ORepublic of Iraq

Ministry of Higher Education and

Scientific Research
University of Baghdad
College of Dentistry

Orthognathic Surgery Types And

Indications

A Project Submitted to
The College of Dentistry, University of Baghdad, Department of
Orthodontics in Partial Fulfillment for the Bachelor of Dental
Surgery

By
Mousa Ibrahim Mousa

Supervised by:
Prof. Iman I. AL sheakli
(B.D.S., M.Sc.)

2020 A.D 1441 A.H

 Certification of the Supervisor
I certify that this project entitled” Orthognathic Surgery Types
And Indication” was prepared by Mousa Ibrahim Mousa under my
supervision at the College of Dentistry/University of Baghdad in
partial fulfilment of the graduation requirements for the Bachelor
degree in dentistry.

Supervisor’s name: Prof. Iman I. AL Sheakli

Date 19/6

I
Dedication
To my parents who supported me and embraced me with
their love and prayers
To my supervisor prof. Iman I. AL Sheakli for her
guidance, help, encouragement and support that made
this project possible

II
 Acknowledgment
Thanks to Allah, the most giving and the most forgiving for everything
given to me and for blessing me.
I would like to thank Assist. Prof. Dr. Nada Jafer MH. Radhi Dean of
College of Dentistry, University of Baghdad for her support to graduate
students. Also, I would like to thank Dr. Nidhal H. Ghaib The Assistant Dean
For Scientific Affairs.
Finally, I would like to thank and express my deep and sincere gratitude
to my supervisor Chairman of Orthodontic Department, College of Dentistry /
University of Baghdad, Prof. Dr. Iman I. Al-Sheakli

III
 Abstract
Orthognathic Surgery is very important in correcting difficult cases with
orthodontic treatment.

Adult patients with significant skeletal malocclusion in whom growth

modification procedures cannot be carried out may also benefit from
orthognathic surgery.

Patients with significant skeletal discrepancies and dentofacial

deformities that cannot be treated satisfactorily by orthodontic management
only. In such cases surgical correction by means of orthognathic surgeries of
maxilla and mandible may be indicated to obtain optimal occlusal and
esthetics results.

There are many cases of deformation that may believe it is sufficient

only with orthodontic treatment without surgery, but in this study, we clarify
that those who need surgical intervention and orthodontic treatment.

IV
 Table Of Contents
Subject Page no
Certification of the Supervisor I
Dedication II
Acknowledgment III
Abstract IV
Table of Contents V
List of Figures VI
List of Tables VII
Introduction 1
Aims Of The Study 2
Chapter 1
1. Review Of Literature
1.1 Patients Presenting For Orthognathic Surgery 3
1.2 Index Of Orthognathic Functional Treatment Need 3
1.3 Malocclusion Severity As An Indication For Surgery 5
Orthognathic Surgery
1.3.1 Abnormalities Of The Maxillary Base 6
1.3.2 Abnormalities Of The Mandibular Base 6
1.3.3 Abnormalities Of The Chin 7
1.4 Planing For Orthognathic Surgery 8
1.4.1 Medical And Dental History 8
1.4.2 Full Face Assessment 9
1.4.3 Facial Profile 9
1.4.4 Assessment Of Anteroposterior Jaw Relationship 10
1.4.5 Assessment Of Vertical Skeletal Relationship 11
1.4.6 Examination Of Chin 12
1.4.7 Intra-Oral Assessment 12
1.4.8 Cephalometric Assessment 13
1.5 The Importance Of Age In Orthognathic Surgery 18
1.6 Common Surgical Procedures 19
1.6.1 Maxillary Procedures 19
1.6.2 Mandibular Procedures 22
Chapter 2
2. Discussion 25
Chapter 3
3. Conclusions And Suggestions 26
References

V
 List of Figures
Figure Page no

Fig. 1 Epker's Envelope Of Discrepancies 5

Fig. 2 Vertical Proportions: Rule Of Thirds. 9

Fig. 3 Facial Profile 10

Fig. 4 Assessment Of Vertical Skeletal Relationship 11

Fig. 5 Mentolabial Sulcus 12

Fig. 6 The SNA Angle 14

Fig. 7 The SNB, And SN-Pog Angles 15

Fig. 8 The ANB Angle 15

Fig. 9 Mandibular Plane Angle 16

Fig. 10 Occlusal Plane Angle 16

Fig. 11 Le Fort 1 Osteotomy. 20

Fig. 12 Anterior Subapical Osteotomy 21

Fig. 13 Posterior Subapical Osteotomy. 21

Fig. 14 Segmented Maxillary Osteotomy 21

Fig. 15 Surgically Assisted Rapid Palatal Expansion (SARPE) 22

Fig. 16 Sagittal Split Osteotomy 23

Fig. 17 Vertical Subsigmoid Osteotomy 24

Fig. 18 Genioplasty. 24

Fig. 19 Anterior subapical osteotomy 24

VI
 List of Tables
Table Page no

Table 1 Index Of Orthognathic Functional Treatment Need 4

Table 2 Facial Profile 10

Table 3 Diagnostic Features Of Dentofacial Deformity 17

VII
 List of abbreviations
Abbreviation/explanation
Fig: figure
H: hairline
Sn: subnasal
Mb: midbrow
Me: soft tissue menton
FMA Angle: Frankfort mandibular plane angle
SNA Angle: Sella-Nasion to A Point angle
SNB Angle: Sella-Nasion to B Point angle
ANB Angle: A point to B Point angle
SN-POG Angle: Sella-Nasion to soft tissue pogonion angle

VIII
 Introduction

Introduction
Orthognathic surgery may be defined as the surgical repositioning of the
maxilla and/or mandible, and/or its segments, with or without orthodontic
repositioning of the teeth, in order to correct dentofacial function, aesthetics
and health. The term ‘orthognathic’ is derived from the Greek orthos: correct
or straight, and gnathos: jaw. (Blackwell and Nani, 2011)
The first orthognathic surgery procedure was performed by (Hullihen,
1848); He published a paper in American Journal of Dental Science named
“Case of Elongation of the Underjaw and Distortion of the Face and Neck,
caused by a Burn, Successfully Treated” in 1849, which is known as world’s
first published paper about orthognathic surgery. He performed the first
mandibular sub-apical osteotomy surgery to correct a protrusive malposed
alveolar segment of the mandible.
surgery is also sometimes defined as the combined orthodontic-
surgical correction of dentoskeletal deformities. The inaccuracy of the
definition lies in the fact that, occasionally, surgical camouflage only is
undertaken, e.g. genioplasty, or very rarely in patient where the postoperative
dental occlusion will be satisfactory without orthodontic treatment. These
cases do not involve orthodontic treatment, but are still classified as
orthognathic Surgery. (Blackwell and Nani, 2011)
Dingman reported cases receiving surgery before orthodontics in 1944,
but there was no comment on the role of orthodontists in the preoperative
treatment plan. The current concept of surgery first is the team approach
between surgeons and orthodontists. (Aziz and Simon, 2004), (Goldwyn and
Simon, 1973)

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 Aims Of The Study

Aims Of The Study

This study done to:
1. To diagnose the abnormality and assess patients that require
orthognathic surgery.
2. To briefly know about the types of orthognathic surgery.

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Chapter One Review of literature

Chapter one
Review Of Literature

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 Chapter One Review of literature

1.1. Patients Presenting For Orthognathic Surgery

An adult patient will ultimately be advised that they require
orthodontic treatment and orthognathic surgery if the discrepancy in their
skeletal base relationship is so severe that orthodontic camouflage either is
not possible or would significantly compromise facial aesthetics.
• Many are unhappy with the way they look and achieving a normal facial
appearance is often a key motivation (Stirling et al., 2007).

• Some are more concerned with functional difficulties associated with their
malocclusion, such as eating or, more rarely, speaking; and
• Others are simply unhappy with the appearance of their teeth.
It can often come as something of a shock to a patient who is primarily
concerned with the appearance of their teeth to be told that not only, they
need orthodontic treatment to correct their position, but facial surgery as
well. In these instances, surgical intervention may be declined and orthodontic
treatment limited to tooth alignment alone, with the patient and orthodontist
accepting the underlying skeletal discrepancy (Arnett and Gunson , 2004).

1.2. Index Of Orthognathic Functional Treatment

Need
The use of indices to prioritize treatment for those most in need is
increasingly being seen within state-funded healthcare systems. In the UK, the
Index of orthodontic treatment need currently defines those malocclusions
that should be treated within the National Health Service (Brook & Shaw,
1989), but it is difficult to apply constructively to cases that require a
combination of orthodontics and surgery. A number of functional indications
 Chapter One Review of literature

for combined treatment are absent from the Index of Orthodontic Treatment
Need, such as the presence of excessive maxillary incisor display at rest. In an
attempt to overcome these limitations, an Index of orthognathic functional
treatment need has been designed and validated to help prioritize the
treatment of combined cases (Ireland et al., 2014) (Table 1).

Table 1: Index of Orthognathic Functional Treatment Need

Very great need for treatment

Defects of cleft lip and palate and other craniofacial anomalies
Increased overjet>9 mm
Reverse overjet≥3 mm
Open bite≥4 mm
Complete scissors bite affecting whole buccal segment(s) with signs of functional
disturbance and/or occlusal trauma

Great need for treatment

Increased overjet≥6 mm and ≤9 mm
Reverse overjet≥0 mm and<3 mm with functional difficulties
Open bite<4 mm with functional difficulties
Increased overbite with evidence of gingival or soft tissue trauma
Upper labial segment gingival exposure≥3 mm at rest
Facial asymmetry associated with occlusal disturbance
Moderate need for treatment
Reverse overjet≥0 mm and<3 mm with no functional difficulties
Open bite<4 mm with no functional difficulties
Upper labial segment gingival exposure≥3 mm at rest
Facial asymmetry with no occlusal disturbance
Mild need for treatment
Increased overbite but no evidence of gingival or soft tissue trauma
Upper labial segment gingival exposure<3 mm at rest with no evidence of
gingival/periodontal effects
Marked occlusal cant with no effect on the occlusion

No need for treatment

Speech difficulties

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 Chapter One Review of literature

1.3 Malocclusion Severity As An Indication For

Orthognathic Surgery
One indication for surgery obviously is a malocclusion too severe for
orthodontics alone. It is possible now to be at least semiquantitative about
the limits of orthodontic treatment in the context of producing normal
occlusion. As the diagrams of the “envelope of discrepancy” (Fig.1) indicate,
the limits vary according to the tooth movement that would be needed. teeth
can be moved farther in some directions than others at any age (the limits for
tooth movement change little if any with age), but growth modification is
possible only while active growth is occurring. Because growth modification in
children enables greater changes than are possible by tooth movement alone.
Some conditions that could have been treated with orthodontics alone in
children (e.g., a centimeter of overjet) become surgical problems in adults. On
the other hand, some conditions that initially might look less severe (e.g., 5
mm of reverse overjet) can be seen even at an early age to require surgery if
they are ever to be corrected (Proffit et al., 2018).

Figure 1 Epker's envelope of discrepancies (Proffit et al, 2018)

Inner envelope: Only orthodontic treatment
Middle envelope: Orthodontic and growth modification
Outermost envelope: Orthognathic surgery
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 Chapter One Review of literature

1.3.1. Abnormalities Of The Maxillary Base

Maxillary Prognathism
Maxillary base may be anteriorly placed (antemaxillism) or may be large
in all dimensions (macromaxillism). Maxillary excess may cause either
protrusion of the upper jaw or elongation of the face, with downward
displacement of the mandible. In vertical maxillary excess, the disfigurement
causes a “long-face syndrome” with accompanying distortion of facial
features. (Epker et al., 1989).
Maxillary Retrognathism
Maxillary base may be posteriorly placed (retromaxillism) or may be
too small in all dimensions (micromaxillism). In the latter condition, also called
maxillary hypoplasia, the growth of the maxilla does not match that of the
lower jaw. There is a collapse of the normal mid-face supporting structures. In
addition to causing difficulties with eating and speech, this deficiency may be
associated with anomalies of the supporting structures of the nose and
cheeks. Partial obstruction of the nasal passages may be present. (Epker et al.,
1989).
Maxillary Asymmetry
When the maxillary base is asymmetric in length and width, e.g.
hemifacial microsomia. Lateromaxillism may occur when a normal maxillary
base is positioned laterally (Epker et al., 1989).

1.3.2 Abnormalities Of The Mandibular Base

Mandibular Prognathism
It could either be that the mandible is too large in all dimensions
(macromandibulism) or that the base of the body is positioned anteriorly
(antemandibulism). Excess mandibular bone causes protrusion of the lower

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 Chapter One Review of literature

jaw beyond the normal alignment with the upper jaw; with a resultant Class
III malocclusion. This can prevent effective biting and chewing of food and
hastens periodontal disease. (Epker et al., 1989).
Mandibular Retrognathism
This could be as a result of the mandible being too small in all
dimensions (micromandibulism) or the base of the body being positioned
posteriorly (retromandibulism). This deficiency of the mandibular bone does
not allow the upper and lower teeth to come together when chewing food
and may affect speech. Sleep may also be impaired due to a retruded or
deficient lower jaw. A deficiency of bone supporting the chin may require
surgery to build up the tissue and provide a normal framework for the chin.
Mandibular Asymmetry
The two halves of the base of the mandible have unequal dimensions;
this may be seen in patients with hemimandibular hyperplasia,
hemimandibular hypertrophy. Both halves of the base of the mandible may
have equal dimensions but may be shifted to one side; this is called
lateromandibulism (Epker et al., 1989).

1.3.3 Abnormalities Of The Chin

The chin should be evaluated separately from the mandible. The chin
prominence includes both bone and soft tissue that may require separate
surgical management. Common abnormalities are:
Macrogenia
the chin is too large in all dimensions. An anteriorly placed normal sized
chin prominence (antegenia) will give a macrogenic appearance. (Singh et al.,
2007).
Microgenia

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 Chapter One Review of literature

the chin is small in all dimensions. A normal sized chin, placed posteriorly
(retrogenia) should be distinguished from microgenia (Singh et al., 2007).

1.4 Planing For Orthognathic Surgery

Orthognathic surgery is the art and science of diagnosis, treatment
planning and execution of treatment by combining orthodontics and oral and
maxillofacial surgery to correct skeletal, dental and soft tissue deformities of
the jaws and associated structures. Problem-oriented diagnosis and
treatment planning approach is a well-established approach in orthodontics
and maxillofacial surgery and can be used in patients who are candidates for
orthognathic surgery. The method involves collecting adequate information
about the patient and distilling from it. The information can then be used to
generate a problem list and outline the treatment strategy. (Mitchell et al.,
2013)

1.4.1 Medical And Dental History

Before embarking on treatment. A thorough medical history is essential

in patients seeking orthodontic–surgical correction. Allergic conditions, blood
dyscrasias, any cardiopulmonary or neurological problems or any other
relevant medical history need to be elicited. A dental history revealing
previous orthodontic and periodontal therapies need to be evaluated, home
care and oral hygiene of the patient are recorded. If good oral hygiene is not
maintained, then such a patient is not a good candidate for orthognathic
surgeries. Any acute periodontal or gingival diseases should be eliminated
before initiating orthodontic or surgical case, although definitive periodontal
procedures are deferred until surgery and orthodontics are completed as

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 Chapter One Review of literature

these treatments may alter the existing periodontal anatomy (premkumar et

al., 2015).

1.4.2. Full Face Assessment (Fig. 2)

The symmetry and vertical proportions of the face are assessed from the
frontal view. No face is completely symmetrical, but marked deviations should
be noted. The ‘ideal’ face can be divided by horizontal lines at the hairline,
nasal base and the chin. The lower third can be further divided so that the
meeting point of the lips is one-third of the way from the base of the nose to
the chin (Ackerman and Proffit, 1997).

Figure 2 Vertical proportions: rule of thirds. Face is

divided into thirds by drawing lines through hairline (H),
midbrow (Mb), subnasale (Sn) and soft-tissue menton (Me9). (premkumar et al, 2015)

1.4.3. Facial Profile

Facial profile helps in diagnosing gross deviation in the maxillo—
mandibular relationship. For example, an individual with concave profile may
exhibit Angle's class III malocclusion. Examination of facial profile is done by

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 Chapter One Review of literature

viewing the patient from the side. Facial profile is assessed by joining two
reference lines as shown in figure 3 (Downs, 1965).
1. First reference line: It is the line joining the forehead to the soft tissue point
A.
Note: Soft tissue point A is the deepest point in the curvature of upper lip.
2. Second reference line: It is the line joining point A to the soft tissue
pogonion.

Figure 3 Facial profile: (A) Straight/Orthognathic profile, (B) Convex facial profile, (C) Concave
facial profile (phulari, 2011)

1.4.4 Assessment Of Anteroposterior Jaw Relationship

Ideally, maxillary skeletal base is 2-3 mm anterior to the mandibular
skeletal base in centric occlusion. The sagittal skeletal relationship can be
clinically assessed by two finger test.

Clinical assessment of anteroposterior jaw relationship can be done by

using the examiner's index and middle fingers placed approximately at point
A and point B, respectively.
Inference of the test: The sagittal skeletal relationship of the patient can be
guessed by relative position of the two fingers.
• If the index finger is slightly ahead of middle finger— it indicates class II
skeletal base pattern.

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 Chapter One Review of literature

• If the middle finger is ahead of the index finger—it indicates class III
skeletal base pattern (phulari, 2011).

1.4.5 Assessment Of Vertical Skeletal Relationship

In an ideal skeletal relationship, the distance between the glabella (a
point between the eyebrow in the midline) and subnasale (base of the nose)
is equal to the distance from the subnasale to the underside of the chin.
Assessment of vertical skeletal relationship is done by measuring the FMA
angle (Fig. 4).
Note: The FMA angle is defined as the angle formed by the following two
reference planes:
1. FH plane (Frankfort horizontal plane—A line between the most superior
point of the external auditory meatus and inferior border of the orbit).
2. Mandibular plane is a line from menton to gonion (phulari, 2011).

Figure 4 Assessment of vertical skeletal relationship is

done by measuring the FMA angle (phulari, 2011)
1.4.6 Examination Of Chin
The mentolabial sulcus is deep in Class II malocclusion while it is shallow
in Class III malocclusion (Fig. 5). Genioplasty can alter the position of the chin
in all three dimensions (premkumar et al., 2015).
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 Chapter One Review of literature

Figure 5 Mentolabial sulcus. (A) Normal depth of mentolabial sulcus in a patient

with Angle’s class I malocclusion, (B) Shallow mentolabial sulcus in a female patient with
bimaxillary protrusion, (C) Deep mentolabial sulcus in a male patient with Angle’s class II
division 2 malocclusion (phulari, 2011).
1.4.7 Intra-Oral Assessment
A full assessment of the dentition and occlusion needs to be
undertaken. Any dental disease needs to be identified, treated and stabilized
before combined orthodontics and orthognathic surgery can begin. The
relationship of one arch to the other is less important in orthognathic cases,
as this part of the problem is often addressed by the surgery. However, each
arch should be individually assessed for alignment and symmetry. The amount
of crowding in each arch should be assessed, as well as the inclination of the
teeth. The inclination of the incisors is important, because in most patients
with a skeletal discrepancy the teeth have been tilted. This is due to the action
of the lips and tongue attempting to achieve an anterior oral seal. This process
is called ‘dento-alveolar compensation’ for the underlying skeletal pattern. In
a Class II skeletal problem, the lower incisors are often proclined by the
tongue. Conversely in a Class III skeletal pattern the lower incisors are often
retroclined by the lower lip, with the upper incisors proclined by the tongue.
It is important to recognize any dento-alveolar compensation, as one of the

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 Chapter One Review of literature

aims of pre-surgical orthodontic treatment is to undo this compensation – a

process known as ‘decompensation’ (Lee, 1994).

1.4.8 Cephalometric Assessment

An incredibly diverse range of cephalometric analyses have been
described, and their normative values are based on varying sample sizes from
different populations. Each analysis has advantages and shortcomings, and no
claim can be made for the universal application of any specific analysis
(Blackwell and Nani, 2011)
Useful method of analyzing skeletal relationships is a group of angular
measurements which relate the maxilla (SNA angle), mandible (SNB angle) and
chin (SND angle; SN-Pog angle) to the anterior cranial base (sella-nasion or SN
plane). An extension of the latter is the ANB angle, which relates the maxilla
to the mandible.

SNA Angle (82 ± 3◦):

Relates the sagittal position of the maxillary apical base (A-point) to the
anterior cranial base (SN). The SNA angle provides an indication of the sagittal
position of the maxilla relative to the anterior cranial base (Figure 6). If the
SNA angle is more than the mean value, then it indicates that maxilla lies more
anteriorly in relation to the cranial base. If SNA angle is less than normal, then
it indicates that maxilla lies more posterior in relation to the cranial base
(Blackwell and Nani, 2011)

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 Chapter One Review of literature

Figure 6 the SNA angle (Blackwell, 2011).

SNB Angle (79 ± 3◦):

Relates the sagittal position of the mandibular apical base (B-point) to
the anterior cranial base (SN). The SNB angle provides an indication of the
sagittal position of the mandible relative to the anterior cranial base (Figure
7). If SNB angle is less than 79°, it is then referred as small SNB angle, which
indicates retrognathism of mandible. If SNB angle is greater than 79°, then it
is called as large SNB angle. Large SNB angle—indicates prognathism of
mandible (Blackwell and Nani, 2011)

SN-POG Angle (80 ± 3◦):

This angle is formed between the most anterior point on the bony chin
(pogonion) and the SN plane (Fig.7). It is important to compare the value of
SNB to SN-Pog. In patients with a prominent chin but mandibular
dentoalveolar (apical base) retrusion, the facial profile may be acceptable
even though the dentoalveolar relationship is unfavorable. This relationship is
common in Class II division 2 type malocclusions. If SN-Pog is smaller than SNB,
the patient is likely to have an excessively recessive bony chin in the sagittal
plane (Blackwell and Nani, 2011)
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 Chapter One Review of literature

Figure 7 The SNB, and SN-Pog angles (Blackwell, 2011)

ANB Angle (3 ± 1◦)

The ANB angle represents the difference between the SNA and SNB
angles, providing an indication of the sagittal discrepancy between the
maxillary and mandibular apical bases (Figure 8). The ANB angle is positive if
point A lies anterior to NB. If NA and NB coincide, the ANB angle is zero. If
point A lies posterior to NB, ANB will be negative (Blackwell, 2011). If ANB
angle is greater than normal, it is known as large ANB angle. It indicates class
II skeletal tendency If ANB angle is smaller than 2°, then it is referred as small
ANB angle. It indicates class III skeletal tendency.

Figure 8 The ANB angle represents the difference between the

SNA and SNB angles, providing an indication of the sagittal
discrepancy between the maxillary and mandibular apical
bases (Blackwell, 2011)

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 Chapter One Review of literature

Mandibular Plane Angle (32°)

Mandibular plane angle gives an indication of growth pattern of an
individual. (Fig.9) Vertical skeletal relationships, it is formed between SN plane
and the mandibular plane. The mandibular plane angle is used in this analysis,
which is a line connecting gonion and gnathion. Increased mandibular plane
angle indicates vertical growth, decreased mandibular plane angle indicates
horizontal growth pattern. (Steiner, 1960).

Figure 9 Mandibular plane angle

Occlusal Plane Angle (14.5°)

Occlusal plane angle indicates the relation of the occlusal plane to the
cranium and face. (Fig.10) It is formed between SN plane and the occlusal
plane. Increased occlusal plane angle indicates vertical growth pattern.
Decreased occlusal plan angle indicates horizontal growth pattern (Steiner,
1960).

Figure 10 Occlusal plane angle (phulari, 2011)

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TABLE 3: Diagnostic Features Of Dentofacial Deformity (Cobourn and

DiBiase, 2016), (Blackwell and Nani, 2011), (Phulari,2011).

Clinical Features Skeletal Assessment Dental Assessment

Maxilla Sagittal Concave facial profile SNA angle decreased Class III
deficiency Retrusive upper lip SNB angle normal Maxillary dental crowding
Alar base narrow ANB angle decreased Maxillary incisors proclined
Sagittal excess Convex facial profile SNA angle increased
Acute nasolabial angle SNB angle normal
ANB angle increased
Vertical excess Convex profile SNA angle increased Class II, Class I
(long Lower facial height SNB angle decreased Anterior open bite
face syndrome) increased ANB angle increased Constricted maxillary arch
Alar base constricted Steep mandibular Dental crowding
Acute nasolabial angle plane angle
Excessive incisor show
Vertical Concave facial profile SNB angle increased Class II, Class I
deficiency Lower facial height ANB angle negative Deep bite
(short face decreased Acute mandibular Crowding in mandibular
syndrome) Nasolabial angle varies plane angle Dentition
Alar base widened
Lack of incisor show
Mandible Convex profile SNA angle normal Class II
Deficiency Retruded chin SNB angle decreased Proclined mandibular
Everted lower lip ANB angle increased Incisors
Deep mentolabial sulcus Retroclined maxillar incisors
Mandible Concave profile SNA angle normal Class III
Excess Deficient appearance of SNB angle increased Proclined maxillary incisors
midface ANB angle decreased Retroclined mandibular
Broad lower third Incisors

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 Chapter One Review of literature

1.5. The Importance Of Age In Orthognathic Surgery

As a general rule, early jaw surgery has little inhibitory effect on further
growth. For this reason, orthognathic surgery should be delayed until growth
is essentially completed in patients who have problems of excessive growth,
especially mandibular prognathism. For patients with growth deficiencies,
surgery can be considered earlier but rarely before the adolescent growth
spurt (Proffit et al., 2018).
Growth Excess
Actively growing patients with mandibular prognathism can be
expected to outgrow early orthodontic or surgical correction and require
retreatment so the timing of this operation often is a critical consideration.
Indirect methods of assessing growth status, such as hand–wrist radiographs
or vertebral stages to determine bone age, are not accurate enough for
planning the time of operation. The best method is serial cephalometric
radiographs, with the surgical procedure delayed until good superimposition
documents that the adult deceleration of growth has occurred. Often the
correction of excessive mandibular growth must be delayed until the late
teens, unless a second, later surgical correction can be justified because of
psychosocial considerations. The situation is not so clear-cut for patients with
the long-face (skeletal open bite) pattern that can be characterized as vertical
maxillary excess. There appears to be a reasonable chance for stable surgical
correction of this problem before growth is totally completed, but the
difference in clinical stability between treatment at, for example, ages 14 and
18 remains incompletely understood. Should patients with a long face have
early surgical treatment? Probably not, unless they are willing to have a
second later operation if additional growth occurs (Proffit et al., 2018).

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Growth Deficiency
Surgery in infancy and early childhood is required for some congenital
problems that involve deficient growth. Craniosynostosis and severe
hemifacial microsomia are two examples. The major indication for
orthognathic surgery before puberty, however, is a progressive deformity
caused by restriction of growth. A common cause is ankylosis of the mandible
(unilaterally or occasionally bilaterally) after a condylar injury or severe
infection. Operation to release the ankylosis, followed by functional appliance
therapy to guide subsequent growth, is needed in these unusual problems A
child with a severe and progressive deficiency should be distinguished from
one with a severe but stable deficiency, such as a child with a small mandible
whose facial proportions are not changing appreciably with growth. A
progressive deficiency is an indication for early surgery, whereas a severe but
stable deficiency usually is not. In keeping with the general principle that
orthognathic surgery has surprisingly little impact on growth, early surgery
does not improve the growth prognosis unless it relieves a specific restriction
on growth, nor does it produce a subsequently normal growth pattern (Proffit
et al., 2018).

1.6 Common Surgical Procedures

1.6.1. Maxillary Procedures
A number of surgical procedures are commonly carried out to alter the
position, width and occlusal plane of the maxilla.
• Le Fort I Osteotomy (Total Maxillary Osteotomy)
This is the most widely used maxillary technique (Fig. 11). The standard
approach is a horseshoe incision of the buccal mucosa and underlying bone,
which results in the maxilla being pedicled on the palatal soft tissues and
blood supply. The maxilla can then be moved upwards (after removal of the

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intervening bone), downwards (with interpositional bone graft), or forwards.

Movement of the maxilla backwards is not feasible in practice (Mitchell et al.
,2013).

Figure 11 Le Fort 1 osteotomy(Cobourn and DiBiase, 2016).

• Segmental Maxillary Surgery

Segments of the maxilla can also be moved by the surgeon, either as an
isolated procedure or, more commonly, in combination with Le Fort I
osteotomy:
• Anterior subapical osteotomy (Wunderer, Cupar or Wassmund) (Fig. 12)
achieves isolated movement of the canine and incisor teeth, for either
reduction of an overjet or correction of a vertical discrepancy, usually anterior
open bite.
• Posterior subapical osteotomy (Schuchardt) (Fig. 13) is occasionally used for
isolated correction of a unilateral posterior crossbite.
• Following Le Fort, I osteotomy (Fig.14), the maxilla can also be divided
bilaterally facilitate correction of a transverse discrepancy, usually expansion
for a bilateral posterior crossbite; or segmented into three pieces for levelling
an occlusal plane during the correction of a vertical discrepancy (Cobourn and
DiBiase, 2016).

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 Chapter One Review of literature

Figure 12 Anterior subapical osteotomy (Cobourn, 2016) Figure 13 Posterior subapical

osteotomy.

Figure 14 Segmented maxillary osteotomy (Cobourn and DiBiase, 2016).

• Surgically Assisted Rapid Palatal Expansion (SARPE)

It is the use of bone cuts to reduce the resistance followed by expansion
of the jackscrew to separate the halves of the maxilla, is another possible
treatment approach for adult patients with a narrow maxilla (Fig. 15). The
original idea of surgically assisted expansion was that cuts in the lateral
buttress of the maxilla would decrease resistance to the point that the
midpalatal suture could be forced open (i.e., microfractured) in older patients.
The primary indication for preliminary SARPE is such severe maxillary
constriction that segmental expansion of the maxilla in the Le Fort I procedure
might compromise the blood supply to the segments (Proffit et al., 2018).

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 Chapter One Review of literature

Figure 15 In this adult patient with maxillary posterior crossbite and severe crowding, surgically assisted rapid
palatal expansion (SARPE) was used to allow transverse expansion that otherwise would not have been
possible. The modern surgical technique includes all the bone cuts for a Le Fort I osteotomy except the
downfracture. (A) Narrow maxillary arch, posterior crossbite, and maxillary incisor crowding before
treatment. (B) Expansion appliance in place after operation and activation of the screw over a period of 4 days
after a brief latency period, showing the amount of expansion that was obtained. (C) Fixed appliance for
completion of alignment. A compressed coil spring that was use to open space for the maxillary left lateral
incisor after the palatal expansion was removed 3 months after operation. (D) Widening the maxilla corrected
the posterior crossbite and provided space to align the incisors, which made it possible to plan later cosmetic
restoration of these stained teeth (Proffit et al., 2018).

1.6.2 Mandibular Procedures

• Sagittal-Split Osteotomy
The sagittal split osteotomy (Fig. 16) now is used for almost all mandibular
surgery because of several advantages over alternative techniques for ramus
surgery:
• The mandible can be moved forward or back as desired, and the tooth-
bearing segment can be rotated down anteriorly (increasing the mandibular
plane angle) when additional anterior face height is desired.
• This procedure is quite compatible with the use of rigid intraoral fixation
(RIF), so immobilization of the jaws during healing is not required.

• Excellent bone-to-bone contact after the osteotomy means that problems

with healing are minimized, and postsurgical stability is good (Proffit et al.,
2018).
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 Chapter One Review of literature

Figure 16 sagittal split osteotomy (phulari, 2011).

• Vertical Subsigmoid Osteotomy (Fig. 17)

The vertical subsigmoid osteotomy is used primarily to move the
mandible backwards for the correction of mandibular prognathism or
asymmetry and involves a cut from the sigmoid notch in front of the condyle,
extending vertically down behind the neurovascular bundle, to the angle of
the mandible (Cobourn and DiBiase, 2016).
• Genioplasty
The genioplasty is an osteotomy involving the inferior border of the chin
and is achieved with a horizontal cut across this region (Fig. 18). The bony
segment can be moved in an anterior or posterior direction to augment or
reduce chin prominence, while vertical reduction can be used to diminish the
height of the anterior mandible. Genioplasty can be used in isolation to correct
mild problems of chin aesthetics, particularly asymmetries; however, it is most
commonly used as an adjunct to bilateral sagittal-split osteotomy, either to
reduce chin prominence or to increase it (Cobourn and DiBiase, 2016).
• Anterior Subapical Osteotomy (Fig.19)
The anterior subapical osteotomy is occasionally used to alter the
position of the lower labial segment in the mandible and requires vertical cuts

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 Chapter One Review of literature

through the alveolus behind the canine teeth, which are joined by a horizontal
cut underneath the root apices to free the anterior segment. The subapical
osteotomy can be utilized in the correction of anterior open bite and
bimaxillary proclination or for levelling an excessive curve of Spee if this
cannot be achieved orthodontically and the anterior face height needs to be
maintained (Cobourn and DiBiase, 2016).

Figure 17 Vertical subsigmoid osteotomy (Cobourn and DiBiase, 2016).

Figure 18 Genioplasty. (Cobourn and DiBiase, 2016).

Figure 19 Anterior subapical osteotomy.(Cobourn and DiBiase, 2016).

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Chapter two Discussion/Comments

Chapter Two
Discussion
 Chapter two Discussion/Comments

The main goals of orthognathic surgery are to achieve a correct bite,

an aesthetic face, and an enlarged airway. While correcting the bite is
important, if the face is not considered, the resulting bone changes might lead
to an unaesthetic result. Patients with significant skeletal discrepancies and
dentofacial deformities cannot be treated satisfactorily by orthodontic
management alone. In such cases surgical correction by means of
orthognathic surgeries of maxilla and mandible may be indicated to obtain
optimal occlusal and esthetics results. Adult patients with significant skeletal
malocclusion in whom growth modification procedures cannot be carried out
may also benefit from orthognathic surgery. A team work approach consists
of an orthodontist and maxillofacial surgeon is necessary to get the best result
concerning the malformation.

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Chapter Three Conclusions And Suggestions

Chapter Three
Conclusions And Suggestions
 Chapter Three Conclusions And Suggestions

Orthognathic surgery is indicated for those patients seeking changes in

aesthetics and function of a magnitude that is not possible with orthodontics
alone. Careful planning and good communication between the orthodontist,
surgeon and the patient is essential to avoid any complications. Current
technology allows the clinician to simulate treatment and plan for optimum
aesthetics and function. However, despite all this, complications could occur
and the clinician should be knowledgeable enough to recognize and respond
effectively.

Suggestions

1. Preoperative photographs are necessary in order to have a record of

pretreatment profile. Morphometric measuremen ts can also be done on
these photographs. Frontal and lateral photographs are usually taken in a
natural head positions.

2. An orthopantomogram is necessary to rule out a periapical or periodontal

pathological condition. The X-ray will also aid in the determination of the
stability of teeth in the supporting tissue and their ability to withstand the
stresses of fixation devices and immobilization. Any impacted/embedded or
ectopic teeth, which may come in the line of the osteotomy cut, should be
preferably extracted 6 months prior to surgery.

3. The team approach may vary according to local circumstances, the

optimum would consist of an orthodontist, an oral and maxillofacial surgeon,
a liaison psychiatrist or clinical psychologist, a specialist in restorative
dentistry, supported by a maxillofacial technician.

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References

References
 References

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