Dr V.RAMKUMAR

CONSULTANT DENTAL &FACIOMAXILLARY SURGEON

TAMILNADU- INDIA(ASIA)

Initial appraisal

• Communication

• Psychological assessment

• Personal history

• Family history

• Medical/dental history

• Social history

• Physical development

Assessment process

• History

• Clinical examination

• Investigations

• Initial diagnosis

• Treatment plan

Patients’ complaints

• Appearance

• Mastication

• Speech

• TMJ pain

• Other – orbital/ocular

History

• Background to deformity

– Family trait, racial characteristics, congenital deformity, acquired deformity

– Psychological motivation, dysmorphophobia, hypochondriacal neurosis

Examination – principles• Head, face, neck• Recognition of syndromes• Head position• Facial height• Facial asymmetry and proportion• Midlines• Soft tissues• Hard tissues• Dentition and occlusion• TMJs• Airway• Speech and nasendoscopy

Clinical examination – extraoral

• Aesthetic proportions• Vertical asymmetry• Lip and nose morphology• Rest position lips• Lip length – tooth exposure• Interalar width – nose• Columella - lip relationship• Chin position and shape• Horizontal asymmetry (med/lat)• Antero-posterior relationship• Malar orbital relationship

Clinical examination – intraoral

• General dental assessment• Occlusal relationship• Centre-line discrepancy – whole face• Overjet – overbite• Cross-bite• Occlusal canting• Incisor inclination• Crowding and spacing• Tongue size, mobility, speech pattern• Cleft cases and velopharyngeal incompetence

Dentition

• Periodontal state

• Caries

• Saveable teeth

• Restorations

• Occlusion

Temporomandibular joints

• Symptoms• Assessment• Radiography• Pathology• Pre-existing dysfunction

– Abnormal load, muscle action

• Internal derangement– Prevention – recognise no overload joint– Avoid posterior open bite

Special investigations – radiography

• OPG – impacted/unerupted teeth– Pathology, bone trabecular pattern

• Cephalogram – lateral to assess jaw bones in relation to base of skull tracingPA ceph to assess asymmetry (vert/lat)

• Periapical and occlusal views• CT scanning• Cineradiology – cleft patient• Other TC99 – condylar growth, MRI

Special investigations – photography

• 2D full face, lips in repose, smiling

• Right and left profiles

• Teeth in occlusion (ant and post)

• 1:1 profile photograph (photo. montage)

• (?orbits/skull from above and below)

• 3D imaging for soft tissue analysis and comparison for pre/post surgery

Study models

• Impressions facebow, waxbite, articulator• Study models – occlusion (plaster/stone)• Anatomical articulation• Model mandible – asymmetry• (stereolithography – asymmetry)• Analysis of model surgery• Assess surgical change, long term

stability/relapse

Models/articulation

• Arch size/relationships

• Occlusion

• Tooth position

• Overbite, overjet

• Occlusal curves

• Molar relationship

Diagnosis• Maxilla

– Hyperplasia – prognathism– Hypoplasia – retrognathia– Vertical excess – deficiency– Asymmetry

• Mandible– Prognathism– Retrognathia– Asymmetry

• Chin correction– Progenia, retrogenia– Macrogenia, microgenia

• Craniofacial– Upper midface – orbits– skull

Immediate preoperative assessment

• Planning – final check

• Cessation of growth

• Speech assessment

• Medical state, eg, URTIS, menses, drugs – NSAIDs

• Adequate records

• Consent

Treatment planning

• Psychological

• Photocephalometric

• Dental

• Presurgical orthodontics

Essential

• Accurate patient reevaluation

• Correct selection – surgical procedure

• Accurate prediction tracing

• Accurate model surgery

Appropriate dental/model surgery

• Tooth size – occlusion• Occlusal plane – AOBs• Arch width – expansion/collapse

– Orthodontic – surgical – orthopaedic

• Space closure• Short roots – resorption• Root convergence• Surgical deficiencies

– Skill, ortho, fixation, instrumentation

• Failure to follow treatment plan• Teeth off basal bone – unstable• Orthodontic failure

Diagnosis and treatment planning 1

• Team approach• Orthodontic• Surgical• Restorative• Periodontal• Speech and language therapy• Psychological• Oral hygiene

Diagnosis and treatment planning 2

• Orthodontic treatment only

• Combined ortho/surgical treatment

• Surgical treatment alone

Diagnosis and treatment planning 3

• Combined ortho/surgical treatment• Tooth alignment, eliminating crowding,

spacing and crossbite• Alteration and co-ordination of arches• Correction of incisor inclination –

decompensation• Flattening of occlusal plane• ‘trials’ of treatment – patient discussion• Surgical fixation• Post surgical orthodontics – fine tuning?• Preparation for surgery

Operative complications

• Patient care – anaesthesia etc

• Maxillary surgery

• Mandibular surgery

• TMJs

• Nerve injury

• Vascular injury

Nerve injury

• Type – neuropraxia, axonotmesis, neurotmesis, neuroma

Management – timing, primary repair,

Nerve grafting, ID, lingual, facial

Post surgery – immediate

• Airway IMF, NT/NP tubes, suction

• Bleeding/circulation - ?blood transfusion

• Swelling – drainage, steroids

• Infection – antibiotics, careful soft tissue closure

• Analgesia – (Sedation X)

• General – DVT, PE, UTI, chest infection

Postop. follow up

• ?IMF period

• Elastic traction/orthopaedic

• Functional appliances

• ?Genioplasty

Post surgical orthodontics

• Avoid opening bite

• Adequate retention

Velopharyngeal insufficiency

• Secondary cleft deformity

• Craniofacial cases

• Access osteotomies – split soft palate

Miscellaneous

• Scars

• Sinus infection

• Plate problems

Poor results – due to:

• Incorrect diagnosis• Inappropirate Rx plan• Unstable orthodontics• Wrong surgical procedure• Poor patient co-operation• Inability to obtain planned position• Relapse – AOB approx 10% (4:40) – 5yr follow up• Poor occlusion – unstable• Inadequate mobilisation• Poor fixation• Unknown cause!

Final thoughts!

• Medico legal complications arise from:

– Poor communication

– Poor planning

– Inappropriate consent

– Poor records

• No operation – no complications

• If you never have seen it, you have not done enough

• If it can happen, it will – to somebody, somewhere

• My patient deserves something better than this.