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Definition: adherence of the superior helix to the
temporal skin with absence of the superior
auriculocephalic sulcus
Surgical correction: release of the superior helix from
the temporal skin and creation of a new superior
auriculocephalic sulcus using skin grafts or local flaps
Stahl ear (Fig. 17-5B)
Definition: an abnormal third crus that arises from the
antihelix and extends horizontally to the helical rim
The superior crus is often hypoplastic or absent.
The scapha is malformed, while the concha is
normal.
Surgical correction: wedge excision of the third crus
with helical advancement
Constricted ear (Fig. 17-5C)
Definition: an inadequate circumference of the helical
rim causing the superior helix to fold over the scapha
Also known as a cup ear or lop ear deformity
Surgical correction: detaching the superior helix from
the scapha and reattaching it at the proper position and
angle
PEARLS
1. Patients with oropharyngeal cancer may complain of referred
otalgia via Arnold’s nerve.
2. A ring block will not provide adequate anesthesia to the concha;
direct local infiltration is required.
3. Children with microtia or prominent ears are usually operated on
between the ages of 6 and 7 when ear growth is nearly
complete and when they are able to participate in postoperative
care and restrictions.
4. In newborns <6 weeks of age, ear molding can be performed to
help reshape many deformed ears due to circulating maternal
estrogens lending malleability to the ear cartilage.
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QUESTIONS YOU WILL BE ASKED
1. What is the most common complication of otoplasty?
Recurrence.
2. What is the blood supply to the anterior surface of the ear?
Perforating branches of the postauricular artery. Superficial
temporal artery only supplies the triangular fossa.
3. What suture technique is most commonly used to correct
prominent ear and how is it placed?
Mustardé suture: horizontal mattress sutures placed between
the scapha cartilage and the conchal cartilage to recreate the
antihelical fold.
4. What are the causes of prominent ear?
Underdeveloped antihelical fold (most common), conchal
hypertrophy, and protruding lobule.
THINGS TO DRAW
Draw the surface anatomy of the ear.
Recommended Readings
1.Beahm EK, Walton RL. Auricular reconstruction for microtia: part I. Anatomy,
embryology, and clinical evaluation. Plast Reconstr Surg. 2002;109(7):2473‐
2482. doi: 10.1097/00006534-200206000-00046
2.Brent B. Auricular repair with autogenous rib cartilage grafts: two decades of
experience with 600 cases. Plast Reconstr Surg. 1992;90(3):355-374;
discussion 375-376.
3.Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg.
2005;115(4):60e‐72e.
4.Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction.
Plast Reconstr Surg. 2012;129(4):701e‐716e. doi:
10.1097/PRS.0b013e3182450d9f
5.Walton RL, Beahm EK. Auricular reconstruction for microtia: part II. Surgical
techniques. Plast Reconstr Surg. 2002;110(1):234‐387. doi:
10.1097/00006534-200207000-00041
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*
Denotes common in-service examination topics.
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18
Orthognathic Surgery
Hossein E. Jazayeri
There is no excellent beauty that hath not some strangeness in the
proportions.
—Francis Bacon
OVERVIEW
From Greek—Ortho: “straight” or “correct” + Gnath: “jaw.”
Goals of treatment include restoration of form and function.
Proper occlusion for mastication.
Ideal facial proportions with harmonious maxillomandibular
relationship.
DENTITION
Pediatric: primary or deciduous teeth
Eruption sequence (months)
*Incisors: 6 months; first teeth
First molars: 12 months
Canines: 16 months
Second molars: 20 months
Nomenclature for the 20 primary teeth
Letter system: A-P
Mnemonic: All Just Kids Teeth (Fig. 18-1B)
A, right maxillary second molar
J, left maxillary second molar
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K, left mandibular second molar
T, right mandibular second molar
Mixed Dentition: when both primary and secondary teeth are
present; age 6-9 years
Adult: secondary, permanent
Eruption sequence (years)
*First molars: 6-7; first adult teeth
Incisors: 6-9
Canines: 9-10
First premolars: 10-12
Second premolars: 11-12
Second molars: 11-13
Third molars: 17-21; “wisdom” teeth
Numbering (international standard): 1-32 (Fig. 18-1A)
Figure 18-1 Permanent teeth
numbering (A) and primary teeth
numbering (B).
(From Wilkins EM. Clinical Practice of
the Dental Hygienist. 12th ed. Wolters
Kluwer; 2017. Figure 9.1.)
1, right maxillary third molar
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17, left mandibular third molar
DENTAL ANATOMY
Crown: above the gingiva
Root: within the bone
Cusp: protruding portion of occlusal surface
Groove: intruding portion of occlusal surface
TERMINOLOGY
Mesial: toward midline (eg, incisors are mesial to molars).
Distal: away from midline.
Buccal: toward the cheek.
Lingual: toward the tongue.
Overbite: vertical relationship of the maxillary and mandibular
tooth apices.
Overjet: horizontal relationship of the maxillary and mandibular
tooth apices.
Proclination: angulation of apex toward the lips.
Retroclination: angulation of apex toward the tongue.
Apertognathia: open bite, negative overbite.
Incisal show: amount of vertical show of maxillary central
incisor in repose.
Centric occlusion: maximal intercuspation of teeth.
Centric relation: mandibular condyles fully seated in glenoid
fossae.
Open bite: part of the dentition does not occlude (can be
anywhere).
Deep bite: a pronounced overbite.
Crossbite: can be buccal, neutral (normal), or lingual. Often
caused by tilting of the maxillary teeth. Crossbite can occur in
either anterior or posterior dentition.
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ANGLE CLASSIFICATION (EDWARD
HARTLEY ANGLE, “FATHER OF
MODERN ORTHODONTICS”)
*Angle Classification: based on the relationship between
the buccal groove of the mandibular first molar and the
mesiobuccal cusp of the maxillary first molar (Fig. 18-2)
Class I: mesial buccal cusp of maxillary first molar in buccal
grove of mandibular first molar
Class II: mesial buccal cusp of maxillary first molar is mesial to
buccal grove of mandibular first molar
Division 1: maxillary incisors are proclined with an overjet
beyond the normal 2-4 mm range
Division 2: retroclination of maxillary incisors
Class III: mesial buccal cusp of maxillary first molar is distal to
buccal grove of mandibular first molar
ORTHOGNATHIC SURGERY
EVALUATION
HISTORY AND PHYSICAL
EXAMINATION
Close Coordination With Orthodontist
Complete Medical and Dental History
Functional concerns: obstructive sleep apnea (OSA),
temporomandibular joint disease (TMD), cleft lip, cleft
palate, craniofacial syndromes (hemifacial microsomia,
Treacher-Collins, Pierre-Robin sequence)
Aesthetic concerns: maxillary/mandibular protrusion,
maxillary/mandibular retrotrusion, facial profile
discrepancies, retruded/protruded chin
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Oral Exam
Occlusion: number of dental contacts; angle classification
Curve of Spee: AP curvature of occlusal plane
Curve of Wilson: lateral curvature of occlusal plane
Midline: coincidence (alignment) of maxillary and
mandibular central incisors
Cant: discrepancy of occlusal plane from horizontal
*Ideal incisal show: 2-4 mm in women; 0-2 mm in men
Restorations and overall dental health (wear of dentition,
chips/cracks)
TMJ: MIO, protrusion, laterotrusion, presence of crepitus,
clicking, subluxation, pain
Aesthetic Evaluation
Neoclassical canon
Measure horizontal thirds and vertical fifths
Assess nose-lip-chin relationship
Determine facial symmetry
Determine facial profile (straight, convex, concave)
RADIOGRAPHIC (CEPHALOMETRIC)
EVALUATION
PA and Lateral Cephalogram ± Orthopantomogram (Panorex)
Determine Convexity/Concavity
Facial Divergence
Anteriorly divergent: soft tissue pogonion anterior to
glabella
Posteriorly divergent: soft tissue pogonion posterior to
glabella
*Key Anatomic Points on Lateral Cephalogram)
Sella: midpoint of the sella turcica of sphenoid bone
Nasion: most concave point on the nasal bone
A point: most concave point on the maxilla
B point: most concave point on the mandible
Pogonion: most forward projecting point on anterior
surface of the chin
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Gonion: the lowest, posterior and lateral point of the
mandibular angle
Gnathion: the midpoint between the pogonion and menton
Menton: the lowest point on the mandibular symphysis
Normative angle values (differ based on race/ethnicity,
sex)
Stella, Nasion, A point (SNA) = 82
Stella, Nasion, B point (SNB) = 80
Figure 18-2 Angle classification of
occlusion. (From Johnson J. Bailey’s Head
and Neck Surgery. 5th ed. Wolters Kluwer;
2014. Figure 80.2.)
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DIAGNOSES AND GENERAL
MANAGEMENT
Treatment Planning
Expansion of the soft tissue envelope with anterior
skeletal movement is generally preferred to the opposite
Anterior movements produce a more youthful, rather
than aged, appearance
Consider but “ignore” normative angles
“Decompensate” occlusion
Orthodontic correction of proclined/retroclined teeth in
preparation for postoperative occlusion
Worsens preoperative occlusion
Virtual surgery can be helpful in preoperative planning
Two-dimensional software (eg, Dolphin).
Cone-beam CT or fan CT obtained, and virtual model
of the skull is generated.
The mandible is defined to prepare the virtual
osteotomies.
The planned osteotomies are defined using the
software.
The maxilla can be manipulated in any plane.
A virtual intermediate splint can be designed and
printed using CAD/CAM technology.
Distal segment of the mandible is manipulated to
the desired occlusion after which a final splint can
be designed and printed.
May determine soft tissue response to skeletal
movement
Estimates postoperative SNA/SNB angles.
Three-dimensional treatment planning is also used
(eg, Medical Modeling).
Casts, model surgery, and occlusal splints
Dental impressions followed by plaster casts
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