**4. Surgical treatment**

The treatment protocol includes three distinct, but successive steps: Orthodontic phases of preparation are enacted prior to surgical treatment. Generally speaking, the stability of expected results depends on both meeting pre-defined objectives for each step as well as on the smooth and proper course of treatment. Otherwise, it could also be compromised by incomplete orthodontic treatment and yield unfavorable outcomes in orthognathic surgery or functional occlusal imbalance following treatment (Figure 8). [8]

Successful surgical correction of dentoskeletal cases is determined by both pre- surgicalorthodontic treatment (which eliminates dental compensation), correct surgical planning, and postoperative orthodontic therapy applied to refine the patient's occlusion. Fixed appliances are normally used in both of these orthodontic stages.

**3- Surgical treatment** 

patient.

fragments.


*Figure 7 : Surgical visual treatment prediction* 

*orthodontic therapy.*

*Manufacture of a global presurgical setup to assist surgical diagnosis accurate prediction of the postoperative skeletal, dental and facial profile has become an essential part of the diagnostic and treatment planning procedure of combined surgical-*

The use of information technology in dental studies general and orthodontics in particular, has contributed to the use of set-up scanning. In this respect, A 3D simulation system has been developed for orthognathic surgery ; it helps to integrate the shape data of the teeth, jawbone and face into the same coordinate system on a computer. The movement of bone associated with

on the smooth and proper course of treatment. It could also be compromised by incomplete orthodontic treatment ; Unfavorable



mandibular osteotomy and the subsequent changes in the facial form can thus be preoperatively estimated. [7]

The three-dimentional setups allow orthognatic surgery simulation through :


outcomes in orthognathic surgery or functional occlusal imbalance following treatment [8]. (Figure 8)

**Figure 8.** The aim of surgical correction is to achieve the right occlusal and skeletal relationships and correct esthetics simultaneously.

### **4.1. Preoperative / pre-surgical orthodontic phase**

In orthognathic surgery cases, orthodontic treatment objectives are for the most part different from those used in conventional orthodontics. The purpose of pre-surgical orthodontics is to position the teeth to the most desirable position in preparation for surgery, to restore the anteroposterior and vertical positions in addition to coordinating incisors. Two main elements must prevail during this first phase: Incisors decompensation and transverse and dental arch coordination. [1, 9]

#### *4.1.1. Anteroposterior dental decompensation*

In the presence of a bone gap, teeth manage to maintain an occlusion with dental compensation in three dimensions.

In the sagittal plane, overjet does not represent magnitudes of bone gap. However, during surgery, bone bases are mobilized to allow dental occlusion [10] in this context, it is clear that the relationship between anterior and posterior bases of incisors determines the magnitude of anterior-posterior relocation of the bone base. [11]

Presurgical orthodontic treatment aims to decompensate incisor inclination toward normal values. It is therefore necessary to define beforehand the objective of the "terminal incisor position". Therefore In the case of skeletal class II, the lower incisors are proclined while the upper incisors are lingual retroclined (Figure 9). In Class III, the reverse pattern is observed; upper incisors are proclined while the lower incisors are retroclined (Figure 13). Bone gap is compensated for by teeth inclination [10] presurgical intra-arch objectives include positioning of the incisors in "ideal" positions, establishment of correct torque, and elimination of toothsize discrepancies so as to permit the establishment of Class I canine and molar relationships after surgery. In orthognathic surgery cases, extraction patterns, and types of mechanics used are frequently the reverse of those used in conventional orthodontics. [11] Very often in skeletal Class II, the first premolars are extracted in order to cover mandibular incisors and obtain a Class I canine relationship. Extraction of the second premolars allows in recovery of the upper incisors and the mesial movement of upper molars. The ultimate goal is to achieve a Class I molar relationship (Figures 10- 12).

**Figure 9.** Dental compensation in skeletal Class II malocclusion

*Figure 7 : Surgical visual treatment prediction* 

patient.

fragments.

140 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Surgical Phase Standardization Maxillofacial mdb reports** 

**Harmonization of facial contours**

**4.1. Preoperative / pre-surgical orthodontic phase**

*4.1.1. Anteroposterior dental decompensation*

anterior-posterior relocation of the bone base. [11]


*orthodontic therapy.*

**3- Surgical treatment** 

simultaneously.

coordination. [1, 9]

in three dimensions.

*Manufacture of a global presurgical setup to assist surgical diagnosis accurate prediction of the postoperative skeletal, dental and facial profile has become an essential part of the diagnostic and treatment planning procedure of combined surgical-*

The use of information technology in dental studies general and orthodontics in particular, has contributed to the use of set-up scanning. In this respect, A 3D simulation system has been developed for orthognathic surgery ; it helps to integrate the shape data of the teeth, jawbone and face into the same coordinate system on a computer. The movement of bone associated with

The treatment protocol includes three distinct, but successive steps: Orthodontic phases of preparation are enacted prior to surgical treatment. Generally speaking, the stability of expected results depends on both meeting pre-defined objectives for each step as well as on the smooth and proper course of treatment. It could also be compromised by incomplete orthodontic treatment ; Unfavorable



**Pre-orthodontic surgery** Decompensation of incisors; Reforming the arches

**Postsurgical orthodontic phase** 

Parallelism of Dental axes

mandibular osteotomy and the subsequent changes in the facial form can thus be preoperatively estimated. [7]

The three-dimentional setups allow orthognatic surgery simulation through :


outcomes in orthognathic surgery or functional occlusal imbalance following treatment [8]. (Figure 8)

**Figure 8.** The aim of surgical correction is to achieve the right occlusal and skeletal relationships and correct esthetics

In orthognathic surgery cases, orthodontic treatment objectives are for the most part different from those used in conventional orthodontics. The purpose of pre-surgical orthodontics is to position the teeth to the most desirable position in preparation for surgery, to restore the anteroposterior and vertical positions in addition to coordinating incisors. Two main elements must prevail during this first phase: Incisors decompensation and transverse and dental arch

In the presence of a bone gap, teeth manage to maintain an occlusion with dental compensation

In the sagittal plane, overjet does not represent magnitudes of bone gap. However, during surgery, bone bases are mobilized to allow dental occlusion [10] in this context, it is clear that the relationship between anterior and posterior bases of incisors determines the magnitude of

Presurgical orthodontic treatment aims to decompensate incisor inclination toward normal values. It is therefore necessary to define beforehand the objective of the "terminal incisor position". Therefore In the case of skeletal class II, the lower incisors are proclined while the upper incisors are lingual retroclined (Figure 9). In Class III, the reverse pattern is observed; upper incisors are proclined while the lower incisors are retroclined (Figure 13). Bone gap is

**Figure 10.** Direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is increased and in some cases (Class II.1 malocclusion), the upper incisors retroclined

*and in some cases (Class II.1 malocclusion), the upper incisors reduced* 

*Figure 10: direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is increased* 

*Figure 10: direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is increased* 

 *Figure 11: Classic pattern extraction of 15, 25, 34 and 44 in order to increase the overjet and presurgically decompensate for the malocclusion. The presurgical position of the teeth dictates the teeth removal and the surgical movement of the jaws and ultimately the soft tissue facial balance.*  **Figure 11.** Classic pattern extraction of 15, 25, 34 and 44 in order to increase the overjet and presurgically decompen‐ sate for the malocclusion. The presurgical position of the teeth dictates the teeth removal and the surgical movement of the jaws and ultimately the soft tissue facial balance.  *Figure 11: Classic pattern extraction of 15, 25, 34 and 44 in order to increase the overjet and presurgically decompensate for the malocclusion. The presurgical position of the teeth dictates the teeth removal and the surgical movement of the jaws and ultimately the soft tissue facial balance.* 

As for skeletal Class III, extraction of upper first premolar is enacted to reposition upper incisors and obtain Class I canine. (Figure  *Figure 12: extraction of 34 and 44 only can be justified*  **Figure 12.** Extraction of 34 and 44 only can be justified

perspective. (Figures 15, 16) In fact, presurgical objectives in the sagittal plane focus on removal of dental compensations. However, surcompensation represents security for stable occlusion and improved aesthetics. This may require the use of Class III elastics in Class II cases (and vice versa), thus allowing for maximal surgical correction of the underlying skeletal deformity. 14) Extraction of the 2nd premolars is not systematic given that therapeutic Class II molar is tolerated from a an occlusodontic perspective. (Figures 15, 16) In fact, presurgical objectives in the sagittal plane focus on removal of dental compensations. However, surcompensation represents security for stable occlusion and improved aesthetics. This may require the use of Class III elastics in Class II cases (and vice versa), thus allowing for maximal surgical correction of the underlying skeletal deformity. As for skeletal Class III, extraction of upper first premolar is enacted to reposition upper incisors and obtain Class I canine relationship. (Figure 14) Extraction of the 2nd premolars is not systematic given that therapeutic Class II molar is tolerated from an occlusodontic perspective. (Figures 15, 16) In fact, presurgical objectives in the sagittal plane focus on removal of dental compensations. However, decompensation represents security for stable occlusion and improved aesthetics.

14) Extraction of the 2nd premolars is not systematic given that therapeutic Class II molar is tolerated from a an occlusodontic

As for skeletal Class III, extraction of upper first premolar is enacted to reposition upper incisors and obtain Class I canine. (Figure

**Figure 13.** Dental compensation seen in skeletal Class III malocclusion

This may require the use of Class III elastics in Class II cases (and vice versa), thus allowing for maximal surgical correction of the underlying skeletal deformity.

*Figure 10: direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is increased* 

*Figure 10: direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is increased* 

 *Figure 11: Classic pattern extraction of 15, 25, 34 and 44 in order to increase the overjet and presurgically decompensate for the malocclusion. The presurgical position of the teeth dictates the teeth removal and the surgical movement of the jaws and ultimately* 

 *Figure 11: Classic pattern extraction of 15, 25, 34 and 44 in order to increase the overjet and presurgically decompensate for the malocclusion. The presurgical position of the teeth dictates the teeth removal and the surgical movement of the jaws and ultimately* 

**Figure 11.** Classic pattern extraction of 15, 25, 34 and 44 in order to increase the overjet and presurgically decompen‐ sate for the malocclusion. The presurgical position of the teeth dictates the teeth removal and the surgical movement of

As for skeletal Class III, extraction of upper first premolar is enacted to reposition upper incisors and obtain Class I canine. (Figure 14) Extraction of the 2nd premolars is not systematic given that therapeutic Class II molar is tolerated from a an occlusodontic perspective. (Figures 15, 16) In fact, presurgical objectives in the sagittal plane focus on removal of dental compensations.

As for skeletal Class III, extraction of upper first premolar is enacted to reposition upper incisors and obtain Class I canine. (Figure 14) Extraction of the 2nd premolars is not systematic given that therapeutic Class II molar is tolerated from a an occlusodontic perspective. (Figures 15, 16) In fact, presurgical objectives in the sagittal plane focus on removal of dental compensations.

As for skeletal Class III, extraction of upper first premolar is enacted to reposition upper incisors and obtain Class I canine relationship. (Figure 14) Extraction of the 2nd premolars is not systematic given that therapeutic Class II molar is tolerated from an occlusodontic perspective. (Figures 15, 16) In fact, presurgical objectives in the sagittal plane focus on removal of dental compensations. However, decompensation represents security for stable occlusion

This may require the use of Class III elastics in Class II cases (and vice versa), thus allowing for maximal surgical correction of the

This may require the use of Class III elastics in Class II cases (and vice versa), thus allowing for maximal surgical correction of the

*and in some cases (Class II.1 malocclusion), the upper incisors reduced* 

142 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

*and in some cases (Class II.1 malocclusion), the upper incisors reduced* 

*the soft tissue facial balance.* 

*the soft tissue facial balance.* 

the jaws and ultimately the soft tissue facial balance.

underlying skeletal deformity.

underlying skeletal deformity.

and improved aesthetics.

 *Figure 12: extraction of 34 and 44 only can be justified* 

 *Figure 12: extraction of 34 and 44 only can be justified* 

**Figure 13.** Dental compensation seen in skeletal Class III malocclusion

**Figure 12.** Extraction of 34 and 44 only can be justified

However, surcompensation represents security for stable occlusion and improved aesthetics.

However, surcompensation represents security for stable occlusion and improved aesthetics.

**Figure 14.** Direction of incisor decompensation in Class III malocclusion: the labial inclination of the lower incisors is increased and the upper incisors reduced *Figure 14: direction of incisor decompensation in Class III malocclusion: the labial inclination of the lower incisors is increased and the upper incisors reduced* 

*Figure 15: Classic pattern extraction of 14, 24, 35 and 45 in order to increase the negative overjet and presurgically decompensate for the malocclusion. Correct planning of the orthodontic tooth positioning before surgery will enhance the surgical potential and, hence, the esthetic result.*  **Figure 15.** Classic pattern extraction of 14, 24, 35 and 45 in order to increase the negative overjet and presurgically de‐ compensate for the malocclusion. Correct planning of the orthodontic tooth positioning before surgery will enhance the surgical potential and, hence, the esthetic result.

One goal of presurgical orthodontics is that maxillary and mandibular transverse diameters coincide for a reasonable intercuspidation after surgery. [10] It was clearly established that both vertical and horizontal recurrence correlates with dental arches incoordination and the persistence of occlusal interferences. The resulting occlusal imbalance is closely related to orthodontic preparation, sometimes without extraction [12] In the transverse plane, differentiation of skeletal from dental problems as well as identification of relative and absolute discrepancies should be carried out presurgically. Orthodontic or surgical

Figure17: Dental arch width must be assessed preoperatively by measuring and comparing the distance between the mesiolingual cusps of the maxillary first molars versus the central fossae of the mandibular first molars. In this case, there are skeletal transverse

In the absence of a major transverse problem, arch compatibility is generally achieved by coordination. [11] This is true for class II cases, where transverse shift goes unoticed as revealed by the manipulation in the corrected position. This is a favorable

 In Class III malocclusion, the endognathy is a frequent symptom which affects the therapy protocol. Any orthodontic attempt inevitably leads to recidivism in this respect. Surgical disjunction or surgically assisted expansion can help to prevent transverse recurrence related to excessive teeth release. [10] Study casts carried out at the end of orthodontic preparation are essential; they allow rectifying any condition that may potentially lead to complication, and thus affects the success and stability of the surgical

The order of importance begins with the direction and amount of squeletal movement, the type of fixation used, and finally, the surgical technique. [3, 14] Other factors were also stated, namely, the maxillomandibular order or surgery-orthontics[15, 16, 17]

*Figure 16:* extraction *of 14 and 24 is often sufficient and molar Class II acceptable.*  **Figure 16.** Extraction of 14 and 24 is often sufficient and molar Class II acceptable.

expansion should be used, depending on individual circumstances. (Figure 17 ) [11]

deficiency which must be corrected bysurgically maxillary expansion.

3.2.1 - **Direction and amount of surgical movement �** 

orthodontic work so that both arches engage properly when the surgical mandibular advancement.

**Transverse arch Coordination** 

procedure. [13] 3.2- Surgical phase

.

#### *4.1.2. Transverse arch coordination*

One goal of presurgical orthodontics is that maxillary and mandibular transverse diameters coincide for a reasonable intercuspation after surgery. [10] It is clearly established that both vertical and horizontal recurrence correlate with dental arches in coordination and the persistence of occlusal interferences. The resulting occlusal imbalance is closely related to orthodontic preparation, sometimes without extraction [12] in the transverse plane; differen‐ tiation of skeletal from dental problems as well as identification of relative and absolute discrepancies should be carried out presurgically. Orthodontic or surgical expansion should be used, depending on individual circumstances (Figure 17). [11] **MEDICAL‐EDITED CHAPTER FOR AOMFS VOL 2**

Figure17: Dental arch width must be assessed preoperatively by measuring and comparing the distance between the mesiolingual cusps of the maxillary first **Figure 17.** Dental arch width must be assessed preoperatively by measuring and comparing the distance between the mesiolingual cusps of the maxillary first molars versus the central fossae of the mandibular first molars. In this case, there are skeletal transverse deficiencies which must be corrected by surgical maxillary expansion.

molars versus the central fossae of the mandibular first molars. In this case, there are skeletal transverse deficiencies which must be corrected by surgical maxillary expansion. In the absence of a major transverse problem, arch compatibility is generally achieved by coordination. [11] This is true for class II cases, where transverse shift goes unnoticed as revealed by the manipulation in the corrected position. This is a favorable orthodontic work so that both arches engage properly when the surgical mandibular advancement is performed.

In the absence of a major transverse problem, arch compatibility is generally achieved by coordination. [11] This is true for class II cases, where transverse shift goes unnoticed as revealed by the manipulation in the corrected position. This is a favorable orthodontic work so that both arches engage properly when the surgical Surgical disjunction or surgically assisted expansion can help to prevent transverse recurrence related to excessive teeth release. [10] Study casts carried out at the end of orthodontic preparation are essential; they allow rectifying any condition that may potentially lead to complications, and thus affects the success and stability of the surgical procedure. [13]

#### mandibular advancement is performed. **4.2. Surgical phase**

.

Surgical disjunction or surgically assisted expansion can help to prevent transverse recurrence related to excessive teeth release. [10] Study casts carried out at the The order of importance begins with the direction and amount of skeletal movement, the type of fixation used, and finally, the surgical technique. [3, 14] Other factors were also stated, namely, the maxillomandibular order or surgery-orthodontics[15- 17]

end of orthodontic preparation are essential; they allow rectifying any condition

#### that may potentially lead to complications, and thus affects the success and *4.2.1. Direction and amount of surgical movement*

3.2‐ Surgical phase

orthodontics[15‐ 17]

stability of the surgical procedure. [13] In a report on the hierarchy of stability in orthognathic surgery, Proffit ranked isolated maxillary advancement as the second most stable orthognathic surgical procedure after

3.2.1 ‐ **Direction and amount of surgical movement**

The order of importance begins with the direction and amount of skeletal

movement, the type of fixation used, and finally, the surgical technique. [3, 14] Other factors were also stated, namely, the maxillomandibular order or surgery‐

In a report on the hierarchy of stability in orthognathic surgery, Proffit ranked isolated maxillary advancement as the second most stable orthognathic surgical procedure after maxillary upward positioning; the latter was performed more than

maxillary advancement with or without mandibular setback. [13, 14]

maxillary upward positioning; the latter was performed more than maxillary advancement with or without mandibular setback. [13, 14]

### *4.2.1.1. Maxillary upward*

*4.1.2. Transverse arch coordination*

144 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

expansion.

**4.2. Surgical phase**

mandibular advancement is performed.

namely, the maxillomandibular order or surgery-orthodontics[15- 17]

stability of the surgical procedure. [13]

3.2.1 ‐ **Direction and amount of surgical movement**

3.2‐ Surgical phase

*4.2.1. Direction and amount of surgical movement*

orthodontics[15‐ 17]

.

One goal of presurgical orthodontics is that maxillary and mandibular transverse diameters coincide for a reasonable intercuspation after surgery. [10] It is clearly established that both vertical and horizontal recurrence correlate with dental arches in coordination and the persistence of occlusal interferences. The resulting occlusal imbalance is closely related to orthodontic preparation, sometimes without extraction [12] in the transverse plane; differen‐ tiation of skeletal from dental problems as well as identification of relative and absolute discrepancies should be carried out presurgically. Orthodontic or surgical expansion should

be used, depending on individual circumstances (Figure 17). [11] **MEDICAL‐EDITED CHAPTER FOR AOMFS VOL 2**

Figure17: Dental arch width must be assessed preoperatively by measuring and comparing the distance between the mesiolingual cusps of the maxillary first

**Figure 17.** Dental arch width must be assessed preoperatively by measuring and comparing the distance between the mesiolingual cusps of the maxillary first molars versus the central fossae of the mandibular first molars. In this case,

In the absence of a major transverse problem, arch compatibility is generally achieved by coordination. [11] This is true for class II cases, where transverse shift goes unnoticed as revealed by the manipulation in the corrected position. This is a favorable orthodontic work so that both arches engage properly when the surgical mandibular advancement is performed. Surgical disjunction or surgically assisted expansion can help to prevent transverse recurrence related to excessive teeth release. [10] Study casts carried out at the end of orthodontic preparation are essential; they allow rectifying any condition that may potentially lead to complications, and thus affects the success and stability of the surgical procedure. [13]

The order of importance begins with the direction and amount of skeletal movement, the type of fixation used, and finally, the surgical technique. [3, 14] Other factors were also stated,

In a report on the hierarchy of stability in orthognathic surgery, Proffit ranked isolated maxillary advancement as the second most stable orthognathic surgical procedure after

there are skeletal transverse deficiencies which must be corrected by surgical maxillary expansion.

molars versus the central fossae of the mandibular first molars. In this case, there are skeletal transverse deficiencies which must be corrected by surgical maxillary

achieved by coordination. [11] This is true for class II cases, where transverse shift goes unnoticed as revealed by the manipulation in the corrected position. This is a favorable orthodontic work so that both arches engage properly when the surgical

Surgical disjunction or surgically assisted expansion can help to prevent transverse recurrence related to excessive teeth release. [10] Study casts carried out at the end of orthodontic preparation are essential; they allow rectifying any condition that may potentially lead to complications, and thus affects the success and

In the absence of a major transverse problem, arch compatibility is generally

The order of importance begins with the direction and amount of skeletal

movement, the type of fixation used, and finally, the surgical technique. [3, 14] Other factors were also stated, namely, the maxillomandibular order or surgery‐

In a report on the hierarchy of stability in orthognathic surgery, Proffit ranked isolated maxillary advancement as the second most stable orthognathic surgical procedure after maxillary upward positioning; the latter was performed more than

maxillary advancement with or without mandibular setback. [13, 14]

Maxillary impaction is recommended in the case of patients with dolichofacial condition and vertical maxillary excess. Excellent skeletal stability is achieved in 90% of the cases, irrespective of the type of osteosynthesis used. [14] Such stability is due to the physiological occlusal adaptation related to mandible rotation. Interocclusal space is then maintained. [14, 18]

In asymmetry correction of the maxilla characterized by the inclination of the occlusal plane, surgery combines maxillary impaction and mandibular surgery. The maxillary component of this asymmetry correction is considered stable [19]

### *4.2.1.2. Mandibular advancement*

Sagittal split ramus osteotomy (SSRO) is a well-established procedure for correcting mandib‐ ular retrognathism. [20] The literature contains a number of studies on postoperative changes after SSRO. At retention phase, relapse occurred due to the increase in mandibular plane and ANB angle, and an increase in overjet. [19, 21] The etiology of relapse is multifactorial, involving the proper seating of the condyles, the amount of advancement, the soft tissue and muscles, the mandibular plane angle, the remaining growth and the skill of the surgeon. [3, 8, 21] It is believed that orthosurgical treatment for the correction of Class II with mandibular advancement could be stable, provided the amount of skeletal movements and the circumja‐ cent soft tissues are respected. Advancements over 10mm lead to horizontal relapse. [14, 21, 22] In systematic review that evaluate horizontal relapse in bilateral sagittal split advancement osteotomy, it was shown that advancements in the range of 6 to 7 mm or more predispose to horizontal relapse. [3]

#### *4.2.1.3. Maxillary advancement*

Maxillary advancement could be stable, provided that skeletal movements, as recommended by some others, were under 6, 8 or 10mm. In fact, the use of rigid fixation and bone grafting for good stability of maxillary advancement up to 6 mm showed no recurrence. [14, 19, 23- 25] For a maxillary advancement of less than 8mm, it was suggested that the maxillary maintain its horizontal postsurgical position (less than 2 mm) in 80% of the cases; a risk of recurrence between from 2 and 4 mm can be seen in 20% of the cases. [25]

#### *4.2.1.4. Mandibular setback*

The sagittal split ramus osteotomy (SSRO) and the intraoral vertical ramus osteotomy (IVRO) are well-established procedures for correcting mandibular prognathism. Both techniques have advantages and disadvantages; include bony contact between the distal and mesial segments and application for both advancement and retraction and the duration of intermaxillary fixation (IMF). Orthognathic surgeons must weigh up these advantages and disadvantages when deciding which surgical treatment to use in cases of mandibular prognathism. Another important factor for surgeons to consider is postoperative stability. While the literature contains a number of studies on postoperative changes after SSRO, a few reports concern postoperative stability after IVRO.

IVRO is a relatively simple technique, which is applicable for only retraction of the mandible. The postoperative changes and stability tend to be influenced by the surgical techniques employed and the skills of the surgeons. In the short term after IVRO, clockwise rotation was observed due a less bony contact between the proximal and distal segments during surgery. After this period of adaptive rotation, the mandible showed a slight tendency to relapse with forward movement up to 2 years after IVRO. [20] With bilateral sagittal split osteotomy setback (BSSO), the relapse is more frequent than vertical osteotomy. However, it is an effective treatment of skeletal class III and a stable procedure in the short and long term. Analyzing the different relapse rates in systematic review showed that main relapse mostly takes place immediate after surgery and in the short term. [2, 14] From the reviewed literature, it was conclude that skeletal relapse is very frequent and was influenced by the magnitude of surgical correction and the inclination of the ramus after surgery. But, compared with mandibular advancement BSSO, the amount of setback was correlated less frequently with the amount of relapse. Opinions differ and generally speaking, the father the distal segment is set back (more than 10mm), the greater the tendency for the proximal segment to rotate. Furthermore, maintaining the initial inclination of the ramus could therefore reduce the tendency to relapse. [2, 14, 22, 26] Other research suggested that post-operative relapse in mandibular setback surgery may relate to the pre-surgical skeletal pattern of each patient and the perimandibular connective tissue action. Additionally, some vertical mandibular relapse after setback surgery may be affected by the postural changes of the tongue and hyoid bone [26] However, it was reported that the role of suprahyoid muscles is less important after a mandibular setback than after advancement or a closing gap.[26,27] Correcting the open bite by orthognathic surgery directed only at the mandible has a high risk of relapse because of mandibular up-repositioning in a counter-clockwise rotation. A mandibular backward repositioning is equally performed to prevent open bite relapse. [28]

#### *4.2.1.5. Maxillary advancement combined with mandibular setback*

The mandibular setback is frequently combined with Le Fort I osteotomy for maxillary advancement when there is a greater discrepancy between the maxilla and mandible and greater labial projection. Surgical correction of Class III malocclusion after combined maxillary and mandibular procedures appears to be a fairly stable procedure for maxillary advance‐ ments up to 5 mm, independent of the type of fixation used to stabilize the mandible. Likewise, no statistically significant differences have been observed between the procedures conducted on both jaws versus the lower jaw only. [21, 29- 31] Over the past few years, the number of patients with mandibular prognathism as a component of a skeletal Class III problem who were treated with mandibular setback alone decreased remarkably, compared with outcomes in patients with two- jaw surgery. A number of reasons to explain such a tendency are listed below: [32, 33]

**•** Restricting the amount of mandibular setback by simultaneously advancing the maxilla contributes to stability.


#### *4.2.1.6. Maxillary expansion*

important factor for surgeons to consider is postoperative stability. While the literature contains a number of studies on postoperative changes after SSRO, a few reports concern post-

IVRO is a relatively simple technique, which is applicable for only retraction of the mandible. The postoperative changes and stability tend to be influenced by the surgical techniques employed and the skills of the surgeons. In the short term after IVRO, clockwise rotation was observed due a less bony contact between the proximal and distal segments during surgery. After this period of adaptive rotation, the mandible showed a slight tendency to relapse with forward movement up to 2 years after IVRO. [20] With bilateral sagittal split osteotomy setback (BSSO), the relapse is more frequent than vertical osteotomy. However, it is an effective treatment of skeletal class III and a stable procedure in the short and long term. Analyzing the different relapse rates in systematic review showed that main relapse mostly takes place immediate after surgery and in the short term. [2, 14] From the reviewed literature, it was conclude that skeletal relapse is very frequent and was influenced by the magnitude of surgical correction and the inclination of the ramus after surgery. But, compared with mandibular advancement BSSO, the amount of setback was correlated less frequently with the amount of relapse. Opinions differ and generally speaking, the father the distal segment is set back (more than 10mm), the greater the tendency for the proximal segment to rotate. Furthermore, maintaining the initial inclination of the ramus could therefore reduce the tendency to relapse. [2, 14, 22, 26] Other research suggested that post-operative relapse in mandibular setback surgery may relate to the pre-surgical skeletal pattern of each patient and the perimandibular connective tissue action. Additionally, some vertical mandibular relapse after setback surgery may be affected by the postural changes of the tongue and hyoid bone [26] However, it was reported that the role of suprahyoid muscles is less important after a mandibular setback than after advancement or a closing gap.[26,27] Correcting the open bite by orthognathic surgery directed only at the mandible has a high risk of relapse because of mandibular up-repositioning in a counter-clockwise rotation. A mandibular backward repositioning is equally performed

operative stability after IVRO.

146 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

to prevent open bite relapse. [28]

below: [32, 33]

contributes to stability.

*4.2.1.5. Maxillary advancement combined with mandibular setback*

The mandibular setback is frequently combined with Le Fort I osteotomy for maxillary advancement when there is a greater discrepancy between the maxilla and mandible and greater labial projection. Surgical correction of Class III malocclusion after combined maxillary and mandibular procedures appears to be a fairly stable procedure for maxillary advance‐ ments up to 5 mm, independent of the type of fixation used to stabilize the mandible. Likewise, no statistically significant differences have been observed between the procedures conducted on both jaws versus the lower jaw only. [21, 29- 31] Over the past few years, the number of patients with mandibular prognathism as a component of a skeletal Class III problem who were treated with mandibular setback alone decreased remarkably, compared with outcomes in patients with two- jaw surgery. A number of reasons to explain such a tendency are listed

**•** Restricting the amount of mandibular setback by simultaneously advancing the maxilla

Transverse maxillomandibular discrepancies are a major component of several malocclusions. The correction of skeletal transverse deficiency of the maxilla may be achieved surgically. [34]

The segmental maxillary osteotomy (SMO) is recommended when a moderate transverse defect of the maxillary bone in the amount of 5 to 6mm require correction. To increase the transverse diameter of the maxilla, maxillary expansion is simultaneously performed with Lefort I planned to correct all maxilla-mandibular discrepancies (vertical and sagittal reposi‐ tioning). It consists at least to two osteotomy lines, one on either side of the palatine raphe, performed after orthodontic preparatory stage. [34, 35] Maxillary expansion is relatively simple, but treatment stability remains a common problem. Overcorrection and rigid osteo‐ synthesis are recommended. In addition, the corrected maxilla should be reinforced with intraoral retention provided by a preformed palatal bar or splint. [14, 35]

The Surgically assisted rapid palatal expansion (SARPE) is used in cases of severe deficit estimated at more than 6 to 7mm; surgically-assisted maxillary expansion, which depends on osseous distraction osteogenesis the separating of segments of bone to create new bone and the movement of whole groups of teeth and their periodontium. This technique works by release of the maxilla bone resistances and assures excellent stability.

### *4.2.1.7. Genioplasty*

The chin is subject to morphological anomalies in the sagittal (retrogenia or progenia), vertical (excess or insufficient height), or transversal (laterogenia) axes. Genioplasty, used alone or in conjunction with other maxillomandibular osteotomies, is an important and reliable technique for the esthetic treatment of the lower facial skeleton. It can be a powerful procedure to improve the facial profile by modifying the position of the chin bones in three planes. Genioplasty is a stable surgical procedure when used in conjunction with rigid internal fixation. So there is no significant relapse after genioplasty and bilateral sagittal split osteotomy or genioplasty alone after 12 months. In fact, the changes are minimal and hard to detect clinically. [36]

#### *4.2.2. Osteotomy fixation (type and materials)*

Osteotomy fixation technique is one of the factors that determine the horizontal and vertical postsurgical relapse potential. The short- and long-term outcomes of different fixation techniques are a topic of interest in the orthodontic literature. [37] In earlier years, maxillary osteotomies were stabilized using intraosseous wires. In the 1980s, rigid internal fixation of osteotomy segments using miniplates and/or screws were introduced in an attempt to decrease postsurgical relapse and to allow earlier mobilization of the mandible. In fact, miniplates were introduced for fixation in BSSO, and have several advantages compared with bicortical screw osteosynthesis, because of the stretching of the musculature and paramandibular tissues, the bilateral compound joints, the masticatory forces, and occlu‐ sion. [27, 37] A number of studies that addressed the value of rigid internal fixation reported that 50% of the total forward relapse of mandible occurred during the 6 weeks after surgery. In contrast, with wire fixation and maxillomandibular fixation, the mandible maintained its position or moved posteriorly during MMF fixation. [33] On the other hand, in study which investigates biomechanical stability of RIF, the relationship between screw placement configurations and stability was demonstrated. It was concluded that bi-cortical screws with a 2.3-mm diameter and triangular configuration were considered as a sufficient fixation tool for BSSO than the linear configuration. [38] However, there is a trend toward increase in relapse from short-term to long-term studies when bicortical screws are used. [3] Bicorti‐ cal screws of titanium, stainless steel, or bioresorbable material show little difference regarding skeletal stability compared with miniplates in the short term. A greater num‐ ber of studies with larger skeletal long-term relapse rates were evident in patients treated with bicortical screws instead of miniplates. [3] The use of bicortical screws or monocortical screws, together with plates, is the most demanding fixation procedure of the craniofacial skeleton when used in mandibular advancement patients. [8] It was also shown that the use of BSSO of the mandible with or without counterclockwise rotation of the occlusal plane for anterior open bite correction, increases stability in the vertical direc‐ tion. [39] Thus, some of the limitations of metal plates and screws used for the fixation of bones have led to the development of plates made from titanium. Such a technique has been in use in orthognathic surgery for about two decades, because of their high biocom‐ patibility and resistance to corrosion. In addition, titanium fixation produces stability for the osteotomy site and allows patients to use their masticatory system functionally immediately after surgery. [40] The development of bioresorbable osteosynthesis devices made it possible to avoid second surgery to remove titanium plates linked sometimes to palpability, infectious complications or allergies; although they are rare. However, con‐ cerns remain about the stability which was related to the movements in orthognathic surgery. [26, 40] The systematic reviews of bioresorbable versus titanium fixation for orthognathic surgery, have shown that bioresorbable fixation systems produce reliable skeletal stability. [40] However, it suggested no statistically significant difference for plate and screw fixation using either titanium or resorbable materials. There are a few studies about the stability of biodegradable devices osteosynthesis and it was recommended that these materials should be used with caution for bony movements of greater magnitude until their usefulness is evaluated in studies with large maxillary advancements. [30]

#### **4.3. Postsurgical orthodontics**

Postsurgical orthodontic treatment involves finalization of the occlusion and retention. Working wire and light up and down elastics or slightly Class II or Class III elastics ensures the refinement of the occlusion. This final stage is equally important to ensure stable results. It is not enough to place orthodontic retainers at the end of treatment. It is appropriate to finalize and fine-tune the occlusion with a view to achieve stability, function, and facial balance. [1, 41]

#### *4.3.1. Functional balance conditions*

osteotomies were stabilized using intraosseous wires. In the 1980s, rigid internal fixation of osteotomy segments using miniplates and/or screws were introduced in an attempt to decrease postsurgical relapse and to allow earlier mobilization of the mandible. In fact, miniplates were introduced for fixation in BSSO, and have several advantages compared with bicortical screw osteosynthesis, because of the stretching of the musculature and paramandibular tissues, the bilateral compound joints, the masticatory forces, and occlu‐ sion. [27, 37] A number of studies that addressed the value of rigid internal fixation reported that 50% of the total forward relapse of mandible occurred during the 6 weeks after surgery. In contrast, with wire fixation and maxillomandibular fixation, the mandible maintained its position or moved posteriorly during MMF fixation. [33] On the other hand, in study which investigates biomechanical stability of RIF, the relationship between screw placement configurations and stability was demonstrated. It was concluded that bi-cortical screws with a 2.3-mm diameter and triangular configuration were considered as a sufficient fixation tool for BSSO than the linear configuration. [38] However, there is a trend toward increase in relapse from short-term to long-term studies when bicortical screws are used. [3] Bicorti‐ cal screws of titanium, stainless steel, or bioresorbable material show little difference regarding skeletal stability compared with miniplates in the short term. A greater num‐ ber of studies with larger skeletal long-term relapse rates were evident in patients treated with bicortical screws instead of miniplates. [3] The use of bicortical screws or monocortical screws, together with plates, is the most demanding fixation procedure of the craniofacial skeleton when used in mandibular advancement patients. [8] It was also shown that the use of BSSO of the mandible with or without counterclockwise rotation of the occlusal plane for anterior open bite correction, increases stability in the vertical direc‐ tion. [39] Thus, some of the limitations of metal plates and screws used for the fixation of bones have led to the development of plates made from titanium. Such a technique has been in use in orthognathic surgery for about two decades, because of their high biocom‐ patibility and resistance to corrosion. In addition, titanium fixation produces stability for the osteotomy site and allows patients to use their masticatory system functionally immediately after surgery. [40] The development of bioresorbable osteosynthesis devices made it possible to avoid second surgery to remove titanium plates linked sometimes to palpability, infectious complications or allergies; although they are rare. However, con‐ cerns remain about the stability which was related to the movements in orthognathic surgery. [26, 40] The systematic reviews of bioresorbable versus titanium fixation for orthognathic surgery, have shown that bioresorbable fixation systems produce reliable skeletal stability. [40] However, it suggested no statistically significant difference for plate and screw fixation using either titanium or resorbable materials. There are a few studies about the stability of biodegradable devices osteosynthesis and it was recommended that these materials should be used with caution for bony movements of greater magnitude until their usefulness is evaluated in studies with large maxillary advancements. [30]

148 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Postsurgical orthodontic treatment involves finalization of the occlusion and retention. Working wire and light up and down elastics or slightly Class II or Class III elastics ensures

**4.3. Postsurgical orthodontics**

Neutralizing the functional matrix at the end of treatment contributes significantly to stability of results. It is important to note that mastery of the neuromuscular environment is an important element of skeletal and dentoalveolar modeling of each patient. The stability of the result after treatment is therefore based on the diagnosis of muscle behavior, and functional rehabilitation.

This final phase of treatment is the best time to prescribe exercises for normalizing orofacial muscles and harmonizing skeletal relationships making rehabilitation more effective.

#### *4.3.2. Occlusion balance conditions*

The finishing and detailing phase, the last stage of active orthognathic surgery treatment, makes it possible to improve the occlusion, by adopting a number of criteria as defined by various authors; the ultimate goal is to improve the esthetic result, on the condition that treatment objectives during the pre-planning phase have been met.

Dental balance should be considered both statically and dynamically. Indeed, intra-arch condition inter-arch relationships, and balance provides functional comfort and lasting results.

Treatment stability depends in part on obtaining a "functional occlusion" consistent with the physiology of TMA. The quality of finishing for some researchers (Tweed) is sufficient as a natural retainer tool.

### *4.3.2.1. The sequence of ortho-surgical treatment*

The sequence of steps of ortho-surgical treatment is illustrated through a clinical case: A 16 year-old patient reported aesthetic and psychological discomfort related to severe skeletofacial discrepancy. The patient also complained of functional difficulty during mastication and expressed concern at his inability to bite using the anterior sector of the dentition. In face and profile views, skeletal class III due to underdevelopment of the upper jaw and to mandibular deformity in frontal, vertical and sagittal dimension was noticed (Figure 18).

Intraoral examination showed severe molar and canine Class III, the absence of overbite and the marked negative overjet. The crowding of the superior incisors was confirmed in occlusal view. The position of the incisors had evidently compensated for the skeletal malocclusion (Figure 19).

The lateral teleradiogram and relative cephalometric values confirmed the diagnosis of serious skeletal Class III (Figure 20).

*Figure 18 : Frontal view, profile and smile of patient before treatment A patient H. presented long and narrow face, concave profile, lack of upper lip support, with maxillary anteroposterior deficiency and mandibular anteroposterior excess. Clinically significant asymmetry of mandible to the right is present.*  **Figure 18.** Frontal view, profile and smile of the patient before treatment showing long and narrow face, concave pro‐ file, lack of upper lip support, with maxillary anteroposterior deficiency and mandibular anteroposterior excess. Clini‐ cally significant deviation of the mandible to the right is present. *Figure 18 : Frontal view, profile and smile of patient before treatment* 

*and mandibular anteroposterior excess. Clinically significant asymmetry of mandible to the right is present.* 

*A patient H. presented long and narrow face, concave profile, lack of upper lip support, with maxillary anteroposterior deficiency*

*position of maxillary lateral incisors) due to narrow maxillary dental arch and compensated mandibular incisors Figure 19 : Pretreatment intraoral photographs: frontal, lateral and occlusion The Class III malocclusion is characterized by an anterior and posterior crossbites . Crowding is present in both arches (palateposition of maxillary lateral incisors) due to narrow maxillary dental arch and compensated mandibular incisors*  **Figure 19.** Pretreatment intraoral photographs: frontal, lateral and occlusion The Class III malocclusion is characterized by an anterior and posterior crossbites. Crowding is present in both arches (palate-position of maxillary lateral inci‐ sors) due to narrow maxillary dental arch and compensated mandibular incisors

*The Class III malocclusion is characterized by an anterior and posterior crossbites . Crowding is present in both arches (palate-*

Given the severe skeletal disharmony, the treatment plan suggested was orthognathic surgery to improve both esthetic and functional problems. The surgery was followed by presurgical preparation of dentition. The treatment plan consisted of extraction of the first maxillary premolars to align the anterior arch, eliminate compensations and to establish ideal incisor, and second mandibular premolars position (Figure 21). The outcome of this preparation is evident in the postorthodontic presurgical intraoral and profile photographs and composite cephalometric tracing. The patient felt his profile was getting worse (Figures 22, 23)

problems. The surgery was followed by presurgical preparation of dentition. The treatment plan consisted of extraction of first


*position of maxillary lateral incisors) due to narrow maxillary dental arch and compensated mandibular incisors* 

*A patient H. presented long and narrow face, concave profile, lack of upper lip support, with maxillary anteroposterior deficiency*

*and mandibular anteroposterior excess. Clinically significant asymmetry of mandible to the right is present.* 

Given the severe skeletal dysharmony, the treatment plan suggested was orthognathic surgery to improve both esthetic and function problems. The surgery was followed by presurgical preparation of dentition. The treatment plan consisted of extraction of first maxillary premolars to align the anterior arch, eliminate compensations and to establish ideal incisor position, and second mandibular premolars. (Figure 21) The outcome of this preparation is evident in the postorthodontic presurgical intraoral and maxillary premolars to align the anterior arch, eliminate compensations and to establish ideal incisor position, and second mandibular premolars. (Figure 21) The outcome of this preparation is evident in the postorthodontic presurgical intraoral and profile photographs and composite cephalometric tracing. The patient felt their profile was getting worse (Figures 22, 23) **Figure 20.** Pretreatment orthopantomogram and lateral teleradiogram of the skull. The orthopantomogram shows and impacted 18 and 28 that must be removed. The maxillomandibular disharmony and incisor compensations were evi‐ dent. Both teleradiogram and cephalometric values showed lingual inclination of mandibular incisors and protrusion of maxillary incisors.

profile photographs and composite cephalometric tracing. The patient felt their profile was getting worse (Figures 22, 23)

*protrusion of maxillary incisors.* 

*Figure 18 : Frontal view, profile and smile of patient before treatment* 

*Figure 18 : Frontal view, profile and smile of patient before treatment* 

cally significant deviation of the mandible to the right is present. *Figure 18 : Frontal view, profile and smile of patient before treatment* 

150 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

*Figure 19 : Pretreatment intraoral photographs: frontal, lateral and occlusion* 

*Figure 19 : Pretreatment intraoral photographs: frontal, lateral and occlusion* 

sors) due to narrow maxillary dental arch and compensated mandibular incisors

*A patient H. presented long and narrow face, concave profile, lack of upper lip support, with maxillary anteroposterior deficiency*

*A patient H. presented long and narrow face, concave profile, lack of upper lip support, with maxillary anteroposterior deficiency*

*The Class III malocclusion is characterized by an anterior and posterior crossbites . Crowding is present in both arches (palate-*

*position of maxillary lateral incisors) due to narrow maxillary dental arch and compensated mandibular incisors* 

Given the severe skeletal disharmony, the treatment plan suggested was orthognathic surgery to improve both esthetic and functional problems. The surgery was followed by presurgical preparation of dentition. The treatment plan consisted of extraction of the first maxillary premolars to align the anterior arch, eliminate compensations and to establish ideal incisor, and second mandibular premolars position (Figure 21). The outcome of this preparation is evident in the postorthodontic presurgical intraoral and profile photographs and composite

*position of maxillary lateral incisors) due to narrow maxillary dental arch and compensated mandibular incisors*  **Figure 19.** Pretreatment intraoral photographs: frontal, lateral and occlusion The Class III malocclusion is characterized by an anterior and posterior crossbites. Crowding is present in both arches (palate-position of maxillary lateral inci‐

cephalometric tracing. The patient felt his profile was getting worse (Figures 22, 23)

*The Class III malocclusion is characterized by an anterior and posterior crossbites . Crowding is present in both arches (palate-*

*and mandibular anteroposterior excess. Clinically significant asymmetry of mandible to the right is present.* 

*and mandibular anteroposterior excess. Clinically significant asymmetry of mandible to the right is present.* 

**Figure 18.** Frontal view, profile and smile of the patient before treatment showing long and narrow face, concave pro‐ file, lack of upper lip support, with maxillary anteroposterior deficiency and mandibular anteroposterior excess. Clini‐

*Figure 21: intraoral views after presurgical orthodontic preparation: immediate preoperative views and radiogram of patient The objective of presurgical treatment should be to create a harmonious form of the maxillary and mandibular dental arches independently of each other. The use of class III elastics is nececessaru to increase the labial inclination of the lower incisors and the negative overjet and presurgically decompensate for the malocclusion.*  **Figure 21. Intraoral views after presurgical orthodontic preparation** The objective of presurgical treatment should be to create a harmonious form of the maxillary and mandibular dental arches independently. The use of class III elastics is necessary to increase the labial inclination of the lower incisors and the negative overjet and presurgically decom‐ pensate for the malocclusion. *Figure 21: intraoral views after presurgical orthodontic preparation: immediate preoperative views and radiogram of patient The objective of presurgical treatment should be to create a harmonious form of the maxillary and mandibular dental arches independently of each other. The use of class III elastics is nececessaru to increase the labial inclination of the lower incisors and the negative overjet and presurgically decompensate for the malocclusion.* 

*Figure 22: pretreatment and presurgical profile views: The worsening of the profile was due to dental decompensation, with the incisors positioned on the bony bases as adequately as possible.*  **Figure 22.** Pretreatment and presurgical profile views: The worsening of the profile was due to dental decompensation, with the incisors positioned on the bony bases as adequately as possible.

*Figure 23: pretreatment and presurgical lateral teleradiographies and composite cephalometric tracing of a patient. Note the values illustrating the decompensation of incisors and the increase of a witts.*  **Figure 23.** Pretreatment and presurgical lateral teleradiographies and composite cephalometric tracing of the patient. Note the values illustrating the decompensation of incisors and the increase of Witts.

Surgical visual treatment objectives are shown in figure 24. Two-jaw surgery was performed in this case. The maxilla was advanced and mandible setbaccked with counterclockewise rotation by means of Lefort I maxillary and sagittal split osteotomies. The postoperative views show the resolution of the main issues, the establishment of a bilateral molar and canine Class I relationship and correct overjet and overbite.The satisfactory aesthetic result in terms of profile appearance and smile line is Surgical visual treatment objectives are shown in Figure 24. Two-jaw surgery was performed in this case. The maxilla was advanced and mandible setback with counterclockwise rotation by means of Lefort I maxillary and sagittal split osteotomies. *Figure 23: pretreatment and presurgical lateral teleradiographies and composite cephalometric tracing of a patient. Note the values illustrating the decompensation of incisors and the increase of a witts.*  Surgical visual treatment objectives are shown in figure 24. Two-jaw surgery was performed in this case. The maxilla was

advanced and mandible setbaccked with counterclockewise rotation by means of Lefort I maxillary and sagittal split osteotomies.

evident from the extraoral photographs, which also show correct upper incisor exposure and normalization of the position of the bony bases. The curve in the contour line is more harmonious after surgical advancement of the maxilla and mandibular setback. (Figures 25, 26, 27) The postoperative views show the resolution of the main issues, the establishment of a bilateral molar and canine Class I relationship and correct overjet and overbite. The satisfactory aesthetic result in terms of profile appearance and smile line is evident from the extraoral photographs, which also show correct upper incisor exposure and normalization of the position of the bony bases. The curve in the contour line is more harmonious after surgical advancement of the maxilla and mandibular setback. (Figures 25- 27) The postoperative views show the resolution of the main issues, the establishment of a bilateral molar and canine Class I relationship and correct overjet and overbite.The satisfactory aesthetic result in terms of profile appearance and smile line is evident from the extraoral photographs, which also show correct upper incisor exposure and normalization of the position of the bony bases. The curve in the contour line is more harmonious after surgical advancement of the maxilla and mandibular setback. (Figures 25, 26, 27)

*Figure 24: Lefort maxillary osteotomy to superiorly reposition and advancement the maxilla to allow the mandible to autorotate and close the openbite.* **Figure 24.** Lefort maxillary osteotomy to superiorly reposition and advance the maxilla to allow the mandible to autorotate and close the openbite.

*exercise programs after fixation,, greatly facilitate treatment.*  **Figure 25.** Immediate postoperative intraoral views: the use of surgical arch wires along with controlled elastic therapy and exercise programs after fixation, greatly facilitate treatment.

*Figure 25: Immediate postoperative intraoral views: the use of surgical arch wires along with controlled elastic therapy and* 

*exercise programs after fixation,, greatly facilitate treatment.* 

*Figure 25: Immediate postoperative intraoral views: the use of surgical arch wires along with controlled elastic therapy and* 

*Figure 23: pretreatment and presurgical lateral teleradiographies and composite cephalometric tracing of a patient. Note the* 

*Figure 23: pretreatment and presurgical lateral teleradiographies and composite cephalometric tracing of a patient. Note the* 

Surgical visual treatment objectives are shown in figure 24. Two-jaw surgery was performed in this case. The maxilla was advanced and mandible setbaccked with counterclockewise rotation by means of Lefort I maxillary and sagittal split osteotomies. The postoperative views show the resolution of the main issues, the establishment of a bilateral molar and canine Class I relationship and correct overjet and overbite.The satisfactory aesthetic result in terms of profile appearance and smile line is evident from the extraoral photographs, which also show correct upper incisor exposure and normalization of the position of the bony bases. The curve in the contour line is more harmonious after surgical advancement of the maxilla and mandibular setback.

**Figure 23.** Pretreatment and presurgical lateral teleradiographies and composite cephalometric tracing of the patient.

Surgical visual treatment objectives are shown in Figure 24. Two-jaw surgery was performed in this case. The maxilla was advanced and mandible setback with counterclockwise rotation

The postoperative views show the resolution of the main issues, the establishment of a bilateral molar and canine Class I relationship and correct overjet and overbite. The satisfactory aesthetic result in terms of profile appearance and smile line is evident from the extraoral photographs, which also show correct upper incisor exposure and normalization of the position of the bony bases. The curve in the contour line is more harmonious after surgical

Surgical visual treatment objectives are shown in figure 24. Two-jaw surgery was performed in this case. The maxilla was advanced and mandible setbaccked with counterclockewise rotation by means of Lefort I maxillary and sagittal split osteotomies. The postoperative views show the resolution of the main issues, the establishment of a bilateral molar and canine Class I relationship and correct overjet and overbite.The satisfactory aesthetic result in terms of profile appearance and smile line is evident from the extraoral photographs, which also show correct upper incisor exposure and normalization of the position of the bony bases. The curve in the contour line is more harmonious after surgical advancement of the maxilla and mandibular setback.

*Figure 24: Lefort maxillary osteotomy to superiorly reposition and advancement the maxilla to allow the mandible to autorotate* 

*Figure 24: Lefort maxillary osteotomy to superiorly reposition and advancement the maxilla to allow the mandible to autorotate* 

*and close the openbite.* **Figure 24.** Lefort maxillary osteotomy to superiorly reposition and advance the maxilla to allow the mandible to auto-

*values illustrating the decompensation of incisors and the increase of a witts.* 

Note the values illustrating the decompensation of incisors and the increase of Witts.

*values illustrating the decompensation of incisors and the increase of a witts.* 

advancement of the maxilla and mandibular setback. (Figures 25- 27)

by means of Lefort I maxillary and sagittal split osteotomies.

152 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

(Figures 25, 26, 27)

(Figures 25, 26, 27)

*and close the openbite.* 

rotate and close the openbite.

**Figure 26.** *and screws. So the witts and the ANB values illustrate the* Clinical appearance and post surgical orthopantomogram and lateral teleradiogram of skull. Note the im‐ *reequilibation of maxillomandibular relationschip. .*  mediate postoperative changes and the osteosynthesis of the maxilla and the mandible with titanium miniplates and screws. The Witts and the ANB values illustrate the re-harmonization of the maxillomandibular relationship..

*and screws. So the witts and the ANB values illustrate the reequilibation of maxillomandibular relationschip. .* 

*We can note the immediate postoperative changesand the steosynthesis of the maxilla and the mandible with titanium miniplates* 

*Figure 26: Clinical appearance and post surgical orthopantomogram and laterolateral teleradiogram of skull.* 

**Figure 27.** Pretreatment and post-surgery composite cephalometric tracing illustrating the soft tissue, skeletal and den‐ tal changes. *Figure 27: Pretreatment and post-surgery composite cephalometric tracing illustrating the soft tissue, skeletal and dental changes.* 

The end results of treatment were gratifying (Figure 28). View the end results of treatment (Figure 28), we can conclude that benefit of repositioning incisive via Class II elastics, surgical

expansion and genioplasty would allow to much better occlusal relationships and aesthetic results.

*Figure 28: The changing profile during treatment and intraoral views after debonding*  **Figure 28.** The changing profile during treatment and intraoral views after debonding

of treatment which belongs, quite naturally, in the arsenal of treatment we can offer our adult patients.

relieved the orthodontist of having only compromised treatment to offer patients with skeletal disharmony.

#### **Conclusion 5. Conclusion**

close collaboration between all the different actors involved; all of which are deal within predefined objetices using a highly personalized approach. Moderate to severe skeletal deformities often requires a combined orthodontic and surgical approach for optimal function and best Stability of results depends on overall treatment plan. Successful treatment depends on a rigorous diagnosis and a treatment, a close collaboration between all the different members

esthetic results. Indeed, given the development of orthodontic and surgery techniques, this approach becomes a fully-fledged form

Orthognatic surgery has created new and exciting oppotunities in the treatment of patients with dentofacial deformities and has

Stability of results depends on overall treatment plan. Successful treatment depends on a rigorous diagnosis and a treatment plan, a

involved; all of which deal within predefined objectives using a highly personalized approach. Moderate to severe skeletal deformities often require a combined orthodontic and surgical approach for optimal function and best esthetic results. Indeed, given the development of orthodontic and surgery techniques, this approach becomes a fully-fledged form of treatment which belongs, quite naturally, in the arsenal of treatment we can offer our adult patients. Orthognathic surgery has created new and exciting opportunities in the treatment of patients with dentofacial deformities and has relieved the orthodontist of having only compromised treatment to offer patients with skeletal disharmony.

One needs to be fully convinced that ortho-surgical treatments should be in no way viewed as a game of chance. The main focus of orthodontic treatment should be on obtaining and maintaining long-term clinically satisfactory stability results. Without stability, the achieve‐ ment of good function and satisfactory aesthetics is obviously not successful.
