Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Surgical Orthodontics
Dr. Aishwarya Sonawane1; Dr. Chetan Patil2; Dr. Pradeep Kawale3
Dr. Pradeep Kumar4; Dr. Snehal Bhalerao5; Dr. Ben Joshua6; Dr. Aameer Parkar7
Yogita Dental College and Hospital

Abstract:- Dentofacial orthopedists serve as guardians of represents the limitations of orthodontic camouflage alone,
facial development, capable of influencing the the middle envelope depicts the boundaries of combined
differential growth of craniofacial structures through orthodontic treatment and growth modification, and the
growth modulation techniques, guiding them towards outer envelope shows the limits of surgical correction.5
favorable outcomes. In cases where facial growth is
complete in adult patients presenting with significant
skeletal discrepancies, surgical repositioning of the jaws
becomes the primary solution, a realm addressed by
surgical orthodontics. The 'envelope of discrepancy'
visually encapsulates current concepts regarding the
extent of change achievable through different treatment
modalities. Maxillomandibular surgeries encompass
various procedures aimed at addressing these issues.
Diagnosis and treatment planning are pivotal in surgical
orthodontics, with cephalometric prediction tracing and
mock surgery playing crucial roles in preoperative
planning.

Keywords:- Surgical Orthodontics, Envelope of

Discrepancy, Prediction Tracing, Mock Surgery.

I. INTRODUCTION

Surgical orthodontics combines orthodontic and

oral/maxillofacial surgery to address musculoskeletal, dento-
osseous, and soft tissue deformities of the jaws. It's suitable Fig 1 Envelope of Discrepancy; Maxilla
for patients with severe skeletal or dentoalveolar issues
beyond correction with orthodontics alone and whose
growth is complete. This approach offers new treatment
options and diagnostic challenges, requiring the clinician to
grasp and apply various treatment concepts for optimal
esthetics, function, and stability.1,2

Over the last 25 years, orthognathic surgery has

advanced significantly due to rapid progress in surgical
technology. This has broadened treatment options beyond
traditional orthodontic camouflage methods. Previously,
dentofacial deformities often relied solely on camouflage
techniques, leading to suboptimal aesthetic results and
instability. Correction of severe malocclusions with jaw
discrepancies typically involves growth modification,
orthodontic camouflage, or orthognathic surgery combined
with orthodontic treatment to reposition the jaws and dental
segments.1,2

II. ENVELOPE OF DISCREPANCY

Fig 2 Envelope of Discrepancy; Mandible
Proffit and Ackerman introduced the envelope of
discrepancy concept to illustrate the potential changes
achievable through different treatment methods. This
diagram simplifies the relationship between three basic
treatment options for skeletal discrepancies. The inner circle

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
The envelopes of discrepancy, showing the amount of
change in the anteroposterior and vertical planes of space
that could be expected from orthodontic tooth movement
alone (the inner envelope), orthodontic tooth movement
combined with growth modification (the middle envelope),
and orthognathic surgery (the outer envelope). The
possibilities of treatment are not symmetric with regard to
the three planes of space. For example, treatment for growth
modification is more effective in mandibular deficiency than
in mandibular excess. 5

 Indications for Surgical-Orthodontic Treatment

 Adults with severe malocclusion

 Adults with severe skeletal discrepancies
 Patients with dentofacial deformities and syndromes,
including cleft lip and palate
 Syndromes featuring facial asymmetries like Pierre
Robin syndrome, Treacher-Collins syndrome, Apert
syndrome, Parry-Romberg syndrome, Goldenhar
syndrome, hemifacial hypertrophy, and unilateral
ankylosis Fig 3 Diagnosis and Treatment Planning
 Syndromes characterized by midface deficiencies such
as craniosynostoses, Apert syndrome, Crouzon III. VARIOUS SURGICAL OPTIONS
syndrome, Pfeiffer syndrome, Binder syndrome,
achondroplasia dwarfism, and cleidocranial dysplasia  Midface Surgeries
 Syndromes involving mandibular deformities including
Pierre Robin syndrome, Treacher-Collins syndrome,  Posterior Repositioning
Goldenhar syndrome (hemifacial microsomia), and  Superior Repositioning
mandibular prognathism observed in Gorlin–Goltz  Maxillary Advancement Surgeries
syndrome, achondroplasia, and Klinefelter
syndrome.2,4,5,8  Lefort I
 High level Lefoert I
 Diagnosis and Treatment Planning  Lefort II
The diagnosis and treatment planning and execution of  Lefort II
treatment comprises four phases
 Inferior Repositioning
 Phase I  Maxillary Anterior Segmental Osteotomy:
Includes assembling the database, synthesizing the  Single Tooth Osteotomy
problem list, diagnosis and team conference.  Posterior Segmental Osteotomy
 Interdental Corticotomy
 Phase ii  Zygomatic Osteotomy
Includes developing interdisciplinary problem list  Horse Shoe Osteotomy
with dentofacial problems in order of priority, and possible
solutions, which forms the tentative treatment plan. A patient
parent doctor team conference is arranged to discuss the
tentative treatment plan with the patient and the family and
definitive plan is arrived.

 Phase iii
Includes the preparatory phase (Restorative,
endodontic, periodontic), the definitive orthodontic-surgical
treatment and continuous team monitoring, re-evaluation,
interaction, and modification of the therapy.

 Phase iv
Maintenance phase. 4,5

Fig 4 Maxillary Superior Repositioning

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Mandibular Surgeries

 Ramus Procedures

 Condylotomy (subcondylar osteotomy)

 Condylectomy
 Sagital split osteotomy
 Vertical subsigmoid osteotomy
 Inverted L osteotomy
 C or arching osteotomy
 Post condylar grafts

 Body Procedures
 Anterior to mental foramen

 Step osteotomy
 Midline symphyseal osteotomy Fig 7 Subapical Osteotomy

 Posterior to Mental Foramen

 Y – osteotomy
 Rectangular ostectomy
 Inverted V ostectomy

 Subapical Procedures

 Anterior
 Posterior
 Total
 Genioplasty

Fig 8 Genioplasty

 Esthetic Changes Accompanying Surgical Orthodontics

6,7

 Esthetic Changes Accompanying Maxillary Superior

Repositioning

 Front Face :

Fig 5 Condylectomy  Widens alar bases

 Reduces exposure of maxillary anterior teeth
 Reduces interlabial distance
 Reduces lower third face vertically
 Shortens distance from upper lip stomion to menton
 Decreases distance from subnasale to mucocutaneous
junction of lower lip

 Profile:

 Accentuates para nasal areas

 Elevates nasal tip
 Reduces interlabial distance
 Increases chin prominence
 Reduces lower third face vertically.
Fig 6 Mandibular Bsso

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Esthetic Changes Accompanying Maxillary Inferior  Cephalometric Prediction Tracing 3,9
Repositioning The basic reasons for doing predictions are:

 Front Face :  To accurately assess the profile esthetic results which

will result from the proposed surgery,
 Lengthens lower third face vertically  To consider the desirability of simultaneous adjunctive
 Increases distance from subnasale to upper lip stomion procedures such as genioplasty, suprahyoid myotomy,
 Increases distance from subnasale to mucocutaneous etc.,
junction of lower lip vermilion  To help determine the sequencing of surgery and
orthodontics (i.e., if the surgery is done first will it be
 Profile: more difficult or easier to do the indicated orthodontics),
 To help decide what type of orthodontics might best be
 Reduces chin prominence employed (i.e., extraction versus non-extraction) and
 Increases upper lip prominence  To determine the anchorage requirements should
 Decreases lower lip prominence. extraction treatment be chosen.
 Decreases acute nasolabial angle
 Prediction Tracing for Mandibular Surgeries
 Esthetic Changes Accompanying Total Maxillary
Advancement  Trace the Stable Structures.
 Add Skeletal Portion Changed by Surgery
 Front Face:  New A-Po Line.
 Placing the Teeth
 Widens alar bases
 Tracing the New Lip Contours
 Increases prominence of upper lip
 Increases exposure of upper lip vermilion
 Cephalometric Prediction for Maxillary Superior
 Reduces chin prominence
Repositioning3, 9
 Profile:
 Trace the Stable Structures
 Determination of Ideal Vertical Position for the Upper
 Accentuates paranasal areas
Incisor
 Reduces prominence of nose elevates nasal tip
 Autorotation of the Mandible
 Elevates nasal tip
 Accentuates upper lip  Genioplasty Determination
 Deaccentuates chin  Placement of Teeth In Ideal Positions
 Nasal Outline
 Esthetic Changes Accompanying Mandibular Setback  Upper Lip outline
 Lower Lip outline
 Front Face:  Chin outline

 Decreases chin prominence  Cephalometric Prediction Tracing for Combined

 Increases exposure of upper lip vermilion Maxillary and Mandibular Cases 3,9
 Decreases lower third face height
 Increases squareness of face  Trace the Stable Structures
 Determine the Ideal Vertical Position for the Upper
 Profile: Incisor
 Autorotation of the Occlusal Plane
 Reduces chin prominence  Mandibular Movement
 Reduces lower lip eversion  Completing the Tracing
 Shortens neck chin line
 Increases paranasal fullness IV. MOCK SURGERY

 Esthetic Changes Accompanying Mandibular  Aims of Model Surgery 2

Advancement
 To locate the problem areas preoperativel y.
 Front Face:  To determine the feasible surgical plan.
 To determine the direction of movement of
 Variable increase in lower third face height dento-osseous segments.
 Reduces lower lip eversion  To view the osteot om y sites directly.
 Reduces prominent labiomental fold  To obtain the measurements of osteot omies.
 To reduce the operating time for desired occlusal results.

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Volume 9, Issue 2, February 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Find the existence of a possible tooth mass problem. V. CONCLUSION
 Find the ideal site for interdental osteot om y.
 Ascertain the presence of transverse discrepancies.  Inadequate orthodontics preparation can jeopardize the
quality of the surgical result. A proper interaction
 Protocol for Mock Surgery 2 between the Orthodontic and Surgical team is essential
so that the best results are achieved.
 Cut the model exactly similar to surgery  We should make a sincere effort to lay an enduring
 Avoid apices or root surfaces of teeth during cutting foundation for a robust and a lasting co-operation
 Detect the problem areas-proximity of roots, bon y between the specialities for the sake of providing
interferences, etc. excellent care for our patients
 Observe and note the movement of dento-osseous  We should be open to criticisms and update ourselves.
segments-rotations-expansion We should be careful not to get entangled in dogmatic
 Consider best aesthetics, functional requirement, axial philosophies
inclination, vertical relationship, and maximum
interdigitation.  Acknowledgement: Nil.
 Consider difference in movements of bony segments of  Conflict of Interest: Nil.
one side to the other side as in the case of facial  Financial Support: Nil.
asymmetry cases in superior positioning of maxilla
REFERENCES
 Postsurgical Objectives2
[1]. AJO-DO Volume 1993 May (395 - 411): SPECIAL
ARTICLE - Arnett and Bergman
[2]. Bruce N Epker, John Paul Stella, Leward c FishIn
dentofacial deformities integrated orthodontic &
surgical correctionEd.2 St.Louis 1996. The CV
Mosby .co
[3]. JCO.Volume 1980 Jan(36 - 52): Surgical-Orthodontic
Cephalometric Prediction Tracing
[4]. Lary. J. Peterson In principles of Oral and
Maxillofacial Surgery J.B Lippincott company,
philadelphia
[5]. Profit WR, Ackerman JLA systematic approach to
orthodontic diagnosis and treatment planning. In
Graber TM and Swain BF editors: Orthodontic
concepts & techniques ed.3 St Louis 1985, the CV
Mosby co
[6]. Rayond G. Fonseca Orthognathic surgery in Oral &
Maxillofacial surgery ed.1 philadelphia 2000 W.B
Saunders company
[7]. Seminars in orthodontics dec 1999 vol.5 no.4
[8]. William R. Profit, Raymond P White In surgical
orthodontic treatment
[9]. Surgical-Orthodontic Cephalometric Prediction
Tracing JCO Volume 1980 Jan (36 – 52)

Fig 9 Postsurgical Objectives

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