ORTHOGNATHIC SURGERY
CAMOUFLAGE VERSUS SURGERY
 The decision for camouflage or surgery must be
made before treatment begins, because the
orthodontic treatment to prepare for surgery often is
just the opposite of orthodontic treatment for
camouflage
 It is a serious error to attempt camouflage on the
theory that if it fails, the patient can then be referred
for surgical correction. At that point, another phase
of "reverse orthodontics" to eliminate the effects of
the original treatment will be required before surgery
can provide both normal jaw relationships and
normal occlusion.
Camouflage v/s
Surgery
Decision for camouflage or surgery must be made
before treatment begins
Greater emphasis on soft tissue consideration
essential when camouflage versus surgery is
considered
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Envelope of
Discrepancy
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Extraction of Teeth and the
Camouflage/Surgery Decision
 The critical importance of deciding on
camouflage or surgery at the beginning of
treatment is illustrated by the difference in
extractions needed with the two approaches
 In camouflage, extraction spaces are used to
produce dental compensations for the jaw
discrepancy and the extractions are planned
accordingly.
• Some degree of dental compensation
accompanies most skeletal jaw discrepancies,
even without treatment.
• If the jaws are to be repositioned surgically,
this dental compensation must be removed.
Otherwise, when the teeth are placed in
normal occlusion, the jaw discrepancy will not
be totally corrected, and dental interferences
make it almost impossible to put the jaws in
their proper relationship to each other
Indications for Orthognathic surgery
 For patients whose orthodontic problem cant
be solved by growth modification and
orthodontic treatment alone . Or
combination of both .
 Surgery should not offer alone but it must be
integrated with orthodontics and other
dental treatment.
Indications for Orthognathic
Surgery
 Severity of skeletal and dental malocclusion
 When growth modification can not be achieved
 Esthetic and psychosocial considerations
Sagital Split osteotomy
Oblique sub condylar
osteotomy
Contemporary Surgical Techniques:
LeFort I osteotomy
Segmental osteotomies
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Mandibular Surgery
Maxillary Surgery
Dentoalveolar Surgery
Distraction Osteogenesis
Adjunctive Facial
procedures
Surgically assisted rapid
Palatal Expansion
(SARPE)
Rhinoplasty
Genioplasty
Sub mental procedures
Lip procedures
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Timing of Surgery
 Usually done when all growth is complete
 Assessed by superimposition of serial lat
cephs
 Can be performed when growth is not yet
complete in cases of psychosocial problems
or great severity when function is
compromised (i.e. breathing, chewing)
Orthognathic Surgery
 Correction of A-P relationships:
 maxillary advancement
 retraction of anterior maxillary segment
 mandibular advancement
 mandibular setback
 double jaw surgery
Surgical Techniques
 Le Fort I
Le Fort III
 Le Fort II
 Le Fort III
Le Fort II
Le Fort I
Le Fort I
Le Fort II
Le Fort III
Orthognathic Surgery
 Correction of Vertical Relationships:
 maxillary impaction/intrusion
 maxillary extrusion
 mandibular ramus surgery
Orthognathic Surgery
 Correction of Transverse Relationships:
 surgically assisted maxillary expansion
 surgically assisted mandibular expansion
Orthognathic Surgery
 Correction of Asymmetries:
 maxilla
 mandible
 maxilla and mandible
Pre Surgical Orthodontic
Objectives
 To level and align the arches and make them
compatible
 to resolve crowding and/or spacing
 to establish anteroposterior and vertical position
of incisors (decompensate)
 to place teeth relative to their own supporting
bone
Check List for Treatment Planning
• A-P relationships
maxillary deficiency/protrusion
mand prognathism/deficiency
amount of deficiency
• Vertical relationships
open bite
deep bite
• Transverse relationships crossbites
before surgery
expansion
surgically assisted expansion
during surgery
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Check List for Treatment Planning
• Asymmetries
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cant of occlusal plane
mandible/chin deviation
Occlusal relationships
Missing teeth/ malformed teeth
Genioplasty
Nose/lip relationship - rhinoplasty
Facial harmony
Horizontal proportion
Facial covexity
The lower third @
A. Increase face height:
 Dolicofacial pattern
 Vertical maxillary excess (VME) 
 High lip line: anterior teeth display too much
 Gummy smile
 Lip length: normal
 ≠ Short lip 
 Excesssive chin height 
B. Decrease face height
 Brachyfacial pattern
 Vertical maxillary deficiency
 Mandibular defienciency 
 Short chin height 
Lower Jaw surgery
 Lower jaw surgery usually done for retraction
or elongation of mandible . Rotation of
mandible in certain cases.
Basal sagittal spilt osteotomy
Segmental osteotomy
Basal sagittal split osteotomy
Retraction of mandible
Advacemnt of lower jaw
Treatment Steps in
Orthognathic Jaw Surgery
1. Step: 12-18 month preoperative
orthodontic treatment (Braces, Invisalign)
2. Step: Surgery (1-3 days in the hospital)
3. Step: 6 month postoperative orthodontic
treatment
Surgical Procedure – Upper
Jaw
Double Jaw or “Bimax”
Surgery
Surgery in the
upper and lower
jaw at the same
time.
Advancement of maxilla
Maxillary impaction
Rotation of maxilla
Surgical expansion of maxilla
Genioplasty
advancement genioplasty
Reduction genioplasty
Distraction Osteogenesis
 First described by Ilizarov for limbs
 Distraction osteogenesis = callostasis = stretching of a
bone callus
 Gradual distraction of bones is accompanied by the
soft tissues = less probability of relapse
 Can be performed for the mandible, maxilla, calvarium,
orbit, midpalatal suture and maxillary or mandibular
alveolus
 Distraction devices can be internal or external
 Internal devices can also be resorbable
Distraction osteogenesis
Distraction Osteogenesis for
the Maxilla
Distraction osteogenesis
Post surgical orthodontics
 This period required 6-8 months for fine
tuning of bite .
Relapse and Stability