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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
Mandibular Surgical Procedures
413
26
14. Jones DL, Wolford LM, Hartog JM.Comparison of methods to
assess neurosensory alterations following orthognathic surgery.
Int J Adult Orthod Orthognath Surg. 1990;5:35–42.
15. Jones DL, Wolford LM.Intraoperative recording of trigeminal
evoked potentials during orthognathic surgery. Int J Adult
Orthod Orthognath Surg. 1990;5:167–74.
16. Wolford LM, Cardenas L.Idiopathic condylar resorption: diagnosis, treatment protocol, and outcomes. Am J Orthod Dentofac
Orthop. 1999;116(6):667–77.
17. Wolford LM. Idiopathic condylar resorption of the temporomandibular joint in teenage girls (cheerleaders syndrome). Bayl
Univ Med Cent Proc. 2001;14(3):246–52.
18. Wolford LM, Dhameja A.Planning for combined TMJ arthroplasty and orthognathic surgery. Atlas Oral Maxillofac Surg Clin
North Am. 2011;19:243–70.
19. Wolford LM, Cottrell DA, Karras SC. Mitek mini anchor in
maxillofacial surgery. In: SMST-94 rst international conference
on shape memory and superelastic technologies. Monterey, CA:
MIAS; 1995. p.477–82.
20. Mehra P, Wolford LM. The Mitek mini anchor for TMJ disc
repositioning: surgical technique and results. Int J Oral
Maxillofac Surg. 2001;30(6):497–503.
21. Wolford LM, Karras S, Mehra P. Concomitant temporomandibular joint and orthognathic surgery: a preliminary report. J
Oral Maxillofac Surg. 2002;60:356–62.
22. Wolford LM. Concomitant temporomandibular joint and
orthognathic surgery. J Oral Maxillofac Surg. 2003;61(10):
1198–204.
23. Wolford LM, Cassano DS, Gonçalves JR, Common
TMJ. Disorders: orthodontic and surgical management. In: JA
MN, Kapila SD, editors. Temporomandibular disorders and orofacial pain: separating controversy from consensus. Ann Arbor,
MI; 2009. p.159–98.
24. Gonçalves JR, Cassano DS, Wolford LM, Santos-Pinto A,
Márquez IM.Postsurgical stability of counterclockwise maxillomandibular advancement surgery: affect of articular disc repositioning. J Oral Maxillofac Surg. 1999;66(4):724–38.
25. Wolford LM, Chemello PD, Hilliard F.Occlusal plane alteration
in orthognathic surgery–part I: effects on function and esthetics.
Am J Orthod Dentofac Orthop. 1994;106:304–16.
26. Chemello PD, Wolford LM, Buschang PH.Occlusal plane alteration in orthognathic surgery–part II: long-term stability of
results. Am J Orthod Dentofac Orthop. 1994;106:434–40.
27. Wolford LM, Chemello PD, Hilliard FW.Occlusal plane alteration in orthognathic surgery. J Oral Maxillofac Surg.
1993;51:730–40; Discussion 740–741.
28. Wolford LM, Karras SC, Mehra P.Considerations for orthognathic surgery during growth, part 1: mandibular deformities. Am J
Orthod Dentofac Orthop. 2001;119:95–101.
29. Wolford LM, Rodrigues DB.Orthognathic considerations in the
young patient and effects on facial growth. In: Preedy VR, editor.
Handbook of growth and growth monitoring in health and disease. NewYork: Springer; 2012. p.1789–808.
Counterclockwise Rotation
oftheMaxillomandibular
Complex fortheCorrection
ofDentofacial Deformities
andSleep Apnea
LarryWolford
Contents
27.1 Occlusal Plane Alteration – 417
27.1.1 History – 417
415
27
27.2 Corrected Frankfort Horizontal Plane – 418
27.3 High Occlusal Plane (HOP) Facial Type – 419
27.3.1 Orthodontic Considerations forHOP Facial Type – 419
27.3.2 Surgical Decrease oftheOPA – 419
27.3.3 Mandibular Surgery First: Sequencing withHealthy TMJs – 419
27.3.4 TMJ Evaluation andTreatment Considerations – 422
27.3.5 TMJ Conditions That Can Aect Surgical Outcomes forCCWR
oftheMMC – 423
27.3.6 MRI Evaluation – 425
27.3.7 TMJ Disc Displacement – 425
27.3.8 Adolescent Internal Condylar Resorption (AICR) – 426
27.3.9 Reactive Arthritis – 426
27.3.10 Connective Tissue/Autoimmune Diseases – 427
27.3.11 Other End-Stage TMJ Pathologies – 427
27.3.12 Repositioning theMandible First withConcomitant TMJ Surgery
(Salvageable Discs) – 427
27.3.13 Repositioning theMaxilla First withConcomitant TMJ Surgery
(Salvageable Disc) – 427
27.3.14 Repositioning theMandible First withConcomitant TMJ Total Joint
Replacement – 428
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_27
27.4 Case 1 (. Figs.27.3, 27.4, and27.5) – 428
27.4.1 The Importance oftheArticular Disc inOrthognathic
Surgery Stability – 429
27.5 Case 2 (. Figs.27.11, 27.12, and27.13) – 429
27.5.1 Outcome Stability withTMJ Concepts Patient-Fitted Total Joint
Prostheses – 432
27.6 Summary – 433
References – 433
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
417
27
27.1 Occlusal Plane Alteration
The correction of dentofacial deformities often requires
double jaw orthognathic surgery to achieve a quality
functional and aesthetic result. An often ignored but
important cephalometric and clinical inter-relationship
in the diagnosis and treatment is the occlusal plane angle
(OPA). The OPA is dened as the angle formed by the
Frankfort horizontal plane (a line through infra-orbitale
tangent to the superior aspect of porion) and a line tangent to the cusp tips of the lower premolars and the buccal groove of the second molar (. Fig. 27.1). The
normal value for adults is 8 ± 4 degrees. An increased or
high occlusal plane angle (HOP) is reected in an
increased mandibular plane angle (dolichocephaly), and
a decreased or low occlusal plane angle (LOP) correlates
with a decreased mandibular plane angle (brachycephaly). The focus of this chapter will be on the HOP facial
morphology since it is commonly associated with sleep
apnea and will describe the diagnostic characteristics,
treatment protocols, and outcome results.
The traditional methods used by most clinicians for
surgical management of the OPA in double jaw surgery
are usually addressed by one of the following three
methods: (1) maintaining the presurgical OPA, (2) establishing the OPA by autorotation of the mandible (usually in an upward and forward direction) when correcting
vertical maxillary hyperplasia, or (3) selectively increasing the OPA relative to Frankfort horizontal plane
(FHP) to “improve stability” (regardless of the steep-
ness of the original OPA) by the posterior intrusion of
the maxilla and vertically shortening the posterior
height of the mandible. Although these methods may
achieve an acceptable relationship of the teeth in centric
relation, they may not provide the optimal functional
and aesthetic relationship of the musculoskeletal structures, dentition, and airway dimensions. As the OPA
increases in steepness and begins to approach the slope
of the TMJ articular eminence, certain functional problems can develop, including (1) loss of canine protected
occlusion, (2) loss of incisal guidance, and (3) development of working and nonworking posterior dental functional interferences. If the clinician believes in the
protected occlusion philosophy, there may be concern
over the application of the traditional treatment methods of increasing the angulation of the OPA in patients
that initially present with an HOP facial morphology.
In addition, the steepness of the OPA can have a profound adverse effect on the dimensions and volume of
the oropharyngeal airway. The steeper the OPA, there is
generally a reduction in the dimensions and volume of
the oropharyngeal airway that can contribute to upper
airway resistance syndrome and sleep apnea.
27.1.1 History
The philosophy and implementation of deliberate alteration of the OPA by counterclockwise rotation (CCWR)
or clockwise rotation (CWR) of the maxillomandibular
. Fig. 27.1 Cephalometric
analysis is an important aspect
for patient diagnosis and
treatment planning. An often
overlooked but essential
inter-relationship is the occlusal
plane angle (OPA) relative to the
Frankfort horizontal reference
plane. The OPA can have a
profound effect on jaw and
occlusal function, facial
esthetics, and airway. When
orthognathic surgery is
considered for a patient,
alteration of the occlusal plan
may be necessary to achieve the
best treatment outcome
Cephalometric Analysis
A. Maxillary Depth
90 + 2 degrees
B. Mandibular Depth
A
B
D
C
88 + 2 degrees
D. Occlusal Plane Angle
8 + 4 degrees
C. Mandibular Plane Angle
25 + 3 degrees
418
L. Wolford
27
complex (MMC) was developed by Wolford in 1981
with the rst known, successfully performed double jaw
CCWR of the MMC by vertical lengthening of the
posterior maxilla and mandible. This procedure was
done prior to the availability of rigid xation. The rst
published reference to the philosophy and surgical
planning of CCWR of the MMC was by Wolford etal.
[1] in 1985. The second reference to CCWR of the OPA
was by Wolford and Hilliard [2] in 1987 where the rst
known case to have CCWR of the MMC was published
(surgery performed in 1981). The patient’s surgery was
carried out specically to correct her severe sleep apnea
and severe facial deformity. Thus, the concept and
application of CCWR of the MMC as an effective
means to maximize functional, esthetic, and airway
outcomes in patients with HOP facial deformities was
introduced.
Wolford etal. [3, 4]. published detailed descriptions
of the clinical and radiographic characteristics of the
HOP facial type that could benet from CCWR of the
MMC, as well as presented the protocols for surgical
management. Kortebein and Wolford [5] in 1991 demonstrated the signicant and positive effect that
CCWR of the MMC had on increasing the oropharyngeal airway as well as the improvement of facial
balance in treating sleep apnea patients. Chemello
et al. [6] in 1994 published a comparative stability
study between CCWR and CWR of the MMC, demonstrating good stability for both in the presence of
healthy TMJs.
Nevertheless, postsurgical stability has remained a
major concern for CCWR of the MMC by many clinicians because of numerous reports of mandibular
relapse related to condylar resorption with simple surgical mandibular advancements, plus the misperceived
problems related to increasing the posterior facial
height; stretching of the suprahyoid, pterygoid, and
masseteric muscles; and adverse effects on the TMJs
[7–21]. It has been reported that the skeletal stability
after CCWR of the MMC is comparable to other mandibular surgical procedures [6, 22, 23], but to obtain
the acceptable level of stability after CCWR, appropriate preoperative orthodontic treatment, proper execution of the surgical procedures, and the presence of
healthy and stable TMJs are essential factors. But
Proft etal [24] found that surgically decreasing the
anterior facial height by CCWR of the mandible jeopardizes the stability of the results. However, with the
development of rigid xation, improvement in surgical
techniques, as well as recognition of preexisting TMJ
pathology and its appropriate management, CCWR of
the MMC has proved to be a very stable procedure [6,
22, 23].
27.2 Corrected Frankfort Horizontal Plane
There are often times when the cephalometric analysis
does not correlate to the clinical assessment of the
patient’s facial morphology. This can be related to an
aberrantly positioned FHP because of vertical malposition of porion or orbitale and/or anteroposterior
malposition of nasion compared to the “normal”
anatomy. In this situation, it can be helpful to reorient
the FHP (i.e., correct the FHP reference line) so that
the cephalometric values for maxillary and mandibular anteroposterior (A-P) positions correlate with the
clinical impression of the patient. This provides application of the normal cephalometric values to assist in
diagnosis and treatment planning (. Fig. 27.2).
Cephalometric analysis tempered with good clinical
judgment can be valuable tools in establishing the
most appropriate orthodontic and surgical treatment
plans.
Corrected Frankfort Horizontal
(CFH) so numbers correlate to
Clinical Evaluation
FH
CFH
10
. Fig. 27.2 The cephalometric analysis of numerical values in ref-
erence to the A-P projection of the maxilla and mandible may not
represent the clinical impression of the patient. In this situation, it
can be helpful to reorient the FHP (i.e., correct the FHP reference
line) so that the cephalometric values for maxillary and mandibular
anteroposterior (A-P) positions correlate with the clinical impression
of the patient. This provides application of the normal cephalometric values to assist in diagnosis and treatment planning
87
86
31
16
3
2
4
25
37
7
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
419
27
27.3 High Occlusal Plane (HOP) Facial Type
HOP facial morphological types are the most common
facial form associated with sleep apnea (. Figs.27.3a,b,
27.4a, b, and 27.5a). Common characteristics of the
HOP facial type generally include some or all of the following: (1) increased OPA (12 degrees or greater); (2)
increased mandibular plane angle; (3) anterior vertical
maxillary hyperplasia, and/or posterior vertical maxillary hypoplasia, as well as transverse hypoplasia; (4)
increased vertical height of the anterior mandible and/
or decreased vertical height of the posterior mandible;
(5) decreased projection of the chin (A-P microgenia);
(6) A-P and posterior vertical mandibular and maxillary
hypoplasia; (7) decreased angulation of maxillary incisors, although overangulation can occur; (8) increased
angulation of mandibular incisors; (9) occurrence of
Class II occlusion, which is common, although Class I
and Class III occlusions can also occur; (10) presence of
anterior open bite that may be accompanied by an
accentuated curve of Spee in the upper arch; (11) hypertrophied turbinates, septal deviation, and nasal airway
obstruction; (12) loss of incisal guidance, loss of canine
protected occlusion, and the presence of working and
nonworking posterior dental interferences in more pronounced cases in which the OPA approaches the slope
of the articular eminence; and (12) decreased oropharyngeal airway where the more severe cases may demonstrate moderate to severe sleep apnea symptoms as a
result of the tongue base and soft palate displaced posteriorly and constricting the oropharyngeal airway.
Normal oropharyngeal airway space measured from the
posterior pharyngeal wall to the soft palate and to the
base of tongue is 11±2mm.
27.3.1 Orthodontic Considerations forHOP
Facial Type
In the HOP facial type, decreasing the angulation of the
maxillary incisors below normal and increasing the
lower incisor angulation during the presurgical orthodontic phase may be indicated so that when the OPA is
decreased surgically, the same amount of angulation
change occurs with an increase in the maxillary incisor
angulation and a decrease in the mandibular incisor
angulation (. Fig.27.6).
If the maxilla is segmentalized at surgery in the HOP
facial type, then the presurgical orthodontic goals, relative to the maxillary incisor angulation, are not as critical as they are for a one-piece maxilla. If the maxilla is
sectioned bilaterally, between the lateral incisors and
canines, the following movements can be accomplished:
(1) optimal maxillary incisor angulation in the nal
surgical position; (2) adjustments for tooth size discrepancies between the maxillary and mandibular anterior
teeth; (3) corrections of transverse, vertical, and anteroposterior arch discrepancies; and (4) leveling the curves
of Spee and Wilson.
27.3.2 Surgical Decrease oftheOPA
In the HOP facial type, the indicated surgical correction
should include a CCWR of the MMC. In open bite
cases or deep bite cases, the maxillary OPA and the
mandibular OPA may be different from each other and
should be evaluated independently. For illustrative purposes, a Class I occlusion case is used with the maxillary
incisor edge as the center of rotation (. Fig.27.6). The
anatomical changes that occur with CCWR of the
MMC include the following: (1) OPA decreases; (2)
mandibular plane angle decreases; (3) maxillary incisor
angulation increases (the same amount of degrees that
the maxillary OPA decreases); (4) mandibular incisor
angulation decreases (the same amount of degrees that
the mandibular OPA decreases); (5) projection of the
chin increases relative to the lower incisor edges; (6) posterior facial height may increase; (7) prominence of the
mandibular angles may increase; (8) perinasal area
moves posteriorly relative to the maxillary incisor edges;
(9) incisal guidance and canine protected occlusion
improves, and posterior working and nonworking interferences are eliminated; and (10) oropharyngeal airway
increases.
The center of rotation affects the aesthetic relationship of the jaws with the other facial structures. If the
center of rotation is at the maxillary incisor edge, as in
.
Fig.27.6, the perinasal area, subnasale area, and the
nasal tip move posteriorly and the chin comes forward.
If rotation is around point A or higher, then the perinasal area and the nose are less affected, but the maxillary
incisor edges come forward, increasing the A-P support
to the upper lip, and the chin also comes further forward. When decreasing the OPA for CCWR and advancing the mandible, the oropharyngeal airway increases
substantially. There is a signicant aesthetic improvement that decreasing the OPA can make with the most
notable change in forward projection of the mandible
and chin.
27.3.3 Mandibular Surgery First:
Sequencing withHealthy TMJs
When the OPA is surgically decreased, it is usually easier
to perform the mandibular osteotomies rst, creating
bilateral posterior open bites as the posterior mandible
is moved downward and usually forward to its new posi-
420
ab
cd
L. Wolford
27
. Fig. 27.3 a This 18-year-old female with AICR demonstrates good frontal facial symmetry. b In prole, the retruded mandible and HOP
facial morphology are evident. c, d The patient is seen three years postsurgery demonstrating good facial balance
ab
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
421
27
a
b
cd
. Fig. 27.4 a, b The Class II end-on occlusal relationship is noted that has been getting progressively worse. c, d At three years postsurgery,
the patient is noted to have a good stable occlusal relationship
88
80
21
6
45
25 25
3
4
10
35
-1
5
8
1
1
1
3
5
18
. Fig. 27.5 a Presurgery cephalometric analysis demonstrates the
HOP facial morphology with the retruded mandible. b, the surgical
prediction tracing illustrates the counter-clockwise rotation of the
maxillomandibular complex as well as repositioning the articular
discs and augmentation genioplasty
27
422
L. Wolford
8°
. Fig. 27.6 For illustrative purposes, a Class I occlusion case is
used with the maxillary incisor edge as the center of rotation. The
anatomical changes that occur with CCWR of the MMC include the
following: [1] OPA decreases; [2] maxillary incisor angulation
increases (the same amount of degrees that the maxillary OPA
decreases); [3] mandibular incisor angulation decreases (the same
amount of degrees that the mandibular OPA decreases); [4] projection of the chin increases relative to the lower incisor edges; and [5]
perinasal area moves posteriorly relative to the maxillary incisor
edges
16°
tion with an intermediate surgical splint. Although
many surgeons prefer to perform the maxillary osteotomies rst, this sequencing makes the surgery much more
difcult as then a signicant anterior open bite must be
developed as the posterior maxilla is repositioned downward to its new position, rotating the mandible downward and backward with the intermediate splint creating
a substantial anterior open bite. Then, the mandibular
osteotomies are completed, but the subsequent CCWR
of the mandible and application of MMF may place
excessive stress on the maxilla and could cause some
maxillary displacement, even in the presence of rigid
xation, resulting in a suboptimal outcome.
Thus, sequencing the mandible rst can be a signicant advantage for CCWR procedures and would progress as follows in the presence of healthy TMJs: (1)
bilateral mandibular ramus sagittal split osteotomies
and removal of third molars if present; (2) application
of intermediate splint and MMF; (3) application of
mandibular rigid xation; (4) removal of MMF and
intermediate splint; (5) maxillary osteotomies, mobilization, removal of third molars if present, segmentation if
indicated, and application of palatal splint; (6) intranasal partial turbinectomies, septoplasty, etc., if indicated;
(7) maximization of occlusal t and placement of MMF;
(8) application of maxillary rigid xation and bone
grafting if indicated; (9) removal of MMF; and (10)
ancillary procedures if indicated such as genioplasty
and rhinoplasty.
When the OPA is decreased, it is much easier to set
the mandible rst into its nal position, with bilateral
mandibular ramus sagittal split osteotomies, creating
bilateral posterior open bites. An intermediate splint
will align the mandible in its new position, and then
rigid xation is applied to the mandible. Usually a sixhole Z-plate with 2-mm-diameter monocortical screws
provides adequate stability for mandibular setbacks
and for most mandibular advancements (.
Fig.27.7).
However, for large advancements, one or two bone
screws can be placed in the ascending ramus for additional stability. Performing the mandibular surgery rst
makes the maxillary surgery much easier with better
positional accuracy. Stabilization of the maxilla is
achieved with four bone plates and grafting with bone
or porous block hydroxyapatite to ll any osseous
defects. In some cases, the vertical height of the ramus
may be increased. However, because most of the cases
requiring CCWR are skeletal and occlusal Class II malocclusions, the distal segment moves inferior but anterior to the pterygoid- masseteric sling. In Class III HOP
skeletal and occlusal relations, because the ramus portion of the distal segment must move down through the
sling, the pterygoid- masseteric sling can be split to
allow the posteroinferior aspect of the distal segment to
rotate down through the sling. The bone eventually
remodels back up to the height of the sling. With these
techniques of CCWR of the MMC, the muscles of
mastication are not lengthened and remain in their
original positions. Rigid xation eliminates the requirement for postsurgery MMF, and usually light-guiding
elastics are all that are necessary to control the occlusion after surgery.
27.3.4 TMJ Evaluation andTreatment
Considerations
Evaluation of the status of the TMJs before surgery is
very important for outcome stability, particularly when
surgery is contemplated to decrease the OPA.Surgical
distal segment
Counterclockwise Rotation of the Maxillomandibular Complex for the Correction of Dentofacial…
423
27
Bony
interface
. Fig. 27.7 The Wolford modication of the mandibular ramus
sagittal split osteotomy maximizes the bony interface between the
proximal and distal segments, provides a vertical stop between the
CCWR of the MMC lengthens the functional moment
arm (mandible), thereby increasing loading to the TMJs
as a result of stretch and tension of the suprahyoid
muscles, periosteum, skin, and other soft tissue elements. It may take several months for the soft tissues to
adapt and reestablish a state of equilibrium. If the
TMJs are healthy and stable, they should be able to
withstand the increased loading through the adaptation
phase. If TMJ pathology is present, then skeletal and
occlusal stability are at risk. Comprehensive assessment
and appropriate management of patients with preexisting TMJ disorder is so important so that the joints can
be properly treated and will be stable when the surgery
is completed.
Al-Moriassi and Wolford [22] published a systematic review and meta-analysis comparing the stability
of CCWR to CWR in the correction of dentofacial
deformities and showed that these techniques are
equally stable and predictable orthognathic surgical
procedures when the TMJs are healthy and stable. In
the presence of uncorrected TMJ pathology, orthognathic surgery outcomes for CCWR or CWR may be
unpredictable relative to stability, function, and pain
factors.
Al-Moriassi and Wolford [23] also publish a systematic review and meta-analysis comparing outcome sta-
6-Hole
Z-plate
Inferior border
cortical bone
segments, and allows the application of a six-hole Z-plate to stabilize
the segments
bility of CCWR of the MMC in the presence of healthy
TMJs or pathological TMJs. The result of this metaanalysis suggests that the CCWR of the MMC is a stable procedure for patients with healthy TMJs and
patients undergoing concomitant TMJ reconstruction
with the Mitek anchor technique or patient-tted total
TMJ prostheses. Surgical results may be unstable in the
presence of untreated TMJ disc displacement and when
TMJ status is not assessed.
27.3.5 TMJ Conditions That Can Aect
Surgical Outcomes forCCWR
oftheMMC
Temporomandibular joint (TMJ) disorders or pathology and dentofacial deformities commonly coexist. The
TMJ pathology may be the causative factor of the jaw
deformity, or develop as a result of the jaw deformity, or
the two entities may develop independent of each other.
Common TMJ pathologies that can coexist with or create HOP facial morphologies include (1) articular disc
dislocation; (2) adolescent internal condylar resorption
(AICR); (3) reactive arthritis; (4) condylar hyperplasia;
(5) ankylosis; (6) congenital deformation or absence of