Aesthetic Considerations in Orthognathic SurgeryOrthognathic Surgery

Mr Paul JohnsonGuildford, England

XX1 COBRACVitoria-ES 2011

Is Orthognathic Surgery Cosmetic Surgery?Cosmetic Surgery?

Yes and No

Orthognathic Surgery

The Treatment of DentofacialDeformityDeformity

Aims

�Correction of dentofacial deformity

�To give a functional occlusion

�To achieve the best aesthetic result�To achieve the best aesthetic result

Paradox

Indication is usually occlusal

Result usually judged by the aesthetic outcome

Mandibular ProceduresMaxillary ProceduresChinChinRhinoplastyCheek implants

• Bilateral Sagittal Split

• Le Fort 1

• Sliding Genioplasty• Sliding Genioplasty

r

Pertaining to beautyPertaining to beauty

A quality which delights A quality which delights the senses

PlaceTimeTimeFashion

Fashion

Beauty is in the eye of the beholderbeholder

But are their any rules?

Treatment planning

So how do you decide what the correct operation is?

Cephalometric analysis. Yes but what is really important?

•Skeletal pattern•Incisor angulation•Face Height •Maxillary Mandibular

Cephalometics

•Maxillary MandibularPlane Angle

Think aesthetics

Starting pointEnd pointWhat to do

What not to do

� Assess the patient.� Consider the immediate effects of planned movements.effects of planned movements.� Consider long term effects.

Mosby 2003

Chapter 4. Evaluation Of Facial Soft TissuesDavid Sarver, William Profitt, James Ackerman

Clinical assessment of facial form

• Facial balance. Thirds and fifths• Lips• Chin\Nose balance• Nose• Nose• Cheekbones and inferior orbital rims.

Facial thirds and fifths

Facial fifths

The Lips

• Lip growth lags behind skeletal growth. Therefore lip competence cannot be assessed until growth complete.

• Lip thickness greater in females than • Lip thickness greater in females than males.

• Lip thickness decreases with age.

• Lip balance.

Upper lip – incisor relationship

Incisal show with the upper lip at rest

� 0 – 4 mm. Female > male

� If > 4mm vertical maxillary excess

� If < 0mm vertical maxillary insufficiency

But must assess in conjunction with mandibular-maxillary plane angle and facial thirds.

Beware of the short upper lip and short clinical crowns.

Chin – nose balance

Nasal aesthetics

� Nasolabial angle� Alar width� Alar width� Paranasal fullness

Nasolabial Angle

100-120 degreesFemale > male

So What effects do osteotomies have on facial

appearance?appearance?

Mandibular movements

Advancement

• Pogonium forward

• Pogonium downward (if curve of Speemaintained)

• Labio-mental angle becomes more • Labio-mental angle becomes more obtuse

• Improved soft tissue support over jaw and neck

Mandibular Setback

• Chin point back

• Labiomental angle more acute

• Decreased soft tissue support

• Nose forward• Nose tip angulation• Nares exposure increased

Nasal Aesthetics and Le Fort 1

• Nares exposure increased• Upper lip forward and flattened

• Subnasale forward• Columella forward• Increased alar width

Adverse Aesthetics following treatment of AOB by maxillary impaction. The ‘Miss Piggy’deformity

Facial Age ChangesLoss of soft tissue volume and skin elasticity and gravitational effects.

�Loss of lip fullness�Loss of curve of upper lipIncrease in upper lip lengthLoss of curve of upper lip

�Increase in upper lip length�Loss of face height�Decrease in upper incisor show�Increase in lower incisor show�Nasal tip moves inferiorly and nasolabial angle becomes more acute

�Deepening of nasolabial grooves and marionette lines

Compensation for Age Changes

�Leave soft tissues oversupported.– Maintains upper lip support

– Decreases nasolabial fold development and marionette linesmarionette lines

�Conservative maxillary impaction.– Maintains incisal show

Examples

Clinical AssessmentNasal humpZygomatic insufficiencyAcute nasolabial angleUndersupported upper lipOversupported lower lip

Orthodontic PlanDecompensationAlignementCoordination

Surgical PlanMaxillary advancementCheek implantsRhinoplasty

Bird-facedeformity

BirdBird--face deformityface deformityPost distractionPost distraction

Conclusions

�Think aesthetics in orthognathic surgery

�Anticipate age changes�Anticipate age changes

Is orthognathic surgery cosmetic?

Yes and no.

Thank You

Mr Paul Johnson