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Surgery in Orthodontics

Ujwal GautamRoll no. 431

BDS 4th year (2009 batch)BPKIHS

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Major procedures

• Orthognathic surgeries• Cosmetic surgeries

Minor procedures

• Extractions– therapeutic extraction– serial extraction– carious teeth– malformed teeth– supernumerary teeth– impacted teeth

• Surgical uncovering of teeth• Frenectomy• Pericision• Corticotomy

Orthognathic surgeries

corrects dento-facial disproportions involving the maxilla, the mandible or both in all three planes of space

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Indication

If neither growth modification procedures nor orthodontic camouflage provides solution

NOT a substitute but adjunct to or in conjunction with orthodontic treatment.

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Camouflage v/s Surgery

Decision for camouflage or surgery must be made before treatment beginsGreater emphasis on soft tissue consideration essential when camouflage versus surgery is considered

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Envelope of Discrepancy

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Surgery preferred over Orthodontic Camouflage for;

o Long Vertical Facial patterno Moderate or severe antero-posterior jaw discrepancyo Crowding >4-6 mmo Exaggerated featureso Transverse Skeletal problem

Contemporary Surgical Techniques:

– Mandibular Surgery– Maxillary Surgery– Dentoalveolar Surgery– Distraction Osteogenesis– Adjunctive Facial

procedures

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LeFort I osteotomy

Segmental osteotomies

Sagital Split osteotomy

Oblique sub condylarosteotomy

Rhinoplasty

Genioplasty

Sub mental procedures

Lip procedures

Surgically assisted rapidPalatal Expansion (SARPE)

Class III mandibular excess

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Class II mandibular deficiency

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Horizontal deficiency and vertical chin excess

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Class II maxillary protrusion

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Excess vertical growth of maxilla and down and back rotation of mandible

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Class III maxillary deficiency and mandibular excess14

Distraction Osteogenesis

• based on manipulation of a healing bone• osteotomized area is stretched before calcification has

occurred in order to generate the formation of additional bone formation and investing soft tissue

• Patients with craniofacial syndrome are the prime candidates

• Advantages of distraction are that – Larger distances of movement are possible than with

conventional orthognathic surgery, and– Deficient jaws can be increased in size at an earlier age

• Disadvantage is that precise movements are not possible15

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Adjunctive Facial procedures

• improve the esthetics of the patient• to improve the soft tissue contours beyond what is available

from repositioning the jaws

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Rhinoplasty

cosmetic surgery of the nose focused on the contour of the nasal dorsum, the shape of the nasal tip and the width of the alar base

particularly effective when nose is deviated to one side, has a prominent dorsal hump, or has a bulbous or distorted tip.

Usually follows LeFort I osteotomy which compromises the appearance of nose

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Chin Augmentation or Reduction

most frequently used adjunct to orthodontics Improves the stability of the lower incisors as well as enhancing

facial appearance tightens the suprahyoid musculature and produces desirable changes in chin-neck contour

Reduction of the chin with osteotomy can be a possibility to camouflage a skeletal Class III problem

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Extractions

Most commonly undertaken minor surgical procedures in conjunction with orthodontic therapy.

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Therapeutic extraction

– for gaining space

– Choice of teeth extraction is based on number of factors including the amount of arch length-tooth material discrepancy, the direction and amount of jaw growth, the facial profile, the state and position of teeth in particular and the entire dentition and finally the age of the patient.

– Integrity of alveolus should be maintained– Permanent 1st premolars are the most commonly extracted teeth

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Serial extractions

– interceptive orthodontic procedure– usually initiated in the early mixed dentition when severe arch

length discrepancy exists

– includes planned extraction of certain deciduous teeth and later specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into normal alignment

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Procedures

Dewels method

Tweeds method

Nance method

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Extraction of supernumerary, impacted and ankylosed teeth

• Involves removal of local cause of malocclusion

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Surgical extraction of bilateral unerupted supernumerary teeth in maxillary central incisor region

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• Impacted teeth can be guided into normal position by removal of overlying soft tissue and removal of bone covering

• orthodontic guidance can be required using attachments to guide erupting tooth into arch

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Surgical uncovering of impacted teeth

Frenectomy

• surgery to remove the interdental fibrous tissue and reposition the frenum

• Generally performed for Midline Diastema • maxillary midline diastema is often accompanied by the insertion of a

thick, fleshy fibrous labial frenum into a notch in the alveolar bone.

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frenectomy performed prior to space closure

Merit- removal of etiology Space closure can be easily attained orthodontically

Demerit- scar tissue that could prevent orthodontic space closure.

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frenectomy should be performed after space closure

Merit- reduces the risk of scar tissue formation that can prevent closure of

midline diastema. post surgical scar tissue stabilizes the teeth together.

Demerit- during closure, soft tissue may be enlarged and sore preventing

complete space closure. if the space is large and frenal attachment is thick, it may not be possible

to completely close the space before surgical intervention, requiring multiple stages of treatment.

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Frenectomy and midline diastema32

Corticotomy

• undertaken in patients having dental proclination with spacing

• Involves sectioning of dento-alveolar region into multiple small units to hasten orthodontic tooth movement

• Although the nerve supply to the teeth is interrupted, sensation usually returns and endodontic treatment almost never required

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Pericision

• Also known as circumferential supracrestal fibrotomy

• Adjunct to an retention procedure after corrrection of rotations• performed to counter the relapse tendency of the stretched gingival

fibres – trans-septal and alveolar crest group in derotated tooth

• Surgical sectioning of gingival fibres• performed a few weeks before removal of orthodontic appliance or

if it is performed at the same time the appliance is removed, a retainer must be inserted almost immediately.

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References

Proffit W. R.; Contemporary Orthodontics; Mosby Inc; 4/e; 2007Bhalajhi S. I.; Orthodontics The Art and Science; Arya(MEDI) Publishing House; 4/e; 2009Proffit, White, Sarver; Contemporary Treatment of Dentofacial Deformity; St. Louis, Mosby,2003Singh G.; Textbook of Orthodontics; Jaypee Brothers Medical Publishers Ltd; 2/e; 2007

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