Relapse after orthodontics and orthognathic surgery

A combined orthodontic and surgical approach is often the treatment of choice for the correction of severe dentofacial deformities. Numerous orthognathic surgical procedures have been developed for this treatment. It is clear that certain orthognathic surgical procedures have a tendency to relapse; many studies have been conducted in an attempt to create a pattern of predictability and a prognosis of stability. This article reviews the literature briefly and presents four cases in which the combined surgical and orthodontic approach produced less than satisfactory results. The small number of patients does not permit statistical evaluation or firm conclusions regarding the occurrence and the etiology of relapse in general. This article underlines the importance of long-term follow-up for all patients treated with a combination of orthodontics and orthognathic surgery.     

Lingual orthodontics and orthognathic surgery

Lingual orthodontics is an appealing option for patients requiring orthognathic surgical correction, since these patients are invariably adults or mature teenagers who are no longer at the usual "orthodontic age." Appearance is undoubtedly the most important motivating factor for adults seeking orthodontic treatment, and since the more physically attractive person has the advantage over the not-so-attractive person, it is self-evident that these patients would prefer an appliance that is less visible. Using the Ormco, Creekmore, or Begg lingual appliances in the maxillary arch and a labial appliance in the mandibular arch, the authors have successfully treated a variety of dentofacial deformities with a combined lingual orthodontic and surgical approach. The aim of this article is to establish some guidelines for the treatment of a variety of surgical cases and to highlight what are perceived to be the advantages and disadvantages of these 3 lingual appliances in the treatment of orthognathic cases and of the lingual orthognathic approach in general.     

Surgical versus orthodontic correction of skeletal Class II malocclusion in adolescents: effects and indications.

To clarify the effects of orthodontic versus surgical treatment and to distinguish more clearly those Class II patients who can be treated successfully with orthodontics alone, we compared three groups of adolescents: forty patients treated successfully with orthognathic surgery, 40 patients treated successfully with orthodontics alone, and 21 patients whose orthodontic treatment was judged to be unsuccessful. Successful surgical treatment was accomplished largely by bringing the mandible forward, but this involved vertically repositioning the maxilla, alone or in combination with advancing the mandible, in 40% of the patients. Successful orthodontic treatment resulted from a combination of retraction of the maxillary incisors and protraction of the mandibular incisors; most of the successfully treated group also had significant vertical growth, and 40% had greater than 2 mm anteroposterior growth. The unsuccessfully treated orthodontic patients initially had greater overjet, more severe mandibular deficiency, and greater anterior facial height than those treated successfully; they also had less retraction of the maxillary incisors and less growth during treatment. In Class II adolescents beyond the growth spurt, surgery is likely to be needed for successful correction of the malocclusion if the overjet is greater than 10 mm, especially if the distance from pogonion to nasion perpendicular is 18 mm or more, mandibular body length is less than 70 mm, or facial height is greater than 125 mm.     

Early orthognathic surgery with three-dimensional image simulation during presurgical orthodontics in adults

To correct dentofacial deformities, three-dimensional skeletal analysis and computerized orthognathic surgery simulation are used to facilitate accurate diagnoses and surgical plans. Computed tomography imaging of dental occlusion can inform three-dimensional facial analyses and orthognathic surgical simulations. Furthermore, three-dimensional laser scans of a cast model of the predetermined postoperative dental occlusion can be used to increase the accuracy of the preoperative surgical simulation. In this study, we prepared cast models of planned postoperative dental occlusions from 12 patients diagnosed with skeletal class III malocclusions with mandibular prognathism and facial asymmetry that had planned to undergo bimaxillary orthognathic surgery during preoperative orthodontic treatment. The data from three-dimensional laser scans of the cast models were used in three-dimensional surgical simulations. Early orthognathic surgeries were performed based on three-dimensional image simulations using the cast images in several presurgical orthodontic states in which teeth alignment, leveling, and space closure were incomplete. After postoperative orthodontic treatments, intraoral examinations revealed that no patient had a posterior open bite or space. The two-dimensional and three-dimensional skeletal analyses showed that no mandibular deviations occurred between the immediate and final postoperative states of orthodontic treatment. These results showed that early orthognathic surgery with three-dimensional computerized simulations based on cast models of predetermined postoperative dental occlusions could provide early correction of facial deformities and improved efficacy of preoperative orthodontic treatment. This approach can reduce the decompensation treatment period of the presurgical orthodontics and contribute to efficient postoperative orthodontic treatments.     

Reprint of team approach for orthognathic surgery

To ensure that orthognathic surgery is successful, functional aspects such as mastication, pronunciation, swallowing and aesthetic factors must be considered. For successful orthognathic surgery, the orthodontist and the surgeon must constantly study and discuss accurate facial analysis, presurgical orthodontics, choice of appropriate surgical methods, and postsurgical orthodontics. In this article, we will discuss the team approach for successful orthodontic treatment and orthognathic surgery, establishing close cooperation between the orthodontist and surgeon.     

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骨性畸形在牙颌面畸形中占有相当高的比例,许多患者要通过正颌手术治疗.通常患者首诊到正畸科、颌面外科(整形外科、正颌外科).是否要行正颌手术治疗往往要取决于正畸科是否能通过代偿正畸治疗解决问题.若代偿矫治的结果能使患者和医生都满意,则患者可以避免更复杂、风险更大的正颌手术治疗;若患者的要求很高(可能是美观方面)或畸形非常严重,单纯正畸治疗已不能很好地解决患者对颌面部美观和功能恢复的要求,正颌手术就是惟一正确的选择、目前,在正畸和手术联合治疗开展比较好的医疗单位,是否手术以及手术如何设计几乎是由正畸医生主导.所以,这就要求正畸医生除了要全面掌握骨性牙颌面畸形术前、术后正畸治疗的理论和临床技能外,还要比较透彻地了解各种正颌手术术式、手术的最大限度、术前术后正畸、(牙合)板制作等方面知识.本文将结合临床实际,就几个正畸和手术联合治疗的重要问题进行讨论,重点在各种畸形正颌手术的术式选择策略,正畸和手术联合治疗的术前、术后正畸治疗原则等.     

Team approach for orthognathic surgery

To ensure that orthognathic surgery is successful, functional aspects such as mastication, pronunciation, swallowing and aesthetic factors must be considered. For successful orthognathic surgery, the orthodontist and the surgeon must constantly study and discuss accurate facial analysis, presurgical orthodontics, choice of appropriate surgical methods, and postsurgical orthodontics.In this article, we will discuss the team approach for successful orthodontic treatment and orthognathic surgery, establishing close cooperation between the orthodontist and surgeon.     

成人骨性安氏Ⅱ类1分类错(牙合)的正颌-正畸联合治疗

目的采用正畸-正颌手术联合治疗骨性安氏Ⅱ类Ⅰ分类错(牙合)患者,介绍手术前后正畸及术前的准备工作.方法11例成人骨性安氏Ⅱ类Ⅰ分类错(牙合)患者,均经术前正畸-正颌手术-术后正畸的治疗过程.手术前后正畸目的是矫正上下颌前牙前突,排齐牙列,协调上下牙弓,平整牙(牙合)曲线,建立正颌术后良好的咬合关系.术前准备包括术前电脑模拟手术、模型外科、(牙合)板制作.结果11例患者建立了良好的咬合关系及协调的上下颌骨关系,面容美观改善.结论骨性错(牙合)畸形患者采用正畸-正颌联合治疗,能获得功能和美观的满意效果,术前正畸、电脑模拟手术、模型外科、(牙合)板制作及术后正畸,每一操作步骤的精确到位均十分重要.     

手术优先模式治疗骨性牙颌面畸形的研究进展

手术优先模式(surgery-first approach, SFA)是指患者在正颌手术前绕过术前正畸这一过程,或者只进行短暂简单的术前正畸,继而直接行正颌手术,以此避免术前正畸出现的暂时性面型恶化,并缩短治疗疗程,提高患者满意度。相较于传统的正畸-正颌模式,SFA有较为严格的选择适应证和禁忌证,手术设计及操作难度提高,治疗后的临床效果和长期稳定性的相关研究也较少。SFA作为传统正畸正颌联合治疗的替代方案,是近年来研究热点之一,本文也将从SFA的概念、优缺点、适应证与禁忌证、手术设计等几个方面作一综述。     

The emotional impact of orthognathic surgery and conventional orthodontics

Previous research by the authors has pointed to depressive reactions among orthognathic surgery patients during the fixation-removal stage and up to 9 months later. However, less is known about emotional shifts among persons who choose to undergo conventional orthodontic treatment after considering surgical orthodontics. In the current study, a standard measure of mood states was applied to 90 surgical patients and 66 who had considered surgery but decided against it. Of these, 33 were undergoing orthodontic treatment and 33 were having no treatment. The mood scale and measures of personality were first applied before surgery and then during orthodontic treatment, just after surgery, at fixation removal, and 6 months after surgery. Nonsurgical respondents completed questionnaires at the same time as their matched surgical respondents. Scores on tension and fatigue increased significantly among surgical patients from before surgery to immediately after surgery and dropped to presurgical levels when fixation was removed. Anger-hostility increased at fixation removal but declined within 5 months. Postsurgical discomfort, pain, and paresthesia, and interpersonal and oral function problems were correlated with postsurgery emotional state. On the later questionnaires, which corresponded to the later periods of orthodontic treatment, patients who had opted for conventional orthodontic treatment reported that they experienced greater depression, anger, and tension. These patients may be particularly vulnerable to emotional problems because their orthodontic treatment may be more complex and of longer duration than that of the typical orthodontic patient. These results point to the importance of continued psychological support for both orthodontic and surgical patients throughout their course of treatment.     

Alveolar osteotomy and rapid orthodontic treatments

When combined with orthodontics, selective periodontal decortication has been shown to be clinically effective in eliminating severe malocclusions three to four times more rapidly than conventional orthodontic treatment. Our technique combines surgical scarring of the cortical bone on both labial and lingual sides of the teeth to be moved, with an augmentation graft to increase alveolar volume. Alveolar spongiosa undergoes rapid transformation as the body attempts to heal the wounds to the cortices resulting in marked tissue turnover. The patient is seen every two weeks and most cases are completed within six months of orthodontic treatment. Moreover, this technique significantly expands the scope of treatment in resolving many skeletal problems such as openbites and severe maxillary constrictions, conditions typically relegated to orthognathic surgery. Clinical outcomes research has shown that the immediate post treatment results settle better during retention and that the long term results become more stable. These facts are likely due to the high tissue turnover induced by decortication as well as the thicker cortical bone resulting from the augmentation grafting.     

Psychosocial factors associated with orthodontic and orthognathic surgical treatment

Recognition of the potential repercussions associated with malocclusion has encouraged investigations aimed at understanding the psychosocial outcomes associated with orthodontics and orthognathic surgery. Of particular interest are the benefits of treatment on judgements of self-image and interpersonal relationships. This article examines patients' adjustment to dentofacial malrelations in an attempt to assess their psychologic well-being before treatment. This discussion is followed by a review of the psychosocial benefits and negative effects associated with orthodontics and orthognathic surgery. Although dentofacial deviations can have some social disadvantages, candidates for corrective treatment appear to be well-adjusted before treatment. Long-term benefits in self-concept, body image, and interpersonal relations after treatment are variable, with larger psychosocial changes generally reported by orthognathic surgery patients than by patients who receive orthodontic treatment alone.     

Redefining our protocol of the orthognathic surgery-first approach after 10 years of experience

The objective of this study was to update and redefine some concepts of the surgery-first (SF) approach, regarding its indications and contraindications, virtual planning work-up, surgical tips, and postoperative orthodontic benefits, after 10 years of experience. A retrospective analysis was made of orthognathic surgical procedures following the SF protocol between January 2010 and December 2019 to review inclusion and exclusion criteria, diagnostic workflow, surgical tips, and postoperative outcomes. A total of 148 SF procedures were performed during this period, which corresponded to only 9.2% of the total orthognathic surgeries performed, which means that we have broadened the exclusion criteria instead of reducing them. Surgical tips include interdental corticotomies solely in cases of anterior crowding and leaving the intermaxillary fixation miniscrews in place postoperatively for orthodontic skeletal anchorage. The mean duration of postoperative orthodontic treatment was reduced in comparison to conventional surgery (36.8 vs 87.5 weeks). The overall degree of satisfaction was high not only for the patients, but also for the orthodontists and surgeon. SF is especially indicated for patients who desire an immediate aesthetic result, with short-term orthodontics, or for treatment of sleep-related breathing disorders, if they meet the established criteria.     

Orthodontics and the upper airway

One of the general aims of orthodontic treatment and of the combination of orthodontics and orthognathic surgery is to achieve good occlusion and aesthetic improvement, especially in cases of severe dentoskeletal deformities. However, on many occasions, the parameters of the upper airways are not taken into account when the aims of conventional treatment are fulfilled. Patients with obstructive alterations during sleep represent for the orthodontist a type of patient who differs from the normal; for them, treatment should include the objective of improving oxygen saturation. Here, functional considerations should outweigh purely aesthetic ones. It is important, when making an orthodontic, surgical or combined diagnosis for a patient, to bear in mind the impact that treatment may have on the upper airways. Good aesthetics should never be achieved for some of our patients at the expense of diminishing the capacity of their upper airways.     

Combining planned 3rd molar extractions with corticotomy and miniplate placement to reduce morbidity and expedite treatment. A case report with 3.5-year follow up

Alveolar corticotomy (ACO) is increasingly popular to accelerate orthodontic tooth movement. However, because it is an invasive surgical procedure, there is still some resistance to its use. Combining ACO with other surgical procedures is a means to employ the method without adding an additional surgical intervention. Combining surgical interventions into one surgery reduces trauma and down time for the patient and also allows clinicians to maximize treatment outcomes. This article illustrates how the anticipation of the 3rd molars extraction created a window of opportunity for the use of ACO and miniplates, to successfully and efficiently retreat a moderate skeletal Class II on a young adult patient who did not accept orthognathic surgery with orthodontics as a retreatment alternative.     

Oral surgeons' considerations in surgical orthodontic treatment

The orthognathic surgeon seldom has to consider further growth and development of the adult jaws. There are, however, limitations in the adult of certain orthodontic procedures that are effective in the young; rapid palatal expansion, for example. The surgeon and the orthodontist must be aware of other procedures that may be substituted. The adult patient has social, economic, and psychological demands that differ from the young. These may mandate a reversal of the traditional staging of orthodontics first, surgery to follow. Instead, consideration can be given to doing only that orthodontics needed to permit surgery, then surgery to correct the skeletal problems, followed by whatever orthodontics are necessary or desired. Various symptoms of MPD are present in most patients with jaw abnormalities and malrelationships. There must be an awareness that trying to provide relief without correcting the structural problem is treating only symptoms. There also must be realization, especially on the part of the patient, that correcting the jaw deformity does not necessarily mean that symptoms will be gone or, if gone, will not recur. Above all, the orthodontic and surgical team should strive to provide the patient with the maximum function compatible with the appearance the patient desires and do it with the least required amount of surgery and orthodontics.     

颌骨牵引成骨术术前术后正畸治疗的初步研究

目的 探讨颌骨牵引成骨术术前术后正畸治疗的要求和原则。方法 对４例患者行颌骨牵引成骨术,年龄１９～２５岁,平均２１．５岁。４例分别行术后、术前术后正畸治疗。结果 ①颌骨牵引成骨术的术前正畸治疗较为简单,一般情况在短时间内排齐上下牙列,便于不锈钢圆丝的应用。②颌骨牵引成骨术的术后正畸治疗最具特色且较为复杂。术后正畸的首要任务是采用颌间垂直牵引,使脱离咬合的后牙在短时间内建立Ｈｅ关系。在垂直牵引时,宜采用非常轻力。有些患乾需要采用颌间交互牵引,在纠正牙区开Ｈｅ的同时,敌正后牙的覆盖的关系。③颌骨牵引成骨术后,有些患者需要扩大上颌牙弓,矫正后牙的反Ｈｅ。④颌骨牵引成骨术后,由于肌肉的牵拉,颌骨有复发的趋势,因此除在骨牵引成骨术后保留骨牵引器２～３个月外,还应在术后正畸治疗时,尽早换用较粗的唇弓,以利于进行Ⅱ类或Ⅲ类颌     

Developmental occlusion, orthodontic interventions, and orthognathic surgery for adolescents

This article addresses issues in orthodontics such as timing of treatment, expansion in the absence of a posterior crossbite, serial ex-tractions, treatment of Class II and III malocclusions, treatment of open bites, extraction versus nonextraction, preservation of E-space to resolve crowding, orthodontics and temporomandibular disorders, orthognathic surgery, and current trends in orthodontics.Although much information is presented on these topics, many controversies still exist. When more data from evidence-based systematic reviews become available, more predictable and standardized orthodontic treatments may develop.     

Improving quality of life with a team approach: a case report

An adolescent female who presented amelogenesis imperfecta with severe anterior open bite, long face, facial asymmetry, high angle, and Class III skeletal pattern was treated with an interdisciplinary (orthodontics, orthognathic surgery, and prosthodontics) treatment approach. Presurgical orthodontic treatment was followed by surgical maxillary posterior impaction with anterior advancement and mandibular setback operation with vertical chin reduction and genioplasty. After the surgery, anterior ceramic laminate veneers and posterior full ceramic onlay-crowns were performed. The results showed that function and esthetics were achieved successfully with interdisciplinary collaboration.     

Orthognathic treatment: how much does it cost?

The aim of this multi-centre retrospective study was to assess the cost, and factors influencing the cost, of combined orthodontic and surgical treatment for dentofacial deformity. The sample, from the south-west of England, comprised 352 subjects (109 males and 243 females) with an age range of 14 to 57 years treated in 11 hospital orthodontic units. Treatment costs were calculated for each subject by combining consumable costs with staff overhead and capital costs. The median total treatment cost was euro 6075.25 (interquartile range: euro 5139.41-euro 7069.68). Out-patient costs comprised 43 per cent. The median orthodontic treatment costs were euro 1456.23 (interquartile range: euro 1283.73-euro 1638.75). Orthodontic costs on average comprised 25 per cent of the total treatment cost. The cost of orthodontics for orthognathic patients in a hospital setting appears to represent excellent value for the state funded National Health Service in the United Kingdom.