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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4496_Библиотеки_им_академика_М_И_Перельмана
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W. Schupp et al.
Diagnosis
Functional Analysis1
2
Esthetic Analysis
Biological Analysis
3
Structural Analysis
4
1: Periodontics/ Endodontics/ Restorative Dentistry not needed
2: Determination of Treatment Goal after Periodontics/ Endodontics/ Restorative Dentistry
Fig. 13.1 Algorithm of orthodontic treatment in orthognathic surgery
Planning if: Treatment
craniomandibular/
musculoskeletal Dysfunction
esthetic deficiency
Disease of;
•
Periodont
•
Endodont
•
Enamel / Dentin
•
Malposition of Teeth
and Jaws
Functional Treatment
Determination of
treatment goal:
Virtual Treatment Simulation
in Aligner Orthodontics and
Orthognatic Surgery
Parodontology/
Endodontology/
Restorative Dentistry
Orthodontics and
Orthognatic Surgery
2
1
Diagnosis Principles
Anamnesis
Careful patient anamnesis is the most important
procedure performed by the dentist in order to
nd out about risk factors and expectations
towards treatment. More than 99% of all relevant diseases are revealed through this simple
procedure. For orthognathic surgery patients,
anamnesis can roughly be divided into two main
parts [4]:
• Family anamnesis: reveals hereditary diseases
as well as familiar dispositions (e.g., dysgnathia, diabetes mellitus, bleeding tendency)
• Personal anamnesis: focuses on present and/
or earlier common diseases, surgical intervention, and vaccination as well as on special
problems within the orofacial system: dental
therapy in the past such as orthodontic treatment, surgical treatment, endodontic or peri-
odontal treatment, problems with the
temporomandibular joints, and posture
problems
Diagnosis ofFunction
The diagnosis of function starts with a short screening test (SST) modied after G.Meyer (Fig.13.2).
If temporomandibular disorders go undetected,
they may negatively affect the course of restorative,
orthognathic, and/or orthodontic treatment, which,
ultimately, could lead to treatment failure. Due to
the high scientic validity of this test and to its
excellent clinical performance in our experience,
we recommend its use as a standard tool for initial
TMD screening of all patients. Such TMD screening is essential in all cases, not only in those where
restorative or orthodontic treatment is planned, but
also for forensic reasons.
This screening instrument consists of a battery
of six easy-to-perform clinical tests, each of
which requires a simple YES or NO response.
The six test items are as follows:
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a
Os temporale
Caondyle
c
inner rotation
b
Fig. 13.2 (a) The occlusal contacts are equal on both
sides with a physiological TMJ and temporal bone; (b)
occlusal contact in a physiological condyle position only
on the left with a lack of posterior support on the right; (c)
1. Asymmetrical mouth opening Ye s No
2. Limited mouth opening Yes No
3. Traumatic eccentric occlusion Ye s No
4. Joint sounds Yes
5. Pain on muscle palpation Ye s No
6. CR = or # CO (cotton roll test) Ye s No
Positive if 2 or more yes
No
1. Asymmetrical mouth opening
This test item is used to assess whether
mouth opening is symmetrical or asymmetrical check relative to the tip of the chin, as
determined using a ruler. If an S-shaped curve
with more than 2 mm deviation from the
straight line (deviation) or one-sided deviation (deection) is observed, then the test
result for this item is positive.
in habitual occlusion, the patient has occlusal contacts
right and left with a compression of the TMJ on the right
and an inare of the temporal bone
2. Limited mouth opening
From a functional point of view, the causes
of limited mouth opening may be of either
myogenic or arthrogenic origin. Normal mouth
opening is dened as an incisal edge distance
(IED) of 40mm during maximum mouth opening. IED measurement is performed using a
ruler or two nger widths by a clinician who
has performed such measurements previously.
Measurements in patients with severe overbite
or open bite should be corrected as needed. If
the IED is less than ca. 40mm, the test result
for this item is positive.
3. Traumatic eccentric occlusion
To assess the mobility of the mandible, the
patient is asked to move the lower jaw to the
right, left and forward in any given order. The
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W. Schupp et al.
patient is then asked if any of these eccentric
movements caused pain. If this is the case
and/or eccentric movement in one of the
above directions is not possible, the test result
for this item is positive.
4. Joint sounds/pain
The examiner asks if the patient has noticed
any clicking sounds or other noises or pain in
one or both jaw joints, and palpates the lateral
condylar poles during mouth opening movement while looking for signs of pain and joint
sounds (clicking or friction). If one of these
risk factors is found, the test result for this
item is positive.
5. Pain on muscle palpation
Neuromuscular discoordination plays a cen-
tral role in temporomandibular joint dysfunction. Neuromuscular coordination decits
usually lead to masticatory muscle hyperactivity, which results in clinical manifestations
such as muscle tension and pain, which generally tends to be asymmetrical. The affected
patients frequently complain of teeth clenching
and grinding. With TMD check, simple digital
palpation tests are used to examine easily
accessible muscles that are representative of
muscular function in the craniomandibular system. The main muscles tested are the masseter
(origin and approach), temporalis anterior, M.
sternocleidomastoid, and M. trapezius, which
are palpated pairwise for assessment and sideto-side comparison. Palpation is performed
with the patient’s head in a relaxed position.
The test is positive if there are any ndings of
asymmetric muscle pain, tension, hardening,
and/or marked hypertrophy.
6. CR=or # CO (cotton roll test)
The cotton roll test (CRT) may be used to
determine whether physiological centric relation (CR) is equal to or not equal to centric
occlusion (CO). The procedure is detailed
below:
Patient sits or stands upright and bites into
maximum intercuspation; he demonstrates
which teeth are in contact here. We block
the occlusion with two cotton rolls between
the rst premolars on the right and left, on
which the patient closes loosely for 5min.
We take out the cotton rolls; the patient
bites again easily and demonstrates where
he now feels contacts. If the patient comes
into the same contacts both times, this is an
indication that CR and CO are the same. If
the patient indicates different contact
points the second time, this is an indication
of CR # CO (positive test) [5].
Any dental treatment, orthodontic treatment, and OGS are also based upon the
centric relation, not upon the habitual
intercuspation.
If we nd two or more positive results in the
SST, a detailed functional examination follows:
Examination of mandibular mobility
During examination of the mandibular mobility, the
following parameters should be documented:
• Incisal edge distance (IED), specication
in millimeters (minimum 40mm)
• Lateral movement of the mandible to the
right and left, specication in millimeters
(minimum 10mm)
• Protrusion of the mandible, specication in
millimeters (minimum 10mm)
• Mouth opening symmetry/asymmetry
• Deviation
• Deection
The temporomandibular joints (TMJ)
The temporomandibular joints are palpated on
their lateral aspect and on their dorsal aspect
(from the inner ear canal) of which the second is the more important examination.
During examination of the temporomandibular joints, the following parameters should be
documented:
• TMJ sound
– Clicking
– Crepitation
• Pain on palpation lateral and more important intra-auricular, specication: x moderate pain, xx pain, and xxx severe pain
• Symmetrical movement of right and left
condyle
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Examination of the musculature of the CMS
When diagnosing chewing muscles, the follow-
ing parameters should be documented:
• Muscle pain, specication: x moderate
pain, xx pain, and xxx severe pain
• Trigger points:
– Localization
– Referred pain
As a standard, we examine the following chew-
ing muscles: masseter muscle; medial (internal) pterygoid muscle; tendon of the
temporalis muscle in front of lateral (external)
pterygoid muscle; temporalis muscle (anterior; medialis; posterior); digastric muscle;
sternocleidomastoid muscle; trapezius
muscle
Examination of occlusal contacts in habitual
intercuspation, in centric occlusion, and in
dynamic occlusion
When examining the occlusal contact points, the
following parameters should be documented:
• Occlusal contacts in maximum habitual
intercuspidation
• Contacts in a more physiologic condyle
position (cotton roll test)
• Contacts in dynamic occlusion:
– Protrusion (incisor guidance)
– Excursion to right (canine guidance;
balance contacts on non-working side)
– Excursion to left (canine guidance; bal-
ance contacts on non-working side)
End Feel Test
During examination of the end feel, the following
parameters should be documented:
• Quantity (extend) of the end feel
• Quality of the end feel—physiological or hard
• Pain
Joint Play Test forTraction
andCompression
The joint play test is an additional diagnosis and
not a part of the diagnosis sheet. In some patients,
the joint play test is useful and sensitive to diagnose joint pathology.
Facial Symmetry
When examining the facial symmetry, the following parameters should be documented:
• Symmetry of the face (Fig.13.3a–c)
• Vertical
• Horizontal [2]
Often, a cone beam computed tomography
(CBCT), gold standard for 3D examination of
bone, or an MRI, gold standard for 3D examination of soft tissue, in this case especially the discus articularis, is necessary for the nal
diagnosis.
Diagnosis ofEsthetics (Fig.13.4a–e)
The esthetic analysis forms the basis in planning
esthetic aspects of therapy.
The esthetic analysis begins with the assessment of the position of the maxillary central incisors in relation to the upper lip, which should
ideally show about 2 mm visible tooth in rest
position. The relation of the visible tooth surface
to the upper lip can be inuenced with orthodontic measures.
This is followed by the examination of the
dental upper midline in relation to the middle of
the upper lip, here the philtrum. A shift of more
than 2 mm is detrimental to appearance. The
course of the incisor teeth axis should also be
evaluated.
The assessment of the gingival margin is an
essential component of the esthetic evaluation.
The vertical part of the visible maxillary anterior
teeth or the part of the visible gingiva (gummy
smile) is evaluated when laughing. The esthetic
level is not more than 3mm of visible gingiva
when laughing.
An ideal tooth–lip relationship can frequently
only be achieved with orthodontic intrusions and
extrusions, or periodontal or orthognathic surgical methods.
The mandibular anterior teeth are integrated
into the evaluation only after planning of the
maxillary teeth has been completed.
The buccal corridor should be lled by the
dental arches.
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Fig. 13.3 Diagnosis sheet for initial examination of esthetics and function
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a
b
c
d
e
161
Fig. 13.4 Esthetic analysis of (a) rest position of lip, (b) upper and/or lower midline deviation, (c) visibility of gums/
teeth when smiling, (d) buccal corridor, (e) incisal edges (With permission from Quintessence Publishing)
Of special signicance is the incisal contour
of the maxillary teeth in relation to the lower lip.
Ideally, the course of the maxillary teeth follows
the curvature of the lower lip. The straight or
opposed course of curvature appears esthetically
disadvantageous.
Indication andContraindication
Orthognathic surgery may reposition the maxilla,
mandible, or chin. It is taken into consideration
when patients are too old for growth modication
or suffer from dentofacial conditions that are too
severe for either surgical or orthodontic camouage. The patient’s appearance and occlusal
function can be improved signicantly, impacting the patient’s sense of self and well-being [6].
Indication for orthognathic surgery therefore
mainly derives from esthetic, functional, and psychosocial reasons [7].
With the introduction and establishment of
temporary anchorage devices (TADs) as an effective treatment option, traditional limitations and
boundaries in orthodontics have widened and
therefore orthognathic surgery may be avoidable
in certain patients [8].
Treatment Goal
Three-Dimensional Treatment
Planning ofOGS
Three-dimensional virtual surgical planning has
become routine practice in orthognathic and
reconstructive surgery for the possibility to realize presurgical evaluation of intraoperative bone
movements, the prediction of postoperative
results, and the high level of accuracy. Surface
superimposition between 3D planned and 3D
postoperative models of the maxillofacial skele-
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W. Schupp et al.
ton showed a medium discrepancy of less than
1 mm in scientic literature. Virtual surgical
planning and 3D surgical splints facilitate diagnosis, treatment planning, and accuracy regardless of sex, dentofacial deformity class, surgery
techniques, entity of advancement, and asymmetry [9].
The CT/CBCT data allows for 3D reconstruction of skeletal and untextured soft tissue volume.
3D stereophotogrammetry technology has
strongly improved the quality of facial soft tissue
surface texture. The combination of these two
technologies allows for an accurate and complete
reconstruction. The 3D virtual head may be used
for orthognathic surgical planning, virtual surgery, and morphological simulation obtained
with a software dedicated to the fusion of 3D
photogrammetric and radiological images [10].
Not only the dental setup is nowadays digitized by means of a virtual treatment simulation
as described before. The 3D virtual treatment
planning of orthognathic surgery has already
been introduced by Xia etal. in 2000 [11].
Cone beam computed tomography (CBCT)
made 3D image acquisition of the full face and
skull of the patient possible at relatively low radiation dose and cost compared to conventional CT
scanning. Additionally, it offers high
accessibility.
Several software companies have succeeded
in the development of virtual software tools, such
as 3D cephalometry, 3D airway analysis, 3D virtual osteotomy and occlusal denition, 3D soft
tissue simulation, 3D-based surgical splint and
template manufacturing, and nally 3D superimposition, which are adequate for 3D virtual diagnosis, treatment planning, and evaluation of
treatment outcome [12].
The OnyxCeph3™ software as an example
offers modules for digital surgical treatment
planning. The 3D treatment simulation module (SIM 3D) (Fig. 13.5a, b) is used to plan
orthodontic and maxillofacial surgical combination treatments. It can be used with malocclusion scans and 2D imaging for the purposes
of initial case discussion between patient,
Fig. 13.5 (a, b) Virtual surface of the module Sim 3D in OnyxCeph3™ for virtual OGS planning (Graphics provided
by Dr. Rolf Kühnert, Image Instruments, Chemnitz)
b
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Fig. 13.5 (continued)
orthodontist, and surgeon (e.g., during a dysgnathia consultation) as well as for the precise
planning of segment osteotomies during the
actual surgical procedure using volume data
(CT, CBCT) and associated intraoral or model
scan. The jaw relations to be set during the
operation can be exported as individual findings and used in the wafer creation module for
the construction of the surgical splints
(Fig.13.6).
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Fig. 13.6 Virtual surface of the wafer creation module in OnyxCeph3™ for virtual splint planning (Graphics provided
by Dr. Rolf Kühnert, Image Instruments, Chemnitz)
W. Schupp et al.
Therapeutical Considerations
Orthodontics First
Orthodontics rst (OF) is the classical and traditional procedure for a combined orthodontic/
orthognathic surgery treatment. Main goal of the
orthodontic treatment before orthognathic surgery is the implementation of congruent dental
arches with decompensation. Hereby, upper and
lower dental arches can be set correctly into the
desired occlusion by means of a surgical splint.
The ultimate goal is to create a situation in which
the teeth are in proper position relative to their
underlying skeletal base [13].
Orthodontic preparation is critical to the success of orthognathic surgery. Different malocclusion types have characteristic dental
compensations that can be identied and
described. Proper planning, monitoring, and
communication between surgeon and orthodontist are critical to avoid potential pitfalls in the
orthodontic preparation [14].
The goal of presurgical orthodontic treatment
is to prepare the dentition for maximal surgical
correction so that, at the time of surgery, the dental arches are compatible with the postsurgical
position and facial balance is achieved [15]. The
goal of the presurgical phase of orthodontics is to
remove the dental compensations and allow optimum surgical correction of the jaw discrepancy
[16].
Recognition and correction of existing dental
compensations allow full correction of skeletal
discrepancies. Presurgical orthodontic goals are
important to dene at the start of treatment and
may not always include complete arch leveling or
space closure, or ideal interdigitation. Orthodontic
preparation dictates the skeletal movements that
are possible at the time of surgery [14].
A short phase of orthodontic treatment postoperatively is usually necessary to detail the nal
occlusion [16].
The combined treatment is complex and
time- consuming and requires full cooperation
between orthodontists and oral surgeons, but all
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of them require detailed information on which
to base their decisions. Surgical orthodontic
patients usually express high levels of satisfaction: 92% would recommend the treatment to a
friend or have the operation again and up to 99%
report an improvement in appearance, function,
or both. Other studies, however, found that some
patients were dissatised because of insufcient
preparation for the operation, lack of warnings
regarding factors such as time spent in hospital,
dietary changes, weight loss, and time off work.
This shows the need to keep patients well
informed of the procedure and its effects on
their lives. The authors conclude that patients
should be informed that the preoperative phase
may last 12–24months [17].
Orthodontic pretreatment prior to orthognathic surgery needs to be clearly differentiated
from habitual, nonsurgically assisted orthodontic
treatment. It is quite useful to place a reminder
into the patient’s agenda if they are treated with
combined orthodontic surgical therapy. Even if
this sounds very simple, in our daily routine, we
quickly tend to treat all of our patients directly
into a class I occlusion. This potential mistake
can be avoided when treating the patient with
aligner orthodontics (AO), as in this case a complete virtual treatment simulation (VTS) will be
worked out in the beginning of the treatment.
Combined orthodontic surgical therapy is a
specialty in our orthodontic ofces and therefore
should also be organized likewise.
In order to obtain a consistent performance in
orthodontic pretreatment and decompensation
that is needed, plaster models should be prepared
on a regular basis in order to assess the respective
situation carefully. With the handheld models,
the later OGS can be simulated in order to assess
whether the dental arch congruence and the
decompensation are sufcient for the OGS or
whether, and if so how, the further treatment
should take place. Today, this is mostly done by
means of scanning, matching in planning software, and possible three-dimensional virtual simulation of the OGS in its current state. Only such
a presurgical orthodontic pretreatment creates the
necessary freedom of movement for the modelsimulated operation and the subsequent OGS.
The three important tissue groups in orthognathic surgery (facial soft tissues, facial skeleton,
and dentition) can be referred to as a triad. This
triad plays a decisive role in planning orthognathic surgery. Technological developments have
led to the development of different threedimensional (3D) technologies such as multiplanar CT and MRI scanning, 3D photography
modalities, and surface scanning. An objective
method to predict surgical and orthodontic outcome should be established based on the integration of structural (soft tissue envelope, facial
skeleton, and dentition) and photographic 3D
images. None of the craniofacial imaging techniques can capture the complete triad with optimal quality. This can only be achieved by “image
fusion” of different imaging techniques to create
a 3D virtual head that can display all triad elements. This may provide an accurate and realistic
prediction model of orthognathic surgery [18].
Continuous evaluation of the patient’s progress throughout treatment and subsequent communication between the surgeon and orthodontist
are recommended to prevent frequent errors,
such as inadequate dental decompensation, poor
appliance selection or management, and occasional contraindicated orthodontic elastic traction or tooth movements [19].
Basic rules of pretreatment with
decompensation:
Make class II worse
During class II—pretreatment, proclination of
lower incisors by leveling them with circum-
ferential, often round wires is incorrect, and a
proper class I cannot be achieved. The exact
opposite is the desired starting situation for
the OGS: the reclination of incisors to create
space in the sagittal. Class III—elastics can be
used for this class II—decompensation [20].
Anteroposteriorly, dental compensations are
removed by ideally positioning the teeth rela-
tive to their apical bases. This will make the
malocclusion look worse presurgically, but it
will unravel the true magnitude of the skeletal
problem, thus allowing an optimal correction
at surgery [12, 21].
Make class III worse
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