Nasal considerations in orthognathic surgery

The functional correction of dentofacial deformities by orthognathic surgery produces major changes in facial appearance. Facial esthetics must therefore be equally appreciated by the orthodontist and the maxillofacial surgeon. The orthodontist must perform a thorough esthetic facial evaluation along with his usual orthodontic evaluation. The treatment plan must then be based on the esthetic evaluation and knowledge of the facial changes caused by orthodontic treatment and skeletal jaw surgery. Central to facial form is the nose. This article will outline the proper functional and esthetic evaluation of the nose in relation to the face. Nasal and upper lip changes associated with maxillary procedures will also be covered in detail. In light of these two areas, proper treatment planning and sequencing will be discussed.     

The emerging soft tissue paradigm in orthodontic diagnosis and treatment planning.

Until now, orthodontic diagnosis and treatment planning has been based on hard tissue relationships and on the Angle paradigm that considers ideal dental occlusion 'nature's intended ideal form'. In this view, the clinician and nature are partners in seeking the ideal. In the modern biological model, variation is accepted as the natural form; ideal occlusion is the exception rather than the rule, and the orthodontist and nature are often adversaries. The orthodontist's task is to achieve the occlusal and facial outcomes that would most benefit that individual patient, whose esthetic concerns are often paramount. Because the soft tissues largely determine the limitations of orthodontic treatment, from the perspectives of function and stability, as well as esthetics, the orthodontist must plan treatment within the patient's limits of soft tissue adaptation and soft tissue contours. This emerging soft tissue paradigm in diagnosis and treatment planning places greater emphasis on clinical examination of soft tissue function and esthetics than has previously been the case, and new information in these areas is required.     

The emerging soft tissue paradigm in orthodontic diagnosis and treatment planning

Until now, orthodontic diagnosis and treatment planning has been based on hard tissue relationships and on the Angle paradigm that considers ideal dental occlusion ‘nature's intended ideal form’. In this view, the clinician and nature are partners in seeking the ideal. In the modem biological model, variation is accepted as the natural form; ideal occlusion is the exception rather than the rule, and the orthodontist and nature are often adversaries. The orthodontist's task is to achieve the occlusal and facial outcomes that would most, benefit that individual patient, whose esthetic concerns are often paramount. Because the soft tissues largely determine the limitations of orthodontic treatment, from the perspectives of function and stability, as well as esthetics, the orthodontist must plan treatment within the patient's limits of soft tissue adaptation and soft tissue contours. This emerging soft tissue paradigm in diagnosis and treatment planning places greater emphasis on clinical examination of soft tissue function and esthetics than has previously been the case, and new information in these areas is required.     

Incorporation of facial plastic surgery in the planning and treatment of orthognathic surgical cases.

Until recently, orthognathic surgery and cosmetic soft tissue surgery have been separate clinical endeavors. This article presents examples of soft tissue surgical procedures carried out with orthognathic surgery to enhance the overall result. Video imaging techniques have been integrated into the planning process to more clearly define functional and esthetic goals. The technical achievement of combined orthognathic and esthetic procedures, as well as the timing of treatment between the orthodontist, oral surgeon, and plastic surgeon, is discussed.     

Cosmetic oral and maxillofacial surgery

The dental specialty of oral and maxillofacial surgery over the last fifteen years has been intimately involved in not only altering the bony facial skeleton, but also the esthetic defects of the facial soft tissue drape. These procedures are currently being taught, in many of our residency programs, along side the art and science of dentoalveolar surgery. When one combines the modification of both the skeletal and soft tissues, the resultant effect can be greater than the sum of its parts. Should one take this a step further and add to the list, proper arch form as prepared by the orthodontist along with cosmetic shape and appearance of the dentition by the restorative dentist using the latest in cosmetic dental techniques, what transforms is a result that has never been seen heretofore in the annals of dentofacial care. To follow are a number of case reports illustrating some salient points.     

Esthetic preferences for facial soft tissue profiles

Our aim was to determine any significant difference in esthetic preferences for facial soft tissue profiles among orthodontists, orthodontic patients and their parents. As orthodontic treatment influences facial profiles, the patients' preference for their profile should be sought before treatment, instead of assuming what the orthodontist feels is ideal.     

Enameloplasty and esthetic finishing in orthodontics-identification and treatment of microesthetic features in orthodontics part 1

Interdisciplinary treatment also has expanded to include not only soft tissue assessment of the periodontal components of the dentition and smile, but of the face as well. The next level of esthetic enhancement certainly will include facial proportionality as a key component in our patient evaluation. This paper expands the diagnostic vision of the dentist to include facial proportions and relationships of hard and soft tissues to improve diagnosis and treatment of dental and facial esthetics.     

The adult orthodontic patient.

Adults now make up an increasing portion of the orthodontist's patient load. Though most seek esthetic correction, requests for multidiscipline treatment are expanding. The etiology of adult malocclusion, unlike that of malocclusion in the young, presents us with psychological and physiologic factors that specifically affect treatment and dictate special diagnostic, planning, and mechanical procedures. The adult patient offers the orthodontist a new challenge and the stimulus to develop successful treatment approaches peculiar to the nongrowing patient. Careful diagnosis and treatment planning on a multidiscipline basis will result in satisfactory resolution of most adult malocclusions, and there is no requirement for esoteric appliances or mechanics. An evaluation of treated cases indicates that all corrective dental movements are possible and that the health, function, and esthetics of the dental apparatus can be markedly improved. The cases presented demonstrate that adults are amenable to treatment over the full orthodontic spectrum. Treating the adult patient can be very satisfying. The patient is invariably pleased with his effort (and your help), once the "braces" are off. Since the original need was great in the patient's mind, success in its satisfaction is especially rewarding and it overflows on everyone involved.     

Chirurgische Untergesichtsverlängerung bei der Therapie von Patienten mit Klasse-II-Dysgnathien und skelettal tiefem Biss – "Short-face- Syndrom"

Among Angle Class II patients scheduled for orthognathic surgery, those with short face syndrome with skeletal deep bite only make up a small portion. Nevertheless, it represents a complex challenge for the orthodontist as well as for the surgeon with respect to the individual treatment goals. The harmony of facial relations is impaired in these patients: The skeletal lower face and consequently the soft tissue profile show a deficit in height compared to the midface. Lengthening of the lower face with its respective effect on facial aesthetics can only be corrected by causal therapy, i.e., a combined approach with surgical enlargement of the gonion angle. In this study, a therapy concept specifically suited for the correction of Class II deformities with short face syndrome is presented. Consequences for the skeletal and dental situation with their benefit for extraoral appearance were tested in a clinical trial (n=15, patients with class II deformities and short face syndrome). To evaluate skeletal and dental changes, cephalograms were taken prior to initiation of orthodontic treatment, 3 days after surgery but before initiation of postsurgery orthodontics, and 1 year after the end of treatment.     

Video imaging: techniques for superimposition of cephalometric radiography and profile images

Computerized video imaging techniques that enable superimposition of cephalometric radiographs and tracings on the image of the soft tissue profile are presented. This superimposition allows visualization of the underlying skeletal and dental hard tissues as they relate to the profile and permits surgical planners to be more cognizant of the limitations that the teeth and occlusion present as the esthetic treatment goals are defined. Step-by-step treatment planning of a patient is used to demonstrate the techniques.     

Case report CB. Surgical vs nonsurgical treatment in the nongrowing patient

With an increase in the number of adults currently seeking orthodontic care, the orthodontist will invariably be faced with the planning and execution of treatment for nongrowing patients with significant skeletal discrepancies. Surgical orthodontic treatment may be the preferred mechanical choice in many of the cases, but may not fit the patient's financial or emotional capabilities. It is often incumbent upon the orthodontist to present alternative treatment options along with the risks and benefits inherent in the dentoalveolar compensation of a malocclusion which is predominantly skeletal. Traditional concerns have been with periodontal and dentoalveolar stability, intermaxillary dental function and soft tissue facial aesthetics with more recent focus on the medical-legal implications of potentially altered temporomandibular joint function. Ultimately the decision to undertake an alternative treatment plan, postpone combination surgical/orthodontic treatment or opt for no treatment must lie with the well informed patient. The following case represents many of the considerations and comprises involved with the treatment of a nongrowing skeletal Class II problem.     

Esthetic Aspects of Orthodontic-Surgical Treatment of Sagittal-Vertical Anomalies: The Example of the Short Face Syndrome

BACKGROUND: Psycho-esthetic aspects play an important role in motivating patients to undergo combined orthodontic-surgical treatment as well as in the subjective appraisal of treatment outcome. The facial soft tissues are the crucial interlink between the underlying skeletal and dental structures and their perception by the patient and his social environment. TREATMENT OF SHORT FACE SYNDROME: In the therapy of Class II malocclusions with skeletal deep bite and short lower face (short face syndrome), the soft tissues and the psycho-esthetic treatment expectations of the patient are taken systematically and appropriately into account during treatment planning and evaluation. PATIENTS AND METHOD: The respective elements of the treatment concept are outlined and explained in this article. Based on the empirical evaluation of 15 patients treated according to this concept, the soft tissue changes in patients with short face syndrome and the changes in esthetic and psychosocial self-perception are reported. RESULTS: The results demonstrate the efficiency of the treatment concept in improving facial soft tissues, especially in the vertical dimension, and the resulting psycho-esthetic benefit to the patient.     

Multifaceted aspects of implant esthetics: the anterior maxilla

Presurgical planning, implant positioning, soft tissue management, esthetic bone grafting, provisionalization, and prosthetic management are the treatment considerations that affect the treatment outcomes that are associated with dental implants in the anterior maxillary area of the oral cavity. Each should be approached with caution to help avoid postoperative esthetic complications and to maximize the esthetic outcome. This article reviews most of the current techniques that help to maximize the esthetic results and introduces a new classification for soft tissue management according to the time of clinical intervention.     

Orthodontic treatment of a congenitally missing maxillary lateral incisor

Clinicians agree that, regardless of gender or race, tooth agenesis has become more prominent in recent societies. The congenital absence of one or more maxillary lateral incisors poses a challenge to effective treatment planning for the restorative dentist. However, the one-sided orthodontic approach of just moving canines mesially to eliminate restorative procedures leads to compromise. Adult patients presenting with malocclusions, missing lateral incisors, or anterior crowding but who fail to get proper orthodontic treatment, requesting instead esthetic solutions that do not establish a stable occlusion, proper alignment, and proper axial inclination of the teeth will have compromised esthetic and periodontal results. An evaluation of anterior smile esthetics must include both static and dynamic evaluations of frontal and profile views to optimize both dental and facial appearance. This article presents how orthodontics is combined with other specialties in treating a congenitally missing lateral incisor. One case is used to illustrate how orthodontic treatment is progressed in collaboration with other specialists. CLINICAL SIGNIFICANCE: Patients with missing teeth, crowding, midline deviation, unesthetic gingival contours, or other restorative needs may require the interaction between various specialists. For the successful treatment of orthodontic-restorative patients, an interdisciplinary team effort is vital.     

牙龈健康与美观——正畸治疗的软组织目标

牙龈健康与美观是正畸治疗目标的重要组成部分。牙周组织健康为牙移动提供了基础,牙齿排列与龈缘 的细微变化可影响牙龈美观。治疗前对牙龈状况的评估是制订多学科联合治疗计划的基础,而研究正畸治疗对牙 龈的影响可为维护牙龈健康和改善牙龈美观提供依据。本文对正畸相关的牙龈健康与美观作一综述。     

Evaluation of the esthetic results of a 40-patient group treated surgically for dentoskeletal class III malocclusion

A dentoskeletal Class III malocclusion results in unesthetic alterations of the soft tissues, which may cause psychologic and interpersonal problems. Surgical treatment, if based on cephalometric evaluations alone, can result in inadequate correction of facial esthetics. The aim of this paper is to discuss the esthetic needs observed in surgical planning of a group of 40 Class III patients and to compare the presurgical esthetic parameters with those recorded in the sixth month of follow-up. To obtain the proper esthetic result and to restore proper stomatognathic functionality, surgical treatment planning required the integration and correction of skeletal cephalometric planning. In 24 of the 40 patients, the skeletal and esthetic planning were in agreement with each other. In the remaining 16 patients, the correction of skeletal planning with the esthetic planning was necessary to obtain the correct esthetic and functional restoration. In all patients, esthetic, radiographic, and functional analysis at the sixth month of follow-up revealed the restoration of correct facial esthetics in the vertical, transverse, and sagittal planes; no temporomandibular joint problems; and a high degree of personal satisfaction regarding the esthetic and functional result obtained, including improvements in social life and in masticatory function. Cephalometric indications should always be compared with esthetic clinical indications and, possibly, the skeletal planning must be corrected by the esthetic needs, so that esthetic and functional success can be reached at the same time.     

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近年来无牙颌种植支持式固定义齿的应用得到了极大的普及。但是由于受到上颌骨的解剖形态、上颌骨吸收形式、种植区牙槽骨的质量、上颌骨在发音中的重要作用、上前牙在面部美学中的重要作用等因素的影响。因此,医生在进行上颌无牙颌种植支持式固定义齿的诊断和设计时需要非常谨慎。本文回顾了近年来关于上颌无牙颌种植支持式固定义齿牙颌面部美学诊断、设计的文章,通过对牙颌面部进行垂直向美学分析,为需要进行上颌无牙颌种植支持式固定义齿修复的患者提供美学设计基础。     

Portrait photography for the dentist.

The increase in popularity of esthetic dentistry and the dental profession's enthusiasm for providing these services are leading to a new paradigm of dental practice. The design of a dental office must now relate to visual and esthetic values rather than just to treating disease or maintaining health. Photography has always been important in dentistry, mostly as documentation and more recently for patient education. Patients' high esthetic expectations put great demands on professional providers. It is the duty of the dentist who provides esthetic services to become schooled in the goals of beauty for a person's entire face, not just the teeth. Portrait photography heightens a dentist's and patient's value of the mouth as the center of beauty in the face. It helps educate the patient and dentist alike, is important for the education of other patients, creates value, markets the dentist's services, enhances the image of the office, and helps in the evaluation and planning for cosmetic treatment. This paper describes the basics of portrait photography and a simple two-light and reflector arrangement that can be used in most offices.     

Extraction defect assessment, classification, and management

Tooth extraction is a traumatic procedure initiating a complex cascade of biochemical and histologic events that inevitably lead to a reduction of alveolar bone and soft tissue. These tissue alterations often lead to an esthetic compromise of the future implant restoration. The hard- and soft-tissue architecture surrounding the extraction defect largely dictates the course of dental implant treatment. The EDS or extraction-defect sounding classification is a novel system introduced to simplify the decision-making process when planning for dental implant therapy following tooth extraction. Dental implant treatment guidelines based on the EDS classification are discussed. A review of pretreatment evaluations necessary to prepare for esthetic implant procedures is also presented.     

Treatment planning and biomechanics of distraction osteogenesis from an orthodontic perspective

As in traditional combined surgical and orthodontic procedures, the orthodontisthas a role in the planning and orthodontic support of patients undergoing distraction osteogenesis. This role includes predistraction assessment of the craniofacial skeleton and occlusal function in addition to planning both the predistraction and postdistraction orthodontic care. Based on careful clinical evaluation, dental study models, photographic analysis, cephalometric evaluation, and evaluation of three-dimensional computed tomographic scans, the orthodontist, in collaboration with the surgeon, plans distraction device placement and the predicted vectors of distraction. Both surgeon and orthodontist closely monitor the patient during the active distraction phase, using intermaxillary elastic traction, sometimes combined with guide planes, bite plates, and stabilization arches, to mold the newly formed bone (regenerate) while optimizing the developing occlusion. Postdistraction change caused by relapse is minimal. Growth after mandibular distraction is variable and appears to be dependent on the genetic program of the native bone and the surrounding soft tissue matrix. A significant advantage of distraction osteogenesis is the gradual lengthening of the soft tissues and surrounding functional spaces. Distraction osteogenesis can be applied at an earlier age than traditional orthognathic surgery because the technique is relatively simple and bone grafts are not required for augmentation of the hypoplastic craniofacial skeleton. In this new technique, the surgeon and the orthodontist have become collaborators in a process that gradually alters the magnitude and direction of craniofacial growth.