Category Archives: Correction of Dentofacial Deformities

ORO~NTRAl COMMUNICATIONS

OROANTRAl COMMUNICATIONS

AI} opening may be made into the maxillary sinus when .. teeth are removed and, occasionally, as a result of trauma. This Si:1US perforation happens particularly when a max- ,. iJIri molar with widely divergent roots that is adjacent to edentulous spaces requires ‘extraction. In this instance.he sinus is likely to have become pneumatized into the  ,edentulous alveolar process surrounding the tooth, which weakens the entire alveolus and brings the tooth erupts into a closer relationship with the ‘sinus cavity. Other causes of perforation into the sinus include < destruction of a portion of the sinus floor by periapical -Lesions, perforation of the floor and sinus membrane with Injudicious use of instruments, forcing a root or tooth into the sinus during attempted removal, and removal of large cystic lesions that encroach on the sinus cavity.  The treatment of oroantral communications is accomplished eicher immediately, when the opening is created, or later, as in the instance of a long-standing fistula or failure of an attempted primary closure.

SUMMARY

SUMMARY
The. treatment of .patlents with dentofacial deformity involves the evaluation and treatment of many types of dental and skeletal problems. These problems require that all practitioners involved in patient care interact in a.multidlsclplinary team approach to treatm”ent.· This se quential. team approach yields the most satisfying results.

POSTSURGICAL TREATMENT PHASE

POSTSURGICAL TREATMENT PHASE
C?mpletiCin of Orthodontics.
When satisfactory range of jaw motion and stability of the osteotomy sites are achieved, the orthoctontic treatment can be finished. The heavy surgical arch wires are removed and replaced with light orthodontic wire. Final alignment and pcsitloning of the teeth is accomplished, as is closure of any residual extraction space. The light vertical elastics are Jeft in place at this time to
override proprioceptive impulses from the teeth, which otherwis-e would cause the patient to seek a new position of tnaximal intercuspation. The settling process proceeds rapidly and rarely takes ..longer than 6 to 10
months.

PERlOPERATIVE CARE OF tHE ORTHOGNATHIC SURGICAL PATIENT

PERlOPERATIVE CARE OF tHE ORTHOGNATHIC SURGICAL PATIENT 

PERlOPERATIVE CARE OF tHE ORTHOGNATHIC SURGICAL PATIENT

PERlOPERATIVE CARE
OF tHE ORTHOGNATHIC
SURGICAL PATIENT

PERlOPERATIVE CARE OF tHE ORTHOGNATHIC SURGICAL PATIENT

PERlOPERATIVE CARE
OF tHE ORTHOGNATHIC
SURGICAL PATIENT

FIG 25-30

FIG 25-30

monitors postoperative progress. The patient is discharged when feeling comfortable, taking food and fluid orally without difficulty, and ambulating well. The postsurgical hospital stay usually ranges from 1 to of days.
Patients generally require only mild-to-moderate pain medication during this time and often require no analgesics after discharge. As soon as is feasible, postoperative radiographs are obtained to ensure that the predicted bone changes have taken place.

!-IG 2S -:) 1 Distraction osteoqenesrs with surgically assisted palatal expansion for correction of transverse maxillary deficiency. A, Severe constriction of maxilla with inadequate arch length (note that severe crowding exists even though premolars have been extracted). B, Expansion device in place. C, Maxilla expanded (note .space between central incisors). Both osteogenesis, with bone formation, and histogenesis, with formation of gingival tissue, are occurring. D, Space closed with anterior teeth orthodontically aligned using newly formed regenerate bone. E, Radiograph showing expansion with immature regenerate if}anterior space. F, Radloqraph after orthodontic alignment. (Text related to these images is found" on page 589.)

!-IG 2S -:) 1 Distraction osteoqenesrs with surgically assisted palatal expansion for correction of transverse
maxillary deficiency. A, Severe constriction of maxilla with inadequate arch length (note that severe
crowding exists even though premolars have been extracted). B, Expansion device in place. C, Maxilla
expanded (note .space between central incisors). Both osteogenesis, with bone formation, and histogenesis,
with formation of gingival tissue, are occurring. D, Space closed with anterior teeth orthodontically
aligned using newly formed regenerate bone. E, Radiograph showing expansion with immature regenerate
if}anterior space. F, Radloqraph after orthodontic alignment. (Text related to these images is found”
on page 589.)

FIG. ~5 3~ Case report of distraction csteogenesis (~O) to correctsevere mandibular deficiency. A and B, Preoperative facial esthetics demonstrating s-evere mandibular deficiency. C and D, Preoperative <!r:clusion demonstrating class II relationship. (Text related to these images is foun~ on page 58g.) Continued

FIG. ~5 3~ Case report of distraction csteogenesis (~O) to correctsevere mandibular deficiency.
A and B, Preoperative facial esthetics demonstrating s-evere mandibular deficiency. C and D, Preoperative
<!r:clusion demonstrating class II relationship. (Text related to these images is foun~ on page 58g.)
Continued

FIG. 25-32

FIG. 25-32

~I('. 2')-3 L-;:

~I(‘. 2’)-3 L-;:

FIG .. 25-33

FIG .. 25-33

pag. (01). After an adequate accommodation period. the occh.c.il splint is removed and thepatient returned to the orthodontist’s care.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISTRACTION OF OEOGENESIS

DISTRACTION OF OEOGENESIS

One nesv approach to correction of deficiencies in the mandible and the maxilla involves the use of distraction osteogenesis (DO). When correcting deformities associatcd with these deficiencies, the conventional osteotomy techniques have several potential limitations (described
previously in this chapter). When large skeletal movements are required, the associatedsoft tissue often cannot adapt to’ the acute changes and stretching that result from the surgical repositioning of bony segments. This
failure of tissue adaptation results in several problems, including surgical relapse, potential excessive loading of the T~IJ structures, and increased severity of neurosensory loss as a result of stretching of nerves. In some cases
tile amount of movement is so large that the ·gaps crcatcd require bone grafts harvested from secondary surgical sites such as the iliac crest.

FIG. 27-.1

FIG. 27-.1

FIG. 25-26 A

FIG. 25-26 

In the case atma~dibalar deficiency, the initial surgical procedure involves performing an osteotomy and placement of the distraction appliance. After a latency period of 7 days, the distraction occurs with a rate and
rhythm of 1 mm per day (completed by activating the appliance 0.5, mm twice each day). Once this distraction is complete the appliance is left is place for the consolidation. phase, which is usually two or three times the
amount of time required for the distraction phase. The appliance is then removed, and’ active orthodontic treatment continues. Fig. 25-32 on pages 597 through 599 demonstrates a case of DO of the mandible.

 

 

Combinatjon Deformities and Asymmetries

Combinatjon Deformities and Asymmetries
Treatment may require a combination of maxillary and mandibular osteotomies to achieve the best possible occlusal, functional, and esthetic result (Figs. 25-27 and 25·28 on pages 590 through 593). Treatment of asymmetry in more than two planes frequently requires maxillary surgery,
mandibular surgery, and inferior border osteotomies, as well as recontouring or augmentation of other areas of the maxilla and mandible (Fig. 25-29 on page 59-4).

Maxillary and Midface Deficiency

Maxillary and Midface Deficiency
Patients with maxillary deficiency commonly appearto have a retruded upper lip, deficiency of the paranasal and infraorbital rim areas, inadequate tooth exposure during smile, and a prominent chin relative to the middle third
of the face.’ Maxillary deficiency may occur in the antero-

Maxillary and Midface Deficiency

Maxillary and Midface Deficiency

Maxillary and Midface Deficiency

Maxillary and Midface Deficiency

is frequently seen.The primary technique for correction of maxillary
deficiency is the Le Fort I osteotomy. This technique can be used for advancement of the maxilla to correct a class III malocclusion and associakd facial abnormalities (fig. 25·24 on .pages 586 and 587). Depending on the magrutude of advancement, bone grafting may be required to improve bone healing and postoperative stability. In the
case of vertical maxillary deficiency, elongation of the IUI\’et third of the face can he accomplished by bone grafting the maxilla in an inferior position with the Le Fort I osteotomy technique (I·ig. 25·25 on page 588). This technique improves overall facial proportion and normalizes
exposure of the incisors during smiling. In severe midface deformities with infraorbital rim and malar eminence deficiency, a l.e Fort III or modified Le Fort III type of osteotomy h necessary. These procedures advance the maxilla and the malar bones and, in some cases, the anterior portion of the nasal bones. This type of treatment is commonly required in patients with craniofacial deformities such as Aport’s or Ciouzori’s syndrome (Fig. 25-26·on page 5H9).

 

 

 

 

Maxillary Excess

Maxillary Excess
Excessive growth of the maxilla may occur in the anteroposterior, vertical, or transverse dimensions. Surgical correction of dentofacial deformities with total maxillary surgery (i.e., Le Fort I) has only become popular since the
early 197,Os. Before that time maxillary surgery was performed on a limited basis, and most techniques repositioned only portions of the maxilla with segmental surgery. During the early years of maxillary surgery, many
techniques were performed in two stages: Facial or buccal cuts were performed during one operative procedure; then sectioning of palatal bone was performed 3 to 4 weeks later. This staging was done under the assumption
that this was necessary to maintain adequate vascular supply to the osteotomized segment. As experience and understanding of these techniques increased, several procedures for anterior and posterior segmental surgery
evolved that used single-stage techniques. 16-1 .

Mandibular Deficiency

Mandibular Deficiency

The most obvious clinical feature of mandibular deficiency is the retruded position of the chin as viewed. from the profile aspect. Other facial features often associated with mandibular deficiency may include an excess labiomental fold with a procumbent appearance of the lower lip, abnormal posture of the upper lip, and poor throat form. Intraorally, mandibular deficiency is associated with class· II molar and cuspid relationships and an increased overjet in the incisor area.

FIG. 25-16 Mandibular advancement techniques. A, Mandibular advancement using vertical osteotomy and iliac crest bone grafts in osteotomy defect. 8, Modified C osteotomy with sagittal splitting of inferior border of mandible combined with iliac crest bone grafts

FIG. 25-16 Mandibular advancement techniques. A, Mandibular
advancement using vertical osteotomy and iliac crest bone grafts in
osteotomy defect. 8, Modified C osteotomy with sagittal splitting of
inferior border of mandible combined with iliac crest bone grafts

FIG 25-7

FIG 25-7

FIG 25-17

FIG 25-17

FIG. 25-18 Total subapical-osteotomy. Dentoalveolar segment of mandible is moved anteriorly, allowing correction of class 1/ malocclusion without increasing chin prominence.

FIG. 25-18 Total subapical-osteotomy. Dentoalveolar segment of
mandible is moved anteriorly, allowing correction of class 1/ malocclusion
without increasing chin prominence.

portion of mandible is osteotomized, moved forward, and stabilized (Fig. 25-19, A, C, and D). In addition to anterior or posterior repositioning of the chin, vertical reduction or augmentation and correction of asymmetries
can also be accomplished with inferior border osteotomies. Alloplastic materials can occasionally be used to augment chin projection; the material is onlayed in areas of bone deficiencies (Fig. 25-19, B).

 

 

 

 

 

 

Mandibular Excess

Mandibular Excess

l.xccss growth of the mandible frequently results in an abnormal occlusion with c1;]ss III molar arid cuspid relationships and a reverse overjet in tile incisor area, An obvi- ‘(JUS facial deformity mav also be evident. Facia! features associated with mandibular excess include a prominence of till’ lowvr th iI’d 01 till’ !;tll’, pa rticularlv ill the ;IJ’l’.1of Ihe lower lip and c hin in thl’ ;tlltl’IOj>()\terior and vertical dimcnviunv. III \l’\’l’ll’ GI\l” till’ large reverse overjet muvdecreased sensation in the area of the lower-lip and chin
during the immediate postoperative period.