Australasian Dentist Issue 89

Category 64 AustrAlAsiAn Dentist interarch elastics can also be utilized to decompensate the dentition prior to orthognathic surgery. For example, to prepare a Class iii patient for orthognathic surgery, Class ii intermaxillary elastics should be used and to prepare a Class ii patient for orthognathic surgery Class iii elastics should be employed. recent literature has been published that suggests foregoing presurgical orthodontics and performing orthognathic surgery first. this approach is not applicable in all the cases and is indicated in cases with minimal crowding in the anterior teeth, favorable curve of spee, and a normal range of angle between the basal bone and upper and lower incisors. 14 Advantages of this “surgery first” protocol includes ability to address the patient’s chief complaint early, immediate improvement of dental function and facial aesthetics, shorter overall treatment times, faster dental movement and ability to achieve difficult dental movements, such as torque of the maxillary incisors, through segmental osteotomies and repositioning of the skeletal segments. 5 Surgical Planning unfortunately, surgical planning is rarely a matter of simply moving the skeletal units to a normalised position. the essence of orthognathic surgical planning is compromise. When performing orthognathic surgical planning the limits of skeletal movement must be defined for every patient based on their unique characteristics. the goals of the surgery must then be prioritised. Although every goal may not be fully realised, a balanced harmonious facial appearance should always be achieved. 5 Orthognathic surgery might trigger 3 to 4 months of higher bone metabolism postoperatively, which might accelerate orthodontic tooth movement. 15 Post operative orthodontics the two primary goals of the postoperative orthodontic phase of orthognathic surgery are to stabilize the skeletal movements and detail and finish the dental occlusion Prior to orthognathic surgery full- dimension stainless steel orthodontic arch wires should be placed with hooks to allow for fixation at the time of surgery (Fig 13) these arch wires will withstand the use of heavy interarch elastics. interarch elastics can be used in the postoperative period to refine any minor skeletal movements that need to occur and counterbalance the soft tissue pull that may lead to relapse. (Fig 14) the amount of preoperative orthodontics will obviously influence how long the postoperative orthodontic period will last. in traditional orthognathic surgery where the majority of dental decompensation occurs before surgery, the postoperative orthodontic period usually lasts between 6 to 12 months. 5 Patient’s perspective and role of counselling For surgeons, orthognathic surgery is a routine procedure, but for patients it is an unknown, time-consuming, and risky treatment. Healthcare providers are often focused on providing information that enables patients to consent to treatment in an informed manner, but they can occasionally fail to give the counseling and practical advice that patients require to improve their experience. Counselling must be provided during the decision-making process, immediately preoperatively, immediately postoperatively, and perhaps 1 year after the surgery. Generally, with such a structured approach the patients are highly appreciative and satisfied with the results achieved at the completion of the treatment. (Fig 15) Conclusion Orthognathic surgery and orthodontic treatment can eliminate severe aesthetic and functional deformities and be a life- changing event for a patient A successful treatment starts from the initial evaluation and culminates on completion of postsurgical orthodontics. Coordination between orthodontist, dentist and a surgeon during the entire treatment is essential. Properly counselled patients feel more prepared for surgery, cope up better with the postoperative side effects, and ultimately manifest greater satisfaction with the treatment outcome. u Dr Geoffrey Hall, Specialist orthodontist BDSc ( Mel) Cert Orth (Uni of Penn) MRACDS ( Orth) Founder and Director of OrthoED, Smilefast and CAPS geoff@orthoed.com.au TEL 1300 073 427 / 03 91080475 For a full list of references contact gapmagazines@optusnet.com.au lInICal Fig 10: The goal of presurgical orthodontics is to decompensate the occlusion. If the teeth are not decompensated prior to orthognathic surgery, dental interferences may occur that prevent ideal positioning of the skeletal subunits Fig 11: Nance arch Fig 12: To achieve anchorage control transpalatal arches may be used. Fig 13: Full size Stainless steel orthodontic arch wires with surgical hooks Fig 14: Interarch elastics can be used in the postoperative period to refine any minor skeletal movements that need to occur and counterbalance the soft tissue pull that may lead to relapse Fig 15: Orthognathic surgery and orthodontic treatment can eliminate severe aesthetic and functional deformities.