|Year : 2019 | Volume
| Issue : 1 | Page : 26-31
Tackling mandibular prognathism with evidence-based surgical orthodontics: A paradigm shift
Vivek P Soni, Akhil A Patil, Mikisha K Shetty, Vibha R Bhatia
Department of Orthodontics and Dento-Facial Orthopedics, Dr. D.Y. Patil University School of Dentistry, Navi Mumbai, Maharashtra, India
|Date of Web Publication||24-Jun-2019|
Dr. Vivek P Soni
Dr D.Y. Patil University Deemed to be School of Dentistry, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
The esthetic outcome of orthognathic surgery has always been of utmost importance to patient as well as the surgeon. With innovations in orthognathic surgical procedures, the addition of soft tissue prediction is a boon to orthodontists and oral surgeons together. The evolution in treatment planning from mere radiographic–cephalometric tracings to simulated surgeries has been a tremendous and path-breaking journey for the field. Three-dimensional printing, soft tissue analysis, splint fabrication, stereolithographic models, rapid prototyping, and various such adjuncts have thereon revolutionized surgical procedures and treatment predictions.
Keywords: Evidence, orthognathic, rapid prototyping, surgical orthodontics, three-dimensional printing, traditional
|How to cite this article:|
Soni VP, Patil AA, Shetty MK, Bhatia VR. Tackling mandibular prognathism with evidence-based surgical orthodontics: A paradigm shift. Indian J Oral Health Res 2019;5:26-31
|How to cite this URL:|
Soni VP, Patil AA, Shetty MK, Bhatia VR. Tackling mandibular prognathism with evidence-based surgical orthodontics: A paradigm shift. Indian J Oral Health Res [serial online] 2019 [cited 2019 Sep 23];5:26-31. Available from: http://www.ijohr.org/text.asp?2019/5/1/26/261148
| Introduction|| |
Orthognathic surgery has toddled and cemented its steps with orthodontists and oral surgeons in its own way and form. Over the past few decades, treatment planning and esthetic outcome prediction have painted its own journey in easing out expectations of the patients undergoing surgical procedures. Be it Le-fort, bilateral sagittal split osteotomies (BSSOs), genioplasty, or facial asymmetry corrections, there are now no surprises awaiting the patient. As for the surgeon, cone beam computed tomography (CBCT) analysis, myography studies, stereolithographic models, and three-dimensional (3D) printing aid in treatment planning and its outcome, prognosis, and relapse tendencies. The prototype models help in performing mock surgeries along with aid in the formation of guide templates for the incisions, setbacks, advancement, and repositioning of the maxilla and mandible. In the olden days, all that was used were cephalometric and standardized photographs to document and predict the favorable position and the final outcome of dental, skeletal, and esthetic positioning of any particular case.
With advancement in technology, conventional techniques should be bid adieu, and this evolving paradigm shift of latest techniques and trends must be accepted for better diagnosis and ideal treatment planning.
Orthognathic surgery is far more than just a series of surgical procedures used to move the jaws, or segments thereof. Diagnosis, including a four-dimensional analysis of a growing and aging craniofacial complex, covered by a manifestly variable soft tissue envelope and treatment planning with its intricacies and complexities are the cornerstones of successful treatment.
A better example to elucidate this would be the transition in the way surgeries are implemented; the routine surgical procedure in excessive mandible cases: the BSSO – operation to reduce mandibular prognathism was not undertaken again for almost 50 years. The first known surgical procedure that may be described as “orthognathic” appears to have been by the American surgeon Hullihen in 1849.,,,
In 1897, Blair (1871–1955) performed the first “double resection of the mandible;” which was essentially a bilateral osteotomy of the mandibular body via an extraoral approach, with parallel cuts in the premolar regions and removal of the osteotomized blocks. Copper wire interosseous ligatures secured the bony segments. In this respect, Ottolengui appears to have been ahead of his time, as modern surgical wafer splints are a modification.,,
| Case Reports|| |
Case presentation 1
A 20-year-old male patient came to the department with a chief complaint of forwardly placed jaw. He presented with a concave profile with skeletal Class III base [Figure 1]. The patient had a Class III molar relation on the right and Class I molar relation on the left with lower midline shifted to the left by 11 mm. The patient showed a reverse overjet on the left side and a negative overbite on the right side. Cephalometric Grummon's analysis confirmed the skeletal asymmetry.
- Correction of the facial asymmetry
- Correction of profile
- To give a stable occlusion
- To improve the functional efficiency of the patient.
- Presurgical orthodontics
1. Incisor decompensation
2. Intra-arch coordination
3. Interarch coordination
- Mock surgery
- Orthognathic surgery
- Postsurgical orthodontics.
4. Finishing and detailing
Before active treatment began, the patient was referred to specialists for extraction of 4 third molars. After that, 0.022” × 0.028” preadjusted edgewise appliances with MBT prescription were placed in both arches. Bands were placed in upper first and second molars and in lower first and second molars. The patient underwent presurgical orthodontics up to 0.019” × 0.025” SS straight archwires on both upper and lower arches.
A face bow transfer of the patient was done, and the casts were mounted onto a Hanau articulator for the mock surgery to be carried out. A splint was fabricated on the final position post the mock surgery. This splint would help to stabilize the jaw during the intraoperative procedure and help to stabilize the position [Figure 2].
The final BSSO surgery was carried out according to the planning, and the jaw was stabilized using the manually prepared splint.
Conventional surgery in the early periods was difficult to plan as there was only two-dimensional techniques available for planning of the surgery [Figure 3].
Case presentation 2
A 24-year-old male patient came to the department with a chief complaint of forwardly placed jaw. He presented a concave profile with a Class III skeletal base [Figure 4]. The patient had a Class III molar occlusion with the lower midline shifted to the left. The patient showed a reverse overjet of − 4 mm.
1. Orthognathic surgery
Keeping in mind the age and the reverse overjet of the patient and the inferences of various surgical cephalometric analysis, orthognathic surgery was chosen. The patient also accepted this treatment option.
- Presurgical orthodontics
- Leveling and aligning
- Correction of dental malocclusion and achievement of decompensation
- Closure of all spaces.
- BSSO setback of mandible.
- Finishing and Detailing
Before active treatment began, the patient was referred to specialists for extraction of 4 third molars. After that, 0.022” × 0.028” preadjusted edgewise appliances with MBT prescription were placed in both arches. Bands with the same prescription were placed in upper first and second molars and in lower first molars. Presurgical orthodontics ended with 0.019” × 0.025” SS straight archwires on both upper and lower arches.
With an advance in technology creating a buzz everywhere, new advanced ways were used to diagnose this case.
The plaster casts of both preoperative occlusions were scanned with a high-resolution optical scanner [Figure 5]. Digital Imaging and Communications in Medicine images of both skull and occlusion were then imported to develop a virtual 3D model of the hard and soft tissue of the head. A 3D cephalometric analysis was done by Simplant OMS.
Recent advances in intraoral digital scanning technology have given orthodontists the ability to eliminate unpleasant impressions while providing patients with more accurate appliances and reduced treatment times. The next paradigm shift in orthodontics is the development of 3D printers, working in conjunction with intraoral scanners [Figure 6].
Case presentation 3
A 26-year-old male patient came to the department with a chief complaint of forwardly placed lower jaw. He presented a concave profile with a Class III skeletal base. The patient had a Class III molar occlusion with the lower midline shifted to the left. The patient showed a reverse overjet of − 11 mm [Figure 7].
- To improve profile of the patient
- To give stable occlusion
- To improve the functional efficiency of the patient.
- BSSO setback of mandible
- Postsurgical orthodontics
- Finishing and Detailing
Like the previous case, everything was digitized to avoid any man-made errors with the diagnosis and treatment plan. Hard tissue and soft tissue simulation was done. CBCT played a vital role in formulation of the treatment plan and also with the comparison of the before and after treatment changes. All cephalometric analysis was carried out by Dolphin software [Figure 8].
A surgery first approach was chosen for the patient. Extraction of all the third molars was done. The patient underwent all the necessary medical tests to be declared physically and mentally fit. BSSO was carried out on the patient under general anesthesia with a setback of 11 mm. After 24 days of surgery, the patient was bonded with 0.022” × 0.028” preadjusted edgewise appliances with MBT prescription in both arches. Bands with the same prescription were placed in upper first and second molars and in lower first molars. Presurgical orthodontics ended with 0.019” × 0.025” SS straight archwires on both upper and lower arches.
Making use of advanced technology for diagnosing and formulating a thorough treatment plan helped in avoiding of errors. The patient was 100% satisfied with treatment outcome [Figure 9].
Latest trends in surgical orthodontics
With the advances in technology and time, the 3d printing universe can be applied to a more wider platform which would help in ease of surgery along with the planning as well as the procedure itself [Figure 10].
Some new trends and advances that might already be in use are,,,,,,,,,,, as follows:
- 3D printed splint
- 3D printed surgical guide
- 3D printed spacers
- 3D printed fixation plates/implants.
| Discussion|| |
Orthodontics and orthognathic surgery have come a long way with varying ways to diagnosis and devise a steady treatment plan. With the steady enhancement of its processes and materials, the distribution of 3D printing technology has widely increased in various fields of medicine. Recent advances in 3D imaging, virtual surgical planning coalesced with CAD/CAM software as well as further developments of 3D printers opened up new probabilities to fabricate more precise patient-specific devices based on patient's 3D digital models for orthognathic surgery.,,,,,,,,,,,
Subsequently, numerous studies have demonstrated that 3D printing technologies help the clinician to condense operative time, upsurge surgical safety, and improve the predictability of surgical outcomes. One must bid goodbye to conventional orthodontic surgery techniques and be ready to welcome the new era in treatment planning. A paradigm shift? Yes of course!,,,,,,,,, [Table 1].
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hullihen SP. Case of elongation of the under jaw and distortion of the face and neck, caused by a burn, successfully treated. Am J Dent Sci 1849;9:157-65.
Blair VP. Report of case of double resection for correction of protrusion of mandible. Dent Cosmos 1906;48:817-20.
Cryer MH. Studies of the anterior and posterior occlusion of the teeth, with suggestions as to treatment. Dent Cosmos 1913;55:673-91.
Skaloud F. A new surgical method for correction of prognathism of the mandible. Oral Surg Oral Med Oral Pathol 1951;4:689-94.
Ernst F. Uber the surgical elimination of the prognathism of the Mandible (Progeny). Zentralbl Chir 1938;65:179.
Obwegeser H. The movement of the lower alveolar extension to the Correction of angle malpositions. German Journal 1969;24:5-15.
Trauner R, Obwegeser H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surg Oral Med Oral Pathol 1957;10:677-89.
Lauren M, McIntyre F. A new computer-assisted method for design and fabrication of occlusal splints. Am J Orthod Dentofacial Orthop 2008;133:S130-5.
Metzger MC, Hohlweg-Majert B, Schwarz U, Teschner M, Hammer B, Schmelzeisen R. Manufacturing splints for orthognathic surgery using a three-dimensional printer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e1-7.
Choi JY, Song KG, Baek SH. Virtual model surgery and wafer fabrication for orthognathic surgery. Int J Oral Maxillofac Surg 2009;38:1306-10.
Choi JY, Hwang JM, Baek SH. Virtual model surgery and wafer fabrication using 2-dimensional cephalograms, 3-dimensional virtual dental models, and stereolithographic technology. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:193-200.
Uribe F, Janakiraman N, Shafer D, Nanda R. Three-dimensional cone-beam computed tomography-based virtual treatment planning and fabrication of a surgical splint for asymmetric patients: Surgery first approach. Am J Orthod Dentofacial Orthop 2013;144:748-58.
Scolozzi P, Herzog G. Total mandibular subapical osteotomy and le fort I osteotomy using piezosurgery and computer-aided designed and manufactured surgical splints: A favorable combination of three techniques in the management of severe mouth asymmetry in parry-romberg syndrome. J Oral Maxillofac Surg 2014;72:991-9.
Scolozzi P. Computer-aided design and computer-aided modeling (CAD/CAM) generated surgical splints, cutting guides and custom-made implants: Which indications in orthognathic surgery? Rev Stomatol Chir Maxillofac Chir Orale 2015;116:343-9.
Vale F, Scherzberg J, Cavaleiro J, Sanz D, Caramelo F, Maló L, et al.
3D virtual planning in orthognathic surgery and CAD/CAM surgical splints generation in one patient with craniofacial microsomia: A case report. Dental Press J Orthod 2016;21:89-100.
Dahan S, Le Gall M, Julié D, Salvadori A. New protocols for the manufacture of surgical splints in surgical-orthodontic treatment. Int Orthod 2011;9:42-62.
Aboul-Hosn Centenero S, Hernández-Alfaro F. 3D planning in orthognathic surgery: CAD/CAM surgical splints and prediction of the soft and hard tissues results – Our experience in 16 cases. J Craniomaxillofac Surg 2012;40:162-8.
Shqaidef A, Ayoub AF, Khambay BS. How accurate are rapid prototyped (RP) final orthognathic surgical wafers? A pilot study. Br J Oral Maxillofac Surg 2014;52:609-14.
Hernández-Alfaro F, Guijarro-Martínez R. New protocol for three-dimensional surgical planning and CAD/CAM splint generation in orthognathic surgery: Anin vitro
study. Int J Oral Maxillofac Surg 2013;42:1547-56.
Ying B, Ye N, Jiang Y, Liu Y, Hu J, Zhu S. Correction of facial asymmetry associated with vertical maxillary excess and mandibular prognathism by combined orthognathic surgery and guiding templates and splints fabricated by rapid prototyping technique. Int J Oral Maxillofac Surg 2015;44:1330-6.
Shaheen E, Sun Y, Jacobs R, Politis C. Three-dimensional printed final occlusal splint for orthognathic surgery: Design and validation. Int J Oral Maxillofac Surg 2017;46:67-71.
Niu LS, Lin HH, Lo LJ. A novel CAD/CAM surgical splint for OGS intraoperative validation of the soft-hard tissue results. In: The 11th
Biennial Congress of the Asian Pacific Craniofacial Association; 2016. p. 41.
Zinser MJ, Mischkowski RA, Sailer HF, Zöller JE. Computer-assisted orthognathic surgery: Feasibility study using multiple CAD/CAM surgical splints. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:673-87.
Zinser MJ, Sailer HF, Ritter L, Braumann B, Maegele M, Zöller JE. A paradigm shift in orthognathic surgery? A comparison of navigation, computer-aided designed/computer-aided manufactured splints, and “classic” intermaxillary splints to surgical transfer of virtual orthognathic planning. J Oral Maxillofac Surg 2013;71:2151.e1-21.
Polley JW, Figueroa AA. Orthognathic positioning system: Intraoperative system to transfer virtual surgical plan to operating field during orthognathic surgery. J Oral Maxillofac Surg 2013;71:911-20.
Jimenez G, Colmenero-Ruı´z C, Roso´n-Go´mez S, Encinas-Bascones A. Inverted L osteotomy. Indications and techniques. J Oral Maxillofac Surg 2013;42:1327.
Peter BF, Brain BF. Inverted L osteotomy: A new approach via intraoral access through the advances of virtual surgical planning and custom fixation. J Oral Maxillofac Surg 2016;2:1-9.
Zhang N, Liu S, Hu Z, Hu J, Zhu S, Li Y. Accuracy of virtual surgical planning in two-jaw orthognathic surgery: Comparison of planned and actual results. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122:143-51.
Suojanen J, Leikola J, Stoor P. The use of patient-specific implants in orthognathic surgery: A series of 32 maxillary osteotomy patients. J Craniomaxillofac Surg 2016;44:1913-6.
Olszewski R, Tranduy K, Reychler H. Innovative procedure for computer-assisted genioplasty: Three-dimensional cephalometry, rapid-prototyping model and surgical splint. Int J Oral Maxillofac Surg 2010;39:721-4.
Olszewski R, Szymor P, Kozakiewicz M. Accuracy of three-dimensional, paper-based models generated using a low-cost, three-dimensional printer. J Craniomaxillofac Surg 2014;42:1847-52.
Kang SH, Lee JW, Lim SH, Kim YH, Kim MK. Validation of mandibular genioplasty using a stereolithographic surgical guide:In vitro
comparison with a manual measurement method based on preoperative surgical simulation. J Oral Maxillofac Surg 2014;72:2032-42.
Lim SH, Kim MK, Kang SH. Genioplasty using a simple CAD/CAM (computer-aided design and computer-aided manufacturing) surgical guide. Maxillofac Plast Reconstr Surg 2015;37:44.
Li B, Shen SG, Yu H, Li J, Xia JJ, Wang X. A new design of CAD/CAM surgical template system for two-piece narrowing genioplasty. Int J Oral Maxillofac Surg 2016;45:560-6.
Yamauchi K, Yamaguchi Y, Katoh H, Takahashi T. Tooth-bone CAD/CAM surgical guide for genioplasty. Br J Oral Maxillofac Surg 2016;54:1134-5.
Philippe B. Computer designed guides and miniplates in orthognathic surgery: A description of the planning and surgical technique. Int J Oral Maxillofac Surg 2015;44:e123.
Lee UL, Kwon JS, Choi YJ. Keyhole system: A computer-assisted designed and computer-assisted manufactured maxillomandibular complex repositioner in orthognathic surgery. J Oral Maxillofac Surg 2015;73:2024-9.
Lin HH, Chang HW, Lo LJ. Development of customized positioning guides using computer-aided design and manufacturing technology for orthognathic surgery. Int J Comput Assist Radiol Surg 2015;10:2021-33.
Brunso J, Franco M, Constantinescu T, Barbier L, Santamaría JA, Alvarez J. Custom-machined miniplates and bone-supported guides for orthognathic surgery: A new surgical procedure. J Oral Maxillofac Surg 2016;74:1061.e1-.061E+15.
Huang SF, Lo LJ, Lin CL. Biomechanical optimization of a custom-made positioning and fixing bone plate for le fort I osteotomy by finite element analysis. Comput Biol Med 2016;68:49-56.
Lin HH, Lonic D, Lo LJ. 3D printing in orthognathic surgery – A literature review. J Formos Med Assoc 2018;117:547-58.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]