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Fig. 13.15 Virtual simulation of mandibular advancement after virtual alignment of the arches
W. Schupp et al.
Fig. 13.16 Virtual “nishing”: Implementation of congruent arches for orthognathic surgery
a
b
c
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Fig. 13.17 (a–c) Extraoral records post-operation with perimandibular swelling
ab c
177
d
Fig. 13.18 (a–f) Intraoral records post-operation show
improved sagittal relationship with the need of orthodontic nishing and detailing in order to establish a good
e
f
interdigitation. IMF screws for postsurgical retention purposes are still in situ
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abc
de
W. Schupp et al.
Fig. 13.19 (a–e) Intraoral records after postsurgical
detailing and nishing and before debonding of attachments. Buttons for up and down elastics were bonded to
the molars in the rst and fourth quadrant. Buttons for
a
Fig. 13.20 (a–c) Extraoral records at the end of the treatment. Patient shows harmonious smile and relaxed lip closure
in habitual intercuspation
b
II elastics were left in situ for retention purposes
for 3 months after debonding of buttons and
attachments (Fig.13.21). The postsurgical OPTG
shows no pathologies (Fig.13.22). Cephalometric
records showed improvement especially in the
vertical conguration (Fig.13.23).
crisscross elastics were bonded to the second molars in
the second and third quadrant. Hooks were bonded to
teeth 13 and 23in order to retain class I relationship with
class II elastics
c
The result was nally retained with a thermoformed retainer in the upper arch and a bonded
lingual retainer [34–42] in the lower arch (Figs.
13.24 and 13.25). Restorative dentistry was
planned for teeth 17 and 16, 25–27, and 36 and
37 but not nished.
a
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ab c
179
d
Fig. 13.21 (a–f) Intraoral records at the end of the treat-
ment show class I relationship on both sides. Restorative
dentistry is planned for upper and lower molars in the sec-
Fig. 13.22 OPTG at the end of the treatment
e
f
ond and third quadrant. Buttons and bonded hooks were
left in situ for retention purposes
Fig. 13.23 (a, b) Lateral cephalogram at the end of the
treatment
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W. Schupp et al.
b
Fig. 13.23 (continued)
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ab c
181
d
Fig. 13.24 (a–e) Intraoral records in the retention phase, 3years after active treatment. Prosthodontic treatment has not
yet taken place due to pregnancy of the patient
e
Digital treatment planning tools and software
have facilitated orthodontic/orthognathic surgery
treatment. As they may lead to a more predictable
therapy for practitioner and patient, these tools
will become even more valuable for orthodontics
and orthognathic surgery in the future.
We would like to thank Ulrike Ehmer and
Thomas Röhr for their kind support in writing
this chapter.
Fig. 13.25 OPTG in the retention phase
Conclusion
Contemporary orthodontics makes it possible to
reposition one or both jaws surgically after orthodontic pretreatment. This provides the patient
with the option of having all components of their
malocclusion and facial esthetic concerns
addressed. Combined orthodontic/orthognathic
surgery treatment is a highly invasive treatment
method which needs careful interdisciplinary
treatment planning to be successful [16].
As surgical side effects such as swelling, neurosensory disturbances, infections, and many
more may arise, the decision for orthognathic
surgery and against orthodontic camouage
treatment should be carefully evaluated and
found together with the patient.
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Decision-Making inOrthognathic
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Surgery by Virtual Planning
andExecution
UlrichMeyer andKerkfeldValentin
14
Introduction
Orthodontic surgery is based on a close collaboration of orthodontists with maxillofacial surgeons. The denition of treatment goals and the
movements of teeth and jaws are based on elaborated treatment protocols. In general, teeth should
be aligned in an ideal teeth arch, including a normalized curve of Spee. Jaws should be placed in
a normalized position, according to reference
planes (e.g., the Frankfurt horizontal level). In
conventional planning for orthognathic surgery,
surgeons use two-dimensional cephalometric
analysis and dental casts mounted on the articulator with a facebow transfer of the patient’s occlusal plane. Manual model surgery is performed to
predict the direction and extent of movement in
the jawbone segment. Splints are then fabricated
in the dental laboratory, to be used during the
operation (Fig. 14.1). When two-jaw surgery is
performed, an interocclusal splint is fabricated to
U. Meyer (*)
Center for Jaw-, Face- and Skull Surgery,
Münster, Germany
Clinic for Cranio-Maxillofacial and Plastic Facial
Surgery, Westdeutsche Kieferklinik, University of
Düsseldorf, Düsseldorf, Germany
e-mail: praxis@mkg-muenster.de
K. Valentin
Clinic for Cranio-Maxillofacial and Plastic Facial
Surgery, Westdeutsche Kieferklinik, University of
Düsseldorf, Düsseldorf, Germany
work as an intermediate guide for repositioning
the maxilla relative to the intact mandible, and a
nal splint is fabricated to determine the desired
surgically planed occlusal position [1]. Several
sources of error and inaccuracy are associated
with the whole cranial situation in plaster model
surgery because of insufcient control of the
three-dimensional transfer of the dental occlusion to the skull.
Compared with such a conventional orthognathic surgery planning, computer-assisted orthodontic and surgical analysis using 3D digital
models has improved the effectiveness of the
treatment planning process by eliminating previous procedures such as the mounting of casts on
the articulator or the cutting and gluing of the
casts [2–6]. Additionally, the visualization of
complex structures in craniofacially malformed
patients (dental, skeletal, and soft tissues) within
a dentofacial deformity has been greatly enhanced
through three-dimensional (3D) data generation.
The computer-assisted data integration allows a
precise and three-dimensional virtual model of
the patient’s anatomy. The 3D model creates an
environment that provides a standardized, safe,
and exible platform for the assessment of various anatomical regions of the head for examination, diagnosis, and planning. Computer
simulation can demonstrate the extent of yaw
rotation in the maxilla and mandible, occlusal
plane canting, and differential length of a mandibular body or the ramus [7–12]. It is also a
© Springer Nature Switzerland AG 2023
U. Meyer (ed.), Fundamentals of Craniofacial Malformations,
https://doi.org/10.1007/978-3-031-28069-6_14
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U. Meyer and K. Valentin
a
b
cd
Fig. 14.1 Steps of conventional split-based plaster model surgery. a) Clinical bite registration, b) articulation of plaster
model in dysgnathic situation, c) model surgery in class I relation, d) splint fabrication
worthwhile tool for surgical training [13].
Favorable occlusal interdigitation and an optimized position of the mandibular condyle after
surgery are essential for obtaining favorable
results. Many studies have demonstrated that the
condyle position changes somewhat after OGS
despite the efforts of clinicians to maintain the
condyle’s original position [14–19].
Whereas some studies have noted the advantages of computer-assisted techniques in predicting possible difculties and complications [20]
and enabling the precise visualization of osteotomized segments and the calculation of bony
interferences [21–24], computer simulation has
also signicant limitations. A computer allows
segmentations (in real osteotomies) and move-
ments of bones in all directions and to an unlimited extent. In the real patient situation,
osteotomies as well as bone movements are limited by multiple factors: the course of nerves and
vessels, the soft tissues (muscles, ligaments,
mucosa, skin) surrounding the bone, and others.
In general, as demonstrated in a systematic literature evaluation, virtual planning seems to be
an accurate and reproducible method for orthognathic treatment planning. When comparing this
technique with the classical planning, virtual
planning appears to be more accurate, especially
in terms of frontal symmetry [25, 26].
In computer-assisted orthognathic surgery,
different extents of surgical execution can be
distinguished:
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