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45. Hwang JJ, Kim KD, Park H, Park CS, Jeong HG.Factors inuencing superimposition error of 3D cephalometric landmarks by plane orientation method using 4 reference points: 4 point superimposition error regression model. PLoS One. 2014;9(11):e110665.

46. Lagravère M, Major P, Carey J.Sensitivity analysis for plane orientation in three-dimensional cephalometric analysis based on superimposition of serial cone beam computed tomography images. Dentomaxillofac Radiol. 2010;39:400–8.

47. Nada RM, Maal TJ, Breuning KH, Bergé SJ, Mostafa YA, Kuijpers-Jagtman AM. Accuracy and reproducibility of voxel based superimposition of cone beam computed tomography models on the anterior cranial base and the zygomatic arches. PLoS One. 2011;6(2):e16520.

48. LeCun Y, Bengio Y, Hinton G.Deep learning. Nature. 2015;521(7553):436–44. https://doi.org/10.1038/

nature14539.

49. Schwendicke F, Samek W, Krois J. Articial intelligence in dentistry: chances and challenges. J Dent Res. 2020;99(7):769–74. https://doi.

org/10.1177/0022034520915714.

50. Schwendicke F, Golla T, Dreher M, Krois J. Convolutional neural networks for dental image diagnostics: a scoping review. J Dent. 2019;91:103226.

51. Schwendicke F, Chaurasia A, Arsiwala L, Lee J-H, Elhennawy K, Jost-Brinkmann P-G, Demarco F, Krois J. Deep learning for cephalometric landmark detection: systematic review and meta-analysis. Clin Oral Investig. 2021;25(7):4299–309.

52. Walsh T. Fuzzy gold standards: approaches to handling an imperfect reference standard. J Dent. 2018;74(Suppl 1):S47–9.

Orthodontic Treatment Principles

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inCraniofacially Malformed Patients Prior toOrthognathic Surgery

BernhardWiechens andPhillippBrockmeyer

Primary Aims ofOrthodontic Treatment

In skeletal dysgnathia, the maxillary and mandibular jawbones are likely to deviate in sagittal, transversal, and vertical dimensions. To maintain a sufcient masticatory function, dental compensation develops. To reach the best possible individual skeletal adjustment during surgery, a solitary integration of the dento-skeletal relation of each jaw is required to be created [1]. Therefore, the primary aim of orthodontic treatment prior to orthognathic surgery is a decompensation to optimize the dental archshape in all dimensions [2].

However, during this period, an optimal occlusion is not present, and certain tooth movements can be performed quite easily during the initial postoperative period [2]. These mainly include vertical adjustments, such as leveling the Spee curve in a former deep-bite conguration [3–5].

Transversal deviations, such as lateral crossbites or nonocclusions as well as an initial extremely small maxillary intercanine distance, should be

B. Wiechens Department of Orthodontics, University Medical Center Göttingen, Göttingen, Germany e-mail: bernhard.wiechens@med.uni-goettingen.de

P. Brockmeyer (*) Department of Oral- and Maxillofacial Surgery, University Medical Center Göttingen, Göttingen, Germany e-mail: phillipp.brockmeyer@med.uni-goettingen.de

corrected by means of a surgical palatal expansion [6]. Special emphasis must be laid on the recurrence tendency in such cases [6]. Retention of the transversal expansion can be accomplished during the decompensation period. A further securing of the transversal dimension after bracket removal and completion of therapy is then not necessary.

The freedom experienced after a transversal expansion is of particular advantage for the subsequent sagittal bite shift; however, it is oftentimes restricted by extremely narrow dental arches in the anterior region and requires a certain willingness to compromise. After the establishment of a correct unimaxillary anterior relation in each case, the transversal relation is dened as the second essential determinant for the subsequent surgical expansion of the patient.It thereforeshould be a crucial matter with regard to preoperative orthodontic treatment [6].

Owing to the high degree of individuality, there is no uniformity concerning the duration of orthodontic decompensation. However, a preoperative period of 12months has been noted to be sufcient in most instances [2].

As patients exhibit a marked reluctance to undergo treatment from 6 months postoperatively, the period of postoperative orthodontic adjustment must as well be considered during primary planning. Therefore, it is advisable to plan only residual tasks for the postoperative procedures that can be implemented after a maximum of 6months [7].

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Therapeutic Incisor Relationship

For planning the entire treatment, the right position of the incisors is of particular importance because of the organism’s ability to compensate for skeletal deviations in sagittal and vertical directions primarily through their inclination [8, 9].

In addition, the incisors are partially subject to dysplastic effects due to atypical muscle functions and habits. Itemization is essential in this context, especially for conservative, purely appliance- based therapeutic approaches [10, 11]. As orthognathic therapy is typically accompanied by a drastic change in soft tissue function after previous skeletal discrepancy, functional reorientation to physiological movement is difcult [12]. Therefore, the main focus lies on tongue dysfunctions, whose therapy should be adjuvant throughout the treatment approach [12].

In principle, patient’s individuality must be considered in any orthodontic intervention, especially concerning surgical support. Thus, in addition to dental space conditions and axial incisor-inclinations, it is primarily the skeletal conguration of the patient that determines the individually correct incisor relation. In this regard, the regression analysis according to Segner and Hasund allows an individual determination [13].

As only adult patients should be subjected to orthognathic surgery in whom residual growth can be excluded as far as possible [14, 15], a target for reconstructivejaw displacement in correct incisor relation is necessary. This should be determined before starting the therapy, after analysis of the individual dysgnathic cephalometry.

Disregarding this basal relationship often leads to compromise conditions, when occlusal reconstruction is performed to guide skeletal displacement [16]. In unimaxillary treatment planning, however, the individual base relation to be aimed for can be achieved more easily by referring to the sagittal face type, since an unoperated reference jaw is available.

In pronounced cases with sagittal and vertical hyperdivergent jaws however, bimaxillary approaches are often unavoidable and involve a

considerable modication of the face type. As a rule, orthognathic face types have a neutral jaw relation at an ANB above 0° and under 4°, whereas retrognathic face types have a neutral ANB above −2° and under 2°, and prognathic face types have a neutral relation at 2° < ANB < 6°. If, for example, a dysgnathic patient shows a natural positioned and inclined maxilla in neutral vertical relation, a bilateral sagittal split osteotomy with therapeutic occlusal reconstruction to an ANB ranging of 2°±2°, is most likely the goal for the patient. Again, the calculation of maxillary and mandibular incisor relation through regression analysis can contribute to treatment accuracy [13].

This approach is more complex for patients with a prognathic face type and clearly negative sagittal jaw relation, since the degree of prognathism of the maxilla must increase and that of the mandible must decrease. In addition, the individual conguration of the patient regarding nutritional status, conguration of the naso- and oropharynx, and sleeping and snoring behavior must be taken into account to decide which degree of backward displacement is tolerable [7, 15, 17–19].

Furthermore, an adjuvant functional genioplasty may be indicated, which in turn could modify the distance ofPgNBmm and would have to be considered for the planned incisor position [13]. Lastly, it must be decided under special consideration of the vertical interbasal relation and individual tooth and gum display, whether a rotation of the jaw or of the entire maxillomandibular complex will be necessary, which will also affect the target-incisor relation [20].

All therapies then have in common whether a planned incisor relation can be realized without further ado based on the jaw target relation, or whether additional space-creation through extractions or proximal enamel reductions are essential in the presence of Tonn and Bolton discrepancies. The previously necessary overcorrection of the mandibular incisor position in advancement cases involving intermaxillary xation, can be avoided with modern plate osteosynthesis, since no or only slight pressure is exerted on the dentition[2].

However, to ensure the best possible freedom for mandibular positioning, generous adjustment

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of themaxillary intercanine distance isadvisable [21, 22]. Regarding the ever-emerging “surgeryrst” treatment option, faster treatment with the regional acceleratory phenomenon at the osteotomy margins and a thus accelerated tooth movement is discussed under the previously reported views of Proft etal. In addition, a more satised patient attitude is mentioned because one’s dysgnathia would be treated faster with shorter total treatment time [23].

Also, surgery-rst concepts often entail segmental surgery, which is per se riskier and technically more demanding. In addition, postoperative orthodontics is more difcult because additional decompensations are often required, sometimes with the obligatory use of temporary bone anchors. Regarding supposedly higher patient satisfaction, it can be said that this is primarily modulated by the duration of postoperative orthodontics. In their study, Kiyak etal. observed a tolerance range of 6months [7]. From this point forward, the patient’s satisfaction level decreased signicantly, which is a fundamental problem for the surgery-rst approach, as a postoperative orthodontic period of 9–12 months is required in most cases. To date, there is insufcient data to support the postulated benets of surgery-rst approaches, as often only moderate- or poor- quality treatment outcomes or studies of moderate or low merit are presented. Rather, patients with pronounced crowding and deep-bite congurations may be contraindicated [24]. Nevertheless, a recent systematic review emphasized the impact of rapid and positive soft tissue change on quality of life, which certainly needs to be discussed in this context [25]. On a global level, it can be stated that the safe conservative approach is still preferred [26].

Stages ofOrthodontic Treatment

During the orthodontic decompensation period, an initial planned dento-skeletal relation is created in each jaw, which allows an individual optimal skeletal reconstruction during surgery.

The patients’ cephalometry is decisive in determining the individual need for displacement, according to which dentoalveolar shaping

is planned. In addition to the important axial position of the incisors, planning regarding the leveling tasks is of vital importance. In this context, tooth extrusions can beperformed more easily after surgery, whereas intrusions should be performed priorto surgery.

The greatest challenges surface through leveling a pronounced Spee curve in low-angle cases or hyperdivergent dentition in high-angle cases. Generally, for decompensation of the rst case, there is either an incisor intrusion or a premolar extrusion. The decisive factor for the therapeutic objective in this case is the desired subsequent facial height. In patients with a reduced lower facial height or generally brachyfacial cranial structure and deep bite, additional stretching of the facial vertical dimension is required [2, 27] (Fig.12.1).

If this is moderate, a combination of postoperative lateral bite elevation by subsequent leveling and preoperative discreet intrusion of the incisor block is also conceivable. This requires a segmental arch technique (Fig.12.2).

Isolated anterior intrusion for leveling purposes would allow a deeper jaw-positioning in the rst case and thus accommodate postoperative bite deepening. For this reason, shifting the leveling task to the postoperative phase seems advantageous, but this does not imply less effort during the preoperative phase (Fig.12.3). In this case, the vertical and anteroposterior incisor positions must be initially set and maintained during shaping of the entire dental arch [27]. The sagittal and transversal alignment of the dental arch is performed in parallel. The implementation of this concept is not possible without modifying the established straight-wire technique. Therefore, vertical steps must be incorporated into all orthodontic wires until the surgical arch conguration is achieved. For this reason, the surgical splint design appears more voluminous in the support zone than in the anterior and posterior regions.

Subsequent to surgery, inverse-Spee wires can be inserted as soon as the general conditions of the patient allow for rapid leveling of the premolar segment, whereby the premolar extrusion proceeds clinically at a conspicuous speed. This clinical phenomenon may be explained by

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b c d

efg

Fig. 12.1 Clinical and radiological representation of a female patient at initial diagnosis. Segments (a and b) illustrate the frontal appearance in habitually closed (a) and smiling mouth posture (b) with signs of a brachycephalic craniofacial structure, a shortened lower face height, and a disturbed dentolabial relationship with lower lip interposition. Segment (c) displays the lateral appearance with additional indication of a sagittal dysgnathia consistent to a receding chin. Segment (d) reveals the corresponding lateral cephalogram with an orthognathic maxilla in ortho-inclination according to SNA (83.7°) and a borderline orthognathic

mandible in ante-inclination according to SNB (77.5°) and ML-NSL (23.6°), respectively. Sagittal interbase relation shows a marked retrognathia according to ANB (6.2°) and Wits (5.0 mm). Vertically, a deep relation according to interbase angle (12.7°) with a corresponding lower anterior inferior facial height (Index= 100.6%) can be found. Segments (e, f) and (g) show the patient’s intraoral conguration at habitual intercuspation in frontal, right-lateral, and left-lateral projection, respectively. In addition, a corresponding retral occlusal position with deep anterior relation along with elongation and protrusion of the upper incisal segment can be seen

Fig. 12.2 Illustration of intrusion base arches used in this case. Maxillary, a three-piece intrusion mechanic, was applied for maximum control of intrusion force and direction. The lower dentition was also treated with an additional intrusion base arch, but a full wire with posterior

the interplay of various effects, such as vertical occlusal decoupling, vertical elastics applied in

steps was applied parallel to control the amount of leveling in the posterior segment while delivering discreet intrusion for the incisors. The main leveling task was planned to execute after surgical treatment to gain additional anterior face height

addition to arch-guided extrusion (Fig.12.4), and healing-induced stimulation of bone metabolism.

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Fig. 12.3 The same patient after systematic orthodontic decompensation. Segments (a-c) show the soft tissue conguration in frontal-habitually closed (a), frontal-smiling(b) and lateral- habitually closed mouth posture (c). In particular, segment b reveals the extent of upper incisor intrusion after applied intrusion mechanics, with special attention to gum and tooth display. Segment (d) displays the lateral cephalogram with ortho-axial relationships of

the incisors to the corresponding jaws regarding long axis angle of maxillary incisors to the nasion-sella line (99.8°) and long axis angle of mandibular incisors to the mandibular plane (93°). Segments (e, f) and (g) show the patient’s intraoral conguration during habitual intercuspation in frontal, right-lateral, and left-lateral projections, respectively. In addition, the advised maintenance of the Spee curve can be observed (e–g)

Fig. 12.4 Same patient 11 days after bilateral sagittal split osteotomy with adjuvant genioplasty. Intermaxillary elastics for postsurgical leveling are applied with adjuvant

consideration of the dental midline (e–g). Images a–d highlight the well-balanced soft and hard tissue reintegration

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Fig. 12.5 Clinical and radiological presentation of the patient at nal evaluation. Segments (a and b) illustrate the frontal appearance in habitually closed (a) and smiling mouth posture (b) with reintegration of the vertical cranial proportion through increase of the lower facial height and adjustment of the dentolabial relation through systematic orthodontic decompensation. Segment (c) displays the lateral appearance with signicant rehabilitation of the mandibular retrognathia and facial proportion. Segment (d) shows the corresponding lateral cephalogram with an orthognathic maxilla (SNA= 83.7°) in ortho-inclination

(NL-NSL= 11.1°) and an orthognathic mandible (SNB=

81.5°) in ortho-inclination (ML-NSL= 35.1°). The sagittal interbase relation shows a neutral conguration (ANB=

3.9°; Wits= 0.9 mm). Vertically, a neutral relation (interbase angle= 21.4°) with a corresponding neutral inferior facial height (ratio= 84.9%) can be seen. Segments (e, f) and (g) show the patient’s intraoral conguration during habitual intercuspation in frontal, right-lateral, and leftlateral projections, respectively. A neutral occlusal position in centric condylar relation could be achieved. Bracket debonding was performed 3 months after surgery

First, the decoupled occlusion of the premolar area is probably of particular importance, as it permits leveling with minimal interference and resistance. Compared with leveling tasks in isolated orthodontic approaches, postoperative extrusion is, therefore, particularly rapid, which means that leveling can be completed after only 2–3months [3, 5] (Fig.12.5).

Furthermore, the initially deected anti-Spee wire receives additional support from the intermaxillary elastics, which, in addition to their vertically directed force vector, may have a preventive effect regarding any cheek or tongue interposition. The regional acceleratory phenomenon, according to Frost [28], which is often cited as the primary explanation for accelerated

tooth movement and is observed in proximal bone healing processes, is not undisputed in connection with ramus osteotomies.

The reason for the rejection as an explanatory approach in postoperative tooth movement, is the topography of the osteotomy line, which is perceived as too peripheral for the phenomenon to occur. Therefore, Proft etal. [2] consider regional acceleration due to bone remodeling after ramus osteotomy to be unlikely. On the other hand, it can be assumed that there is a generally higher metabolic activity due to the surgical intervention and the subsequent healing phase, which may ultimately also be reciprocally related to tooth movement.

In addition to orthodontically guided leveling, surgical approaches via subapical osteotomies

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for intrusion of the anterior segment are also described. However, these should be reserved for severe cases and are generally not used for dentoalveolar leveling of the mandible.

The same applies to segmental osteotomies for maxillary leveling, where it is essential to ensure segmented leveling of the anterior and lateral segments, as the slightest appliance-induced anterior extrusions would undermine the desired decompensation and could thus promote a postoperative recurrence with bite opening.

Furthermore, surgically guided leveling of the maxilla may require additional bone, further complicating an already extensive procedure. In addition, wound healing problems, risk of pseudarthrosis, and general risk of infection must be considered with these approaches. Therefore,we, refrain from segmented approaches and focus on the best possible dentoalveolar decompensation with the possible aid of temporary skeletal anchorage devices.

Archwires

After successful orthodontic decompensation, the actual preoperative occlusion can be assessed using situation models. These models are primarily used for guiding the decompensation measures performed and ascertaining whether the primary planned target occlusion can be freed from sliding obstacles.

Although many cases involve trivial rotations and only minor alignment decits that can be corrected within a short period, difculties arise in positioning the target occlusion when the intercanine relationship is extremely tight. For example, to correct an Angle class II occlusion, repositioning may not be to the desired degree, or the orthodontist may even be tempted to overcorrect it mesially, which can lead to postoperative problems or even require surgical reintervention.

Another issue is the insufcient leveling of second molars, which represents a signicant movement restriction in transversal, sagittal, and vertical repositioning due to over-exposition.

In addition to the reconstruction of the sagittal bite position, supraposition often leads to impaired anterior support or reduced rotational freedom of the mandible in the presence of asymmetries. For this reason, consideration should be given to the inclusion and correct preoperative adjustment of the second molars while considering the intercanine distance of the maxilla, which in many cases is provided with an additional offset. If the desired target occlusion can be achieved as early as 6weeks before the planned surgical procedure, the condition should be maintained with high-dimension steel arch-wires.

This primarily considers the precision requirements of the planning models prior to reconstructive surgery, as it must already be assumed that the appliance will be passive during impressiontaking. This is the only way to ensure an optimum t of the splints for thesurgical procedure. Depending on the system used, different rectangular dimensions are recommended for this purpose. A minimum dimension of 0.016×0.022mm steel for the 18-slot appliance and 0.019×0.025mm steel for the 22-slot appliance is well suited. Higher dimensioned arch- wires, such as the 0.017×0.025mm steel in the 18-slot or the 0.021×0.025mm TMA in the 22-slot, are also conceivable.

However, an improved torque transmission in the anterior region must be expected, which requires more time, that in turn is opposed to a completely passive appliance at the time of surgery. On the day of inpatient admission, i.e., 1day prior to the surgery, the t of the surgical splints is checked and hooks for intermaxillary xation are attached on the intebracket arch-wire segments or vestibular attachments for lingual appliances and aligners. These auxiliary elements should not be attached at an early stage because, on the one hand, soft tissue irritations have been reported despite gingival adaptation of the hooks, and, on the other hand, excessive clamping of the hooks can plausibly give rise to unwanted bending of the arch-wire, which is particularly important with larger bracket spacing. However, it should be emphasized at this point that the use of movable hooks must be avoided.

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References

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3. Sabri R. Orthodontic objectives in orthognathic surgery: state of the art today. World J Orthod. 2006;7:177–91.

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org/10.1371/journal.pone.0210461.

10. Proft WR. Equilibrium theory revisited: factors inuencing position of the teeth. Angle Orthod. 1978;48:175–86.

11. Bowden BD. A longitudinal study of the effects of digit- and dummy-sucking. Am J Orthod. 1966;52:887–901.

12. Foletti J-M, Antonarakis GS, Galant C, Courvoisier DS, Scolozzi P. Is atypical swallowing associated with relapse in orthognathic patients? A retrospective study of 256 patients. J Oral Maxillofac Surg. 2018;76:1084–90. https://doi.org/10.1016/j.

joms.2017.09.007.

13. Segner D, Hasund A.Individualisierte Kephalometrie. Hamburg: Segner; 2003.

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org/10.1016/j.bjoms.2015.07.004.

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Orthodontic Therapy

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intheContext ofOrthognathic Surgery

WernerSchupp, JuliaFunke, andJuliaHaubrich

Introduction

Algorithm ofOrthodontic Treatment inOrthognathic Surgery (OGS) Patients

For any orthodontic therapy which includes the combined orthodontic-orthognathic surgery treatment, there is an existing algorithm for the procedure of diagnosis, treatment planning, and treatment itself (Fig.13.1) [1]. Functional analysis should always be the starting point in orthodontics [2]. In case a pathology is detected in the temporomandibular system (TMS), a pre-

treatment by means of an occlusal splint is obligate. In certain cases, supportive manual therapy is indicated [3]. Obvious dental inammation needs immediate primary care. After functional therapy has been successful and no temporomandibular disorder is present, esthetic analysis follows.

At the same time, exact biological diagnosis is carried out. If there are signs for caries or inammation of periapical or periodontal tissues, the patient will be referred to a specialist. Finally, structural analysis with the treatment planning of combined orthodontic therapy and orthognathic surgery is conducted.

W. Schupp (*) · J. Funke · J. Haubrich Private Practice of Orthodontics and Orofacial Orthopaedics, Köln, Germany e-mail: schupp@schupp-ortho.de;

funke@schupp-ortho.de; haubrich@schupp-ortho.de

https://doi.org/10.1007/978-3-031-28069-6_13

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