivated by external pressures were very
poor candidates compared to the patients
responding to internal pressures
- EDGERTON &
KNOOR
www.indiandentalacadem
y.com
18
19. Psychological considerations in
orthognathic surgery
Structured interview technique
Prevent some of the pitfalls of cosmetic surgery that
result in postoperative dissatisfaction
Post operative dissatisfaction is usually as a result of
lack of understanding between the patient and
surgeon
www.indiandentalacadem
y.com
19
20. Psychological considerations in
orthognathic surgery
Structured interview technique
1. How does the patient perceive the deformity ?
2. How does the deformity affect the patient’s
personality ?
3. Why did the patient decide to have the problem
corrected ?
4. What does patient expect from surgery ?
5. Has the patientwww.indiandentalacadem ?
had previous surgery
y.com
20
21. Psychological considerations in
orthognathic surgery
• Positive reactors / group I
• Neutral reactors / group II
• Negative reactors / group III
www.indiandentalacadem
y.com
21
22. Psychological considerations in
orthognathic surgery
Is the deformity developmental or acquired ?
• Greater emotional stability is seen in patients with
congenital deformity
• No concept of NORMAL
• Patients with an acquired deformity will have a
distorted image of their former appearance
• Clinician should be frank about the possibilities of
treatment
Age
• Adolescents would be expected to have fewer
www.indiandentalacadem
postoperative emotional problems
y.com
22
23. Psychological considerations in
orthognathic surgery
Supportive measures
• Explaining the surgical goal
- Show the pictures of other patients
- encourage the patient
- limitations & risks must be explained
- should not promise
• Anticipating post operative depression
• Seeking psychiatric consultation
www.indiandentalacadem
y.com
23
24. Collection of records
Physical status
•
•
•
•
Medical history
Dental history
Family history
Evaluation of the physical growth status
chronic conditions are of great concern
www.indiandentalacadem
y.com
24
27. Collection of records
Clinical examination data
To determine what diagnostic records are
required
1. Health of the hard and soft tissues
2. Oral function including TMJ
3. Facial proportions and esthetics
www.indiandentalacadem
y.com
27
28. Collection of records
Health of the hard and soft tissues
•
•
•
•
OPG
– overall dentition
Bitewing – inter-proximal caries
Occlusal - palate & impacted teeth
Midline IOPAs
ex; diastema
www.indiandentalacadem
y.com
28
29. Collection of records
Periodontal health
•
•
•
•
Bleeding on probing
Periodontal breakdown
Pockets
Adequacy of attached gingiva
www.indiandentalacadem
y.com
29
30. Collection of records
Oral function
•
•
•
•
Speech - lisping
Mastication
Cheek & lip biting
TMJ problems
- symptoms
- muscle examination
- Range of motion
www.indiandentalacadem
y.com
30
31. Collection of records
TMJ radiographs
1. Trans-cranial radiographs
– lataeral 1/3 of the
condyle
2. Tomographs / laminographs - multiple views
3. Computed tomography
- anteroposterior and
lateral views
4. Arthrography
- disk morphology &
position
5. Magnetic resonance images ( MRI )
- precise method
- hard & soft tissues
www.indiandentalacadem
y.com
31
32. CT scan of right TMJ
www.indiandentalacadem
y.com
32
33. PHOTOGRAPHS
FACIAL
• Frontal with relaxed lip position
• Frontal with smile
• Three quarter view
• Profile view
• Submental view
INTRAORAL
frontal
• Teeth on occlusion
right lateral
left lateral
upper
• Occlusal views
lower
www.indiandentalacadem
y.com
33
36. Facial keys to orthodontic diagnosis and
treatment planning: PART 1
- W. Arnett, T. Bergman
AJODO 1993 April
• Head orientation - Natural Head position
• Condyle position - Centric Relation
• Lip posture
- Ralaxed Lip Posture
www.indiandentalacadem
y.com
36
37. NATURAL HEAD POSITION
• Orientation of the head assumed naturally
• 2 degree standard deviation
www.indiandentalacadem
y.com
37
41. Facial keys to orthodontic diagnosis and
treatment planning: PART 2
- W. Arnett, T. Bergman
AJODO 1993 MAY
I. Frontal view
a.. Relaxed lip
b. Functional analysis
1. Closed lip
2. Smile
II. Profile
a. Relaxed lip
www.indiandentalacadem
y.com
41
49. Lower one third evaluation
Relaxed position
Upper lip : lower lip = 1:2
Upper lip
19 – 22mm
Short upper lip ( 18mm or less )
• Increased interlabial gap
• Incisor exposure
Lower lip
38 – 44mm
• Anatomic short lower lip – class II malocclusions
• Secondary to posture
www.indiandentalacadem
y.com
• Anatomic long lower lip – class III malocclusions
49
50. Lower one third evaluation
Upper tooth to lip relation
Normal range is 1-5mm
women show more within this range
Disharmony is due to
1.
2.
3.
4.
Upper lip length
Lower lip length
Thickness of the lips
The angle of the view
www.indiandentalacadem
y.com
50
51. Incisor to lip relations
Interlabial gap
Lip incompetence
• Short philtrum/anatomic
short upper lip
• Vertical maxillary excess
• Excessive overjet – upper lip
blocks the lower lip
www.indiandentalacadem
y.com
51
52. Lower one third evaluation
Closed lip position
Mentalis contraction, lip strain,
alar base narrowing
www.indiandentalacadem
y.com
52
53. Smile position with lip level
• 2mm of gingival exposure
• If the patient has normal crown exposure at repose
and gummy smile maxilla should not be impacted
• The gingival smile is never treated to ideal at the
expense of underexposing the incisors in the relaxed
lip position
www.indiandentalacadem
y.com
53
54. Incisor to lip relations
Anesthetic reverse resting maxillary
lip line
www.indiandentalacadem
y.com
54
55. Incisor to lip relations
Commissure height
A line connected from the alar
bases through subspinale is
perpendicular to the commissural
Line
Drooping of commissures
- ageing, facial jowling
www.indiandentalacadem
y.com
55
56. Incisor to lip relations
Maxillary lip to upper incisor at rest
Age differentials
Excess incisor show at rest
•
•
•
•
Short upper lip
Vertical maxillary excess
Excessive crown height
Detorqued max. incisors
www.indiandentalacadem
y.com
56
57. Incisor to lip relations
Inadequate incisor show at rest
•
•
•
•
Excessive upper lip height
Vertical max. deficiency
Inadequate crown height
Flared maxillary incisors
Dental characteristic of ageing is to show less
upper incisor exposure and more lower
incisor exposure
www.indiandentalacadem
y.com
57
59. Incisor to lip relations
Gingival display on smile
Gummy smile
•
•
•
•
•
Short philtrum
Vertical max. excess
Excessive curtain on smile
Gingival hyperplasia
Upright max.incisors
www.indiandentalacadem
y.com
59
60. Incisor to lip relations
Crown length
Vertical height of max. central incisors
Adults
Children -
9-12mm (males )
9.5mm (females )
4.5 mm
www.indiandentalacadem
y.com
60
61. Incisor to lip relations
Lip incompetence in children
www.indiandentalacadem
y.com
61
62. Incisor to lip relations
Periodontal contribution in adolescents
- kokich
Gingival margin is 1mm coronal to the
Cemento-enamel junction
www.indiandentalacadem
y.com
62
70. Soft tissue Profile angle
General harmony of the
forehead, mid face, and
lower face
Class I occlusion – 1650 to 1750
Extremes of the angle are usually due to
skeletal disharmony
www.indiandentalacadem
y.com
70
72. Profile view
Nasolabial angle
• Range is 850 – 1050 ( 1000)
• Females show more
obtuse angle
• Indicate the position of the maxillary teeth and the
contour of the lower border of the nose
www.indiandentalacadem
y.com
72
74. Profile view
Factors to be considered in treatment plan
•
•
•
•
•
•
Existing angle
Estimation of the lip tension
Antero-posterior lip thickness
Magnitude of the mandibular retrusion
Extraction versus non-extraction
Surgical movement of the maxilla
Maxillary setback – nasal elongation, alar base
depression, opening of the nasolabial angle
( premature ageing )
www.indiandentalacadem
y.com
74
77. Profile view
Orbital rim
• Anteroro-posterior
indicator of
Maxillary position
• The globe is positioned 2-4mm anterior
to the orbital rim
www.indiandentalacadem
y.com
77
81. Profile view
Nasal projection
Subnasale to nasal tip
Normal is 16-20mm
Important in contemplating anterior movement of the
maxilla
www.indiandentalacadem
y.com
81
82. Profile view
Throat length
& contour
Neck throat junction soft tissue menton
Mandibular setback is contraindicated in case
of a short, sagging neck
www.indiandentalacadem
y.com
82
83. Lower face analysis on profile view
Chin neck angle
www.indiandentalacadem
y.com
83
84. Lower face analysis on profile view
Labiomental sulcus
www.indiandentalacadem
y.com
84
86. Transverse facial & dental proportions
Rule of fifths
Middle fifth of the face
www.indiandentalacadem
y.com
86
87. Transverse facial & dental proportions
The middle fifth of the face
The distance between 2 inner canthi of the eye
www.indiandentalacadem
y.com
87
88. Transverse facial & dental proportions
The medial fifths
of the face
A line from outer canthus
of the eyes should be coincident with the
gonial angles of the mandible
www.indiandentalacadem
y.com
88
90. Transverse facial & dental proportions
The outer fifth
of the face
outer canthus of the eye to the helix of the ear
www.indiandentalacadem
y.com
90
97. Systematic evaluation of dental & facial
asymmetry
• Nasal tip to midsagittal plane
• Maxillary dental midline to midsagittal plane
• Max.dental midline to mand.dental midline
• Mand. Dental midline to midsymphysis
• Midsymphysis to mid sagittal plane
www.indiandentalacadem
y.com
97
98. Systematic evaluation of dental & facial
asymmetry
Nasal tip to midsagittal plane
The position of the nasal tip is best evaluated
by having the patient elevate the head
slightly and visualizing the position of the tip
to the midsagittal plane
Maxillary dental midline to midsagital plane
Deviations of the maxillary dental midline
from the midsagittal plane
www.indiandentalacadem
y.com
98
107. Analysis of hand wrist radiograph
• To estimate the patient’s
skeletal age
• poor correlation with
jaw growth
www.indiandentalacadem
y.com
107
108. Radiographic analysis
Lateral cephalograms
• Relationship of the jaws to the cranium
• Relationship of the both the jaws
• Relationship of the teeth to the jaw bases
www.indiandentalacadem
y.com
108
109. Radiographic analysis
Postero-anterior films
Vertical lines – transverse asymmetries
Horizontal planes - vertical position of
structures
Different analyses
• Rickett’s analysis
• Grummons analysis
• Grayson’s analysis
• Hewittt’ analysis
• Chierici’ method
www.indiandentalacadem
y.com
109
114. Surgically assisted orthopedic expansion
• RME screw should be
placed immeadiately after
osteotomy to enhance the
orthopedic force
• Osteotomy through the
lateral maxilla, including
the separation at pterigomaxillary region
www.indiandentalacadem
y.com
114
118. Backward movement
• Very limited movement ( 3-5mm )
Downward movement
• Technically possible but anatomically less
stable
• Interpositional bone grafts provide
mechanical stability
• Stretch of the soft tissues
www.indiandentalacadem
y.com
118
119. Mandible
• Any movements but
not downward movements
at Gonial region
• Mandibular plane changes
• Soft tissue stretch
• Condylar position in the fossa
www.indiandentalacadem
y.com
119
120. Implications of incomplete growth
• Growth following surgery
• Need for second surgery
• Early surgery is contraindicated for excess
growth
www.indiandentalacadem
y.com
120
121. Logical sequence of treatment planning
• Pathologic versus developmental problems
• Pathologic
- chronic systemic diseases
- local conditions
- psychologic conditions
www.indiandentalacadem
y.com
121
122. • Prioritizing the developmental problem list
• Orthodontic risks
• Surgical risks
- Predictable sequelae
- Unanticipated complications
- Catastrophic events
www.indiandentalacadem
y.com
122
124. Tracing overlay method
• Simplest way to simulate the effects of the
mandibular surgery
• Limited to surgery that does not affect the
vertical position of the maxilla
www.indiandentalacadem
y.com
124
134. Advantages
• Patient counseling
• Comparison of diff. Treatment plan options
• Less risk of post operative dissatisfaction
Disadvantages
• Dental relations are unknown
• Distortions with some soft wares
www.indiandentalacadem
y.com
134
143. Body osteotomies
• In cases where satisfactory dental relations are to
be established
• Short bodies, Asymmetries, Open bite
• Changes in arch width
www.indiandentalacadem
y.com
143
160. TREATMENT PLANNING FOR ADULTS
Chin prominence
– Genioplasty with
angulated osteotomy
www.indiandentalacadem
y.com
160
161. MANDIBULAR DEFICIENCY- LONG FACE
Extra-oral
•
•
•
•
Excessive ant.face height
Lip incompetence
Skeletal class II malocclusion
Hypo-plastic upper lip
Intra oral
•
•
•
•
•
•
Class II malocclusion
Crowding in the lower
Over eruption of posterior teeth
Tendency towards ant.open bite
Narrow maxilla & posterior cross bite
www.indiandentalacadem
Tipping of palatal plane down posteriorly
y.com
161
162. .Treatment planning – adults
Decreasing the lower face height
• Superior positioning of the maxilla
( LeFort I total / Segmental osteotomy )
• Mandibular surgery
( Ramus osteotomy )
• Superior repositioning of the chin
( Inferior border osteotomy )
www.indiandentalacadem
y.com
162
166. Class III problems
• More mand. Growth
than normal
• Growth continues after
adolescence longer than
Normal
Heavy forces for longtime wear – Restrict maxillary
growth
Shorter periods of wear - Rotation the mandible
down & back
www.indiandentalacadem
y.com
166
167. Class III problems
Maxillary deficiency – Face mask therapy
Age- 8 yrs or children
Patients with transverse discrepancy
- RME
www.indiandentalacadem
y.com
167
168. Class III problems
Surgical camouflage
- Reduction genioplasty
• Increase the face height
• Flassidity of soft tissue
www.indiandentalacadem
y.com
168
169. Class III problems
Onlay grafts
• Mid face deficiencies
• Grafts in the paranasal, alar base and
zygomatic areas
www.indiandentalacadem
y.com
169
170. Class III problems
Maxillary versus maxillary surgery
• Volume of the oral cavity
• Unesthetic “Turkey gobbler” appearance
Suction lipectomy
www.indiandentalacadem
y.com
170
171. Class III problems
Timing of orthognathic surgery
Excess mandibular growth
Relapse tendencies
Maxillary deficiency
• Favorable maxillary growth
• Prolonged mandibular growth
www.indiandentalacadem
y.com
171
173. Class III problems- cleft patients
Bone grafts
Timing of the graft – before the eruption of the
tooth
• To establish bone continuity
• Acts as a matrix
www.indiandentalacadem
y.com
173
174. Class III problems - cleft patients
Comprehensive orthodontics
Secondary esthetic procedures
1. Nose-lip revision
2. Pharyngeal surgery
• Compensation from lat. Pharyngeal wall
• Enlarged tonsils
www.indiandentalacadem
y.com
174
175. Class III problems - cleft patients
Orthognathic surgery
After conclusion of active growth
Maxillary surgery
• Lip scars
• Palatal scar
• Cleft palate speech
www.indiandentalacadem
y.com
175
177. Dento facial asymmetry
In preadolescent children
Growth modification
with asymmetric
functional appliances
( hybrid appliances )
www.indiandentalacadem
y.com
177
178. Dento facial asymmetry
In adolescents
Avoid surgery until adolescent growth spurt
ends
Ankylosed condyle
Release of condyle from glenoid fossa
www.indiandentalacadem
y.com
178
179. Dento facial asymmetry
In adults
Can not be managed orthodontically or
orthopedically
• Ramus osteotomy
• Maxillary surgery / asymmetric onlay grafts
• Inferior border osteotomy
www.indiandentalacadem
y.com
179
181. References
• Contemporary treatment of dentofacial deformity
- R.P.WHITE.W.R.PROFFIT & DAVID.M.SARVER
• A text book of oral surgery
- MOORE
• Introduction to orthognathic surgery – color atlas
- J.P.REYNEKE & W.G.EVANS
• LEE HELDT & ERNEST A.HAFFKE –The psychological and social
aspects of orthognathic surgery
- AMJ.ORTHOD vol.82, 1992
• G.W.ARNETT & ROBERT.T.BERGMAN – Facial keys to
orthodontic diagnosis ; Part I - AJODO April, 1993
• G.W.ARNETT & ROBERT.T.BERGMAN – Facial keys to
www.indiandentalacadem
orthodontic diagnosis ; Part II – AJODO MAY, 1993
y.com
181
182. Thank you
For more details please visit
www.indiandentalacademy.com
www.indiandentalacadem
y.com
182