Optimizing Orthognathic Surgery E-Book

Konrad Wangerin

• Herausgeber: Quintessence Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 600

Veröffentlichungsjahr: 2023

Beschreibung

A comprehensive guide to interdisciplinary treatment approaches for dysgnathia correction based on considerations of both orofacial function and facial esthetics. Written by international experts with over 30 years of surgical experience, this book shares valuable insights gained through close collaboration with orthodontists, dental practitioners, prosthodontists, ENT specialists, speech therapists, and more. The integration of intraoral distraction surgery into orthognathic procedures is explored with a special focus on severe cases. The wealth of treatment strategies and solutions presented within these pages will navigate readers through the intricate pathways of managing complex craniofacial malformations. Step-by-step guide for documentation, diagnosis, and planning of orthognathic surgical procedures Comprehensive methods and techniques for dysgnathia correction Identifying potential dangers and limitations Indications for interdisciplinary treatment planning Effective treatment sequences and surgical planning Descriptions of analog and digital approaches Strategies for choosing between the maxilla and mandible first approaches Practical tips and tricks for successful outcomes Balancing function and esthetics in treatment strategies In-depth case reports highlighting complex scenarios Long-term results and their significance in treatment evaluation This invaluable resource serves as an unwavering compass for the treatment of both simple and complex craniofacial malformations, guiding practitioners on their surgical journey, providing the knowledge, techniques, and insights needed to deliver exceptional patient care and achieve outstanding surgical outcomes.

Leseprobe

OPTIMIZINGORTHOGNATHIC SURGERY

Diagnosis • Planning • Procedures

KONRAD WANGERINCAROLINE FEDDER (EDS)

OPTIMIZINGORTHOGNATHIC SURGERY

Diagnosis • Planning • Procedures

KONRAD WANGERINCAROLINE FEDDER (EDS)

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ISBN 978-3-86867-673-0

Quintessenz Verlags-GmbH

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Quintessence Publishing Co Ltd

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Copyright © 2023

Quintessenz Verlags-GmbH

All rights reserved. This book or any part thereof may not be reproduced, stored in aretrieval system, or transmitted in any form or by any means, electronic, mechanical,photocopying, or otherwise, without prior written permission of the publisher.

Editing, Layout, Production and Reproduction:

Quintessenz Verlags-GmbH, Berlin, Germany

In memoriam

Bodo Hoffmeister

Franz Härle

Thomas Lambrecht

Kiel Connection

Foreword

The editors represent two generations of maxillofacial surgeons, both specializing in orthognathic surgery, who operated together for nearly 5 years. For Konrad Wangerin, these were the last 5 years of his 35-year career, and for Caroline Fedder, the first 5 years after residency. The surgical experience of the older surgeon, who was instrumental in the development of maxillary jaw distraction methods, and the precise now mainly digital treatment planning of the younger surgeon complement each other across the generations.

The chapters with precise photographic documentation, a systematically detailed clinical examination form, and the surgical planning chapter include all steps of a complete case documentation. They also answer the question of when it is appropriate to operate on the mandible first and when to operate on the maxilla first in a maxillomandibular osteotomy.

All surgical methods of orthognathic surgery, including distractions and their indications, are listed. These explanations demonstrate the extensive surgical experience of the author team through an unfiltered presentation of risks, complications, error prevention, limitations of successful method application, and alternatives. A well-considered strategy of complex, multi-stage interdisciplinary treatments – who does what, and when, whether in one stage or two stages, often with orthodontic or dental support – is derived from the illustrated complex case descriptions.

Conventional surgical planning has been gradually replaced by digital 3D surgical planning for years. The increasing complexity of cases has led to more detailed digital planning. It all began with Thomas Lambrecht, who described 3D Styrodur Modeling Technology based on CT and MRI scans in his monograph in 1995, published by Quintessenz Verlag, and even explained examples from orthognathic surgery. Like the editors and the author of this foreword, he was also part of the “Kiel Connection.”

The current application of this digital 3D planning technique helps the younger generation of surgeons to identify operative challenges and risks during surgical planning, while the older generation had to rely on long-term practical experience. With this 3D planning technique, what used to be solely dysgnathic surgery has evolved into functional and esthetic facial surgery. Modern, complex plastic surgical treatment concepts aimed at improving overall facial esthetics are presented in Volume 1, as well as additional esthetic procedures on the facial soft tissue.

Volume 1 will be complemented by a second volume, in which the interdisciplinary nature of complex treatments will be described in an exciting manner. These include long-term results of 10 to 20 years or more – such long-term results are rare in recent literature. We must not lose sight of the fact that with our surgical outcomes, we are not only sending our patients into a short post-observation period but into the rest of their lives. We have a long-term responsibility for important functions and esthetics, and we should take it seriously. Volumes 1 and 2 are important guides in this regard.

Rolf Ewers, Vienna

Preface

The present book explains the current principles of orthognathic surgery: recognize, evaluate, and act. It contains, described in a practical manner, all the details of photographic diagnostics, conventional surgical planning, and surgical simulations with the production of surgical splints. Exemplary clinical cases explain the entire treatment procedures.

Not only are all common dysgnathic surgical methods explained with indications, advantages and disadvantages, limitations, and potential errors using clinical examples, but also the necessary accompanying procedures in neighboring regions such as the midface, nose, and neck, which have often been overlooked in the past.

Different distraction methods are also successfully integrated into orthognathic surgery as a necessary step for the staged treatment of complex cases. Illustrated examples explain the complexity of the treatment. The function of the temporomandibular joint and the nasopharyngeal airway are not forgotten. A case involving accelerated orthodontic treatment that takes advantage of the postoperative RAP (regional acceleratory phenomenon) effect is also described.

Anesthetic peculiarities that arise from the intraoperative close proximity of both areas of work are presented. Critical phases of surgery are facilitated by extremely precise anesthesiologic support.

While the correction of malocclusion has been the goal of orthognathic surgery in past decades, today it is the normalization of the facial skeleton and the shaping of a harmonious face with esthetic contours. Several chapters deal with modern plastic surgical treatment concepts and demonstrate impressive esthetic results.

Today, the development of 3D modeling technology has advanced to the point where it can routinely be applied to the surgical planning of even complex dysgnathic corrections. Using a case example, all steps of this phenomenal and forward-looking surgical planning technique are systematically presented. The reverse planning approach, which leads to the prefabrication of individual osteosynthesis plates for the maxilla based on virtual surgical planning on the 3D CT model, which, when used intraoperatively, replace the previous reliance on surgical splints, is also demonstrated. Both developments have the potential to predict the surgical changes in the facial profile, including facial contours. The future goal is to present the patient with their virtual new face preoperatively, which can likely be achieved through surgical changes to the facial skeleton and correction of the malocclusion. However, this foresight is limited by the facial soft tissues and the individual’s facial expressions, which cannot yet be digitally captured or altered, either preoperatively or postoperatively.

Konrad Wangerin, Stuttgart

Caroline Fedder, Göppingen

June 2023

Editors

Konrad Wangerin,

Prof Dr Dr Dr hc

Konrad Wangerin studied medicine and dentistry at the Universities of Münster and Cologne, Germany, and in Munich, Germany, at the Technical University and Ludwig Maximilians University.

His specialization in Maxillofacial Surgery followed from 1979 to1982 at the Ludwig Maximilians University of Munich and at the Christian-Albrecht University of Kiel, Germany. Afterwards he became Senior Registrar and finished his PhD 1988 in Kiel.

In 1990 he moved to the Department of Plastic, Maxillofacial, and Reconstructive Surgery at Marienhospital Stuttgart, Germany, became Chief Surgeon in 1991, and in 1994 was appointed as Adjunct Professor of the Medical Faculty of the University of Kiel and Medical Director at the Marienhospital.

By 1994 he had operated the first intraoral mandibular distraction worldwide and invented several intraoral distractors for the mandible and maxilla, gaining huge experience in distraction work and lecturing and operating around the world.

In 2002 he was awarded an Honorary Degree from the Technical University of Cluj-Napoca, Romania.

After his retirement in 2011, he continued as Senior Director in the medius Clinic Ostfildern-Ruit, and since 2014 he has worked in the private office for maxillofacial and oral surgery together with Dr Roman Beniashvili, at Schorndorf, near Stuttgart, Germany.

Caroline Fedder,

Dr med

Caroline Fedder studied medicine and dentistry at the Medizinische Hochschule Hannover, Germany, and University of Wales College of Medicine, United Kingdom, from 1996 and completed her thesis (Dr med) 2005 in Hannover. She started her medical specialization in maxillofacial surgery in the private Stadtparkpraxis in Hannover, continued at the University Hospital Zürich, Switzerland, and finished 2010 at Katharinenhospital, Stuttgart, Germany.

She met chairman Konrad Wangerin at the Marienhospital Stuttgart, where she joined his department and began her additional specialization in Orthognathic Surgery.

In 2014 she became Senior Registrar at the medius Clinic Ostfildern-Ruit, and in 2019 gained the specialization Plastic Operations. In the same year she co-founded the clinic for maxillofacial and plastic facial surgery of the Alb-Fils Clinics Göppingen, Germany, and became leading Senior Registrar. Dr Fedder regularly lectures on orthognathic surgery, especially in interdisciplinary symposia with orthodontists, and dedicates her time to facilitating open access to knowledge and high-quality training for surgeons in orthognathic surgery.

Acknowledgments

Konrad Wangerin

This book would not have been possible without the help and collaboration of many colleagues, staff members, friends, and, above all, our patients. I would like to express my thanks to all those who allowed me to depict individual treatment steps or results visually.

I extend a heartfelt thank you to Kathleen Weber and Christian Lange. They have accompanied me for many years, providing unlimited time and all the strength of their organizational skills and computer knowledge. Their support has been tremendous.

Without my longtime friend and orthodontic buddy, Dr Christopher-George Hepburn from Ludwigsburg, Germany, the photographic foundation of this book would not have been achievable. We owe our decades-long trustful interdisciplinary collaboration in two such different fields as orthodontics and maxillofacial surgery, both conservative and surgical, to his father, Dr Christian Hepburn, who passed away in April of this year at the age of 90. Both have played a significant role in many combined complex treatment plans, and Christopher is a co-editor of Volume 2, in which we present our complex treatment cases and long-term results. The two employees of the orthodontic practice, Claudia Brunsch and Carmen Saub, also deserve grateful mention.

I also thank my senior physician and later successor at the clinic, Dr Dr Dr Winfried Kretschmer, with whom I have successfully collaborated for over 20 years, as well as our friends Prof Dr Mihaela and Prof Dr Grigore Baciut from Cluj-Napoca in Romania. Special thanks go to our visiting physician, Hytham Al Rabadi MD from Amman, Jordan, my practice partner Dr Roman Beniashvili from Schorndorf, Germany, along with Dr Bastian Kern from Waiblingen, Dr Claudia Schrempf from Stuttgart, Germany, Dr Hartwig Paulo from Gelsenkirchen, Germany, Dr Hans-Jörg Becker and his wife Uschi Becker from Zurich, Switzerland, and my friend Dr Bernhard Fuchs from Leonberg, Germany,

I was delighted that Caroline Fedder agreed to work on this project, and thank her for her diligence and precision.

Thanks also to the Ruiter/Göppingen team, including Nadine Kramer, Jessica Coimbra Marques, Claudia Geiger, Jessica Stahlbaum, and Vanessa Wolfer. Thanks also to Judit and Sanjeewa Perera from Ludwigsburg, and their involvement in the facial deformities support association..

Thanks to Andreas Reinhardt from Kiel, Germany, for the wonderful drawings, thanks to ZTM Horst-Dieter Kraus from Stuttgart, and thanks also to the medical-technical advice and support from Barbara Schneider, Kristine Schröder, Joachim Schmid, Andreas Burger, and Adalbert Frech from Tuttlingen, Germany.

And finally, the last thank you goes to the most important people in my life, my family, Andrea, Adrian, and Gregor. Thank you for your understanding and patience.

Caroline Fedder

First and foremost, a big thank you to all the patients who allowed me to use their photos, radiographs, and treatment records, without which the compilation of such a comprehensive and hopefully informative textbook would never have been possible. Many descriptions become even clearer with the exemplary images – we learn from what we see. A special thanks at this point goes to the patient whose case I was allowed to present in detail in the surgical planning chapter.

Furthermore, I would like to thank my long-standing team, now located in the Alb-Fils clinics in Göppingen after three relocations, who have supported me beyond their working hours in taking photos, selecting radiographs/photos, and, in some cases, serving as models. Kathleen Weber, Vanessa Wolfer, Jessica Coimbra-Marques, Jessica Stahlbaum, Nadine Kramer, Claudia Geiger, Ina Schmitt, and Adela Sabau deserve special mention. They were always ready to implement the next crazy task without hesitation. My team carries me through each working day with the knowledge of fulfilling a meaningful task that is also enjoyable. Teaching and seeing my young colleagues grow professionally is a great gift.

Heartfelt thanks also to Ingo Röthele, who patiently and devotedly carried out the technically and time-consuming professional photo documentation of conventional planning. The model operation was carried out by Jan Ternes – our long-standing dental technician – who has become a master at achieving the desired target occlusion quietly and diligently, always finding a solution based on his, like ours, extensive experience of 3D printing.

I would like to thank my dear colleague and good friend Bergen Pak for countless joyful professional discussions at the highest level, which have always helped me progress, and for his unconditional friendship.

I also want to thank my family, who have supported me throughout this extensive project and shown understanding for the many hours I spent at my desk.

Last but not least, I thank Konrad for the incredible fortune of hiring me as a young specialist and teaching me so much about orthognathic surgery. Your self-critical and inquisitive nature from the very beginning – always asking “Could I/we have planned it even better to achieve an even better result?” – was electrifying and groundbreaking for me from the first moment. Your enthusiasm for orthognathic surgery has always been contagious. You have never settled for what you have already achieved but always sought further development, new projects, new ideas, new energy. Thank you so much for the unique opportunity to plan and write this book. I hope I can pass on this enthusiasm to the next generation of maxillofacial surgeons.

Shared knowledge is double knowledge.

Contributors

Andreas Burger

Medicon Company, Tuttlingen, Germany

Dr med dent Stefan Clotten

Private Practice, Bad Vilbel, Germany

Dr med Sven Heinrich

Private Practice, Berlin, Germany

Dr med dent Christopher-George Hepburn

Private Practice, Ludwigsburg, Germany

Prof Dr med Dr med dent Philipp Jürgens

Private Practice, Munich, Germany

Dr med Dr med dent Wolfgang Kater

Gesundheitscampus Bad Homburg, Bad Homburg vor der Höhe, Germany

Dr med Eduard Kehrberger-Crook

Private Practice, Stadecken-Elsheim, Germany

Dr med Dr med dent Dr Winfried Kretschmer

Klinik für Mund-, Kiefer- und plastische Gesichtschirurgie, Klinik am Eichert, Göppingen, Germany

PD Dr med dent Björn Ludwig

Private Practice, Traben-Trarbach, Germany

Dr (stom) Ramo Poturak

Private Practice, Bad Soden, Germany

Prof Dr med Dr med dent Alexander Schramm

Klinik für Mund-, Kiefer- und Gesichtschirurgie der Universität Ulm, Ulm, Germany

Prof Dr med Dr med dent Gwen R. J. Swennen

Department of Maxillofacial Surgery, AZ Sint-Jan Brugge-Oostende, Oostende, Belgium

ZT Jan Ternes

Klinik für Mund-, Kiefer- und plastische Gesichtschirurgie, Klinik am Eichert, Göppingen, Germany

Dr med Albino Triaca

Klinik Pyramide, Zürich, Switzerland

Dr med dent Dieter Weber

Private Practice, Leinfelden-Echterdingen, Germany

Prof Dr med Dr med dent Frank Wilde

Klinik für Mund-, Kiefer- und Gesichtschirurgie der Universität Ulm, Ulm, Germany

Contents

Foreword Rolf Ewers

Preface

Editors

Acknowledgments

Contributors

Part A: Diagnosis

Chapter 1

Guidelines for photographic documentation of dentofacial malformations

Caroline Fedder

Chapter 2

Initial documentation of a dentofacial malformation

Caroline Fedder

Chapter 3

Modified cephalometric analysis for prediction planning

Konrad Wangerin, Caroline Fedder

Part B: Planning

Chapter 4

Surgical planning for dentofacial malformation

Caroline Fedder

Chapter 5

Model operation

Caroline Fedder, Jan Ternes

Chapter 6

Surgical planning and methodology with splint creation

Konrad Wangerin, Caroline Fedder, Winfried Kretschmer, Jan Ternes

Chapter 7

3D virtual individualized treatment planning of orthognathic surgery: 10-step protocol

Gwen R. J. Swennen

Chapter 8

Computer-assisted planning and splintless maxillary positioning in complex maxillomandibular surgery

Frank Wilde, Alexander Schramm

Part C: Procedures

Chapter 9

The surgical processing of bones – yesterday – today – tomorrow

Philipp Jürgens

Chapter 10

Le Fort I osteotomy

Konrad Wangerin

Chapter 11

Maxillary segmentation after Le Fort I osteotomy

Konrad Wangerin, Christopher-George Hepburn, Winfried Kretschmer

Chapter 12

Transmaxillary septorhinoplasty

Konrad Wangerin

Chapter 13

Mandibular sagittal split osteotomy

Konrad Wangerin, Wolfgang Kater

Chapter 14

Transantral maxillary distraction

Konrad Wangerin, Christopher-George Hepburn

Chapter 15

Transverse maxillary distraction

Konrad Wangerin, Christopher-George Hepburn, Andreas Burger, Björn Ludwig

Chapter 16

Transverse mandibular distraction

Konrad Wangerin, Christopher-George Hepburn, Dieter Weber

Chapter 17

Horizontal mandibular distraction

Konrad Wangerin

Chapter 18

Ramus distraction

Konrad Wangerin, Christopher-George Hepburn

Chapter 19

Chin correction (genioplasty)

Konrad Wangerin, Caroline Fedder

Chapter 20

Chin wing osteotomy

Albino Triaca, Sven Heinrich

Chapter 21

Anterior mandibular segmental distraction osteogenesis

Konrad Wangerin, Christopher-George Hepburn

Chapter 22

Anterior mandibular block rotation

Konrad Wangerin, Christopher-George Hepburn

Chapter 23

Secondary septorhinoplasty

Winfried Kretschmer

Chapter 24

Bone harvesting from the iliac crest

Konrad Wangerin

Chapter 25

Autologous fat grafting (lipofilling)

Konrad Wangerin

Chapter 26

Nasal–upper lip complex

Konrad Wangerin

Chapter 27

Zygomatic arch augmentation and reduction

Konrad Wangerin, Winfried Kretschmer

Chapter 28

Segment osteotomies

Konrad Wangerin, Christopher-George Hepburn

Chapter 29

Periodontally accelerated osteogenic orthodontics: a treatment case

Stefan Clotten, Ramo Poturak

Chapter 30

Anesthesia in dysgnathia surgery

Eduard Kehrberger-Crook

PART A

1

Guidelines for photographic documentation of dentofacial malformations

Caroline Fedder

1.1 General

This chapter summarizes the guidelines for the photographic documentation of dentofacial malformations. To ensure that no impressions of the cheek retractor are visible in the subsequent photos, it is advisable to take the facial photos first, followed by the intraoral photos.

1.2 Facial photography

1.2.1 Equipment

In order to enable measurement on the photos after printing, the patient and the photographer must be positioned at the correct distance in order to obtain a true-to-scale printout on DIN A4 (Fig 1-1).

Fig 1-1 Positioning of the camera at the same height as the eyes of the patient.

Markings on the floor for the patient’s and the photographer’s chairs ensure that the photographer is always at the same defined distance from the patient. If necessary, markings can be placed for standardized rotations (90/45 degrees) of the patient on the floor and/or on the wall.

A solid color background should be used.

1.2.2 Camera / photographer

The camera should be positioned on a tripod, or photo-grapher positioned on a chair with castors adjustable in height using the feet. This allows the camera to be held at the level of the patient’s head (Fig 1-2), and the photographer’s hands to remain on the camera.

Fig 1-2a Positioning of the camera at the same height as the eyes of the patient (red line), and positioning of the patient’s head so that the Frankfort horizontal plane (yellow line) is parallel to the floor.

Fig 1-2b Positioning of the interpupillary line parallel to the floor.

Fig 1-2c Positioning of the Frankfort horizontal plane parallel to the floor.

For precise adjustment of half-profile images, the photographer can roll to the side on a circular path without changing his or her posture.

1.2.3 Patient

Position the patient on a height-adjustable swivel chair or chair with a small headrest that does not take up too much space during the exposure.

Large earrings, jewelry, scarves, caps, glasses, etc, should be removed. Long hair should be tied up and tucked behind the ears. Eyes should be open so that the pupils are visible. The patient should sit upright with a straight spine. Shoulders should hang relaxed. Both soles of the feet should be placed completely on the floor.

The head should be kept straight so that the Frankfort horizontal line and interpupillary line are parallel to the floor (except for the frontal image in habitual posture) (Figs 1-3).

Fig 1-3 Habitual head position.

There should be sufficient distance to the background to avoid a drop shadow, or a slave flash can be used.

1.2.4 Recording

The entire head with attachment of shoulders should be photographed (caudal, eg, to the suprasternal notch).

For profile pictures, crop the image from the hair at the back rather than the tip of the nose at the front if cropping is required.

Frontal view in habitual posture

The patient should sit down on the chair and hold their head in their individual “natural” posture. The neck and the base of the shoulders are included in this photo, so that the posture can be judged.

It is important to check whether the patient is holding their head at an angle. Referral to an orthopedist may be necessary for assessment of the cervical spine/vertebral column (eg, scoliosis), or clarification of other syndromes (eg, hemifacial microsomia), depending on whether only the face is asymmetrical or if there is an additional scoliosis of the spine.

In the photographic example (Fig 1-3), the patient holds her head slightly tilted to the left and twisted to the right (the left tragus is more visible than the right).

All other frontal views

The eyes should be horizontal, so that the interpupillary line is parallel to floor.

The head should be kept straight (not turned or tilted). Check that both ears can be seen at the same distance, and note that the ears may stick out different amounts.

Frontal view with relaxed lips

This view is shown in Fig 1-4. In addition, here the teeth should be in resting position (let the patient hum “Mmmm” if necessary).

Fig 1-4 Frontal view with relaxed lips.

Lips must be relaxed (if necessary, have the patient moisten their lips with the tongue). In the case of lip closure insufficiency, the lips would be open accordingly.

This image is important to measure:

zygomatic contour

lip closure insufficiency

the facial thirds (upper, middle, and lower face)

the ratio of upper lip length to lower lip length, of lip white to lip red.

The photographic example (Fig 1-5) shows the following:

Fig 1-5 Frontal view showing the facial thirds, the distance between the median corners of the eyes, width of mouth, and alar width.

Frontal view with slightly open mouth

For this view (Fig 1-6), refer to the frontal view requirements above. The upper lip should be relaxed. Maxillary anterior teeth should be visible up to the incisal edg (if visible with relaxed lips).

Fig 1-6 Frontal view with slightly open mouth.

This view is important for the following reasons:

The photographic example (Fig 1-7) shows the following:

Fig 1-7 Measurement of the anterior maxillary teeth.

Measurement of the maxillary anterior tooth show

Target: 3 to 4 mm.

Frontal view smiling

For this view (Fig 1-8), refer to the frontal view requirements above. The patient should smile in a relaxed manner.

Fig 1-8 Frontal view smiling.

This view is important for the following reasons:

Determination of whether the upper lip on smiling and laughing are different.

Assessment of the symmetry and height of the anterior dental arch, and whether the dental arch is straight.

Determination of facial symmetry. The interpupillary line in relation to the facial midline is important for determining the symmetry of the maxilla and mandible and as a basis for postoperative changes in the face.

Identification of the facial midline is demonstrated in the photographic example (Fig 1-9):

Fig 1-9 Interpupillary line (red horizontal line), determination of the middle of the face via half of the distance from the pupils (yellow lines), and identification of the facial midline (red vertical line).

Check that the photo is taken symmetrically: Is the head held turned? Are the ears the same size? Can the tragus be seen to the same extent on both sides? In this case, the patient has tilted her head slightly to the right.

The interpupillary line can be drawn (between the two pupillary light reflexes): Check that the eyes are at the same level (they could be different eg, in case of hemifacial microsomia or after fractures). Only then can the reconstructed facial midline be used for surgical planning. Alternatively, the median eyelid angles can be used for reconstruction of the facial midline.

Determination of the facial midline: Determine the midpoint between the pupillary light reflexes and draw down perpendicularly. Alternatively, determine the midpoint between the two median eyelid angles (to be used especially in case of unilateral strabismus) and draw down perpendicularly. Check whether the constructed facial midline is on the glabella/nasal bridge center. If not, is the photo really taken symmetrically (see above)?

Determination of the lateral deviation to the facial midline of the nose tip, anterior nasal spine, philtrum, center of the maxilla (= approximal contact 11/21 [tooth numbering according to FDI notation]), center of the mandible (= approximal contact 31/41), and chin tip.

Target: The tip of the nose, anterior nasal spine, upper lip, lower lip, and chin should ideally be in the middle.

Frontal view laughing

For this view (Fig 1-10), refer to the frontal view requirements above.

Fig 1-10 Frontal view laughing.

This is the natural maximum smile, and is important for assessment of:

Anterior smile show

Lip contour when smiling

Whether a “gummy” smile is present (ie, part of the gingiva is visible)

Buccal corridors (black triangles next to the maxillary posterior region) to determine the transverse width and shape of the maxilla. Note whether posterior teeth are visible, and any asymmetry of the lateral dental arch or canines.

The photographic example shows the anterior tooth show during laughter.

Target: no or a low gingival smile.

Frontal view with spatula

For this view (Fig 1-11), refer to the frontal view requirements above.

Fig 1-11 Frontal view with spatula.

Check beforehand that the spatula is not bent or twisted. Place the spatula on the tips of the maxillary canine. The patient should hold the spatula carefully with the teeth. The spatula must not be bent, but must remain straight. If necessary, have the patient hold the spatula from below with their thumb (Fig 1-12).

Fig 1-12 Frontal view with retained spatula.

This view is important for the following reasons:

Determination of the facial midline and the position of the tip of the nose, anterior nasal spine, maxilla, mandible, and chin in relation to the determined facial midline

To check if the interpupillary line is parallel to the spatula (ie, if the maxilla is parallel to the interpupillary line).

The photographic example (Fig 1-13) shows the following:

Fig 1-13 Determination of whether the transverse maxillary plane (lower red horizontal line) is parallel to the interpupillary line (yellow line).

Determination of the correct position of the maxillary transverse plane:

Draw the interpupillary line

Connect the tips of the canines (lower red horizontal line)

Draw the perpendicular lines down from the pupillary light reflexes to the top of the spatula (white arrows)

Measure the distance on both sides (white arrows).

Target:

the tip of the nose, anterior nasal spine, and center of the maxilla and the mandible should be in the middle of the face

the maxilla (= top of the spatula) should be parallel to the interpupillary line.

In the example, measured from the canine tips, this patient’s maxilla is parallel to the interpupillary line.

Caution: If the canines are differently abraded or a canine is intruded, this level cannot be used as a reference for the maxillary position. Alternatively, it is possible to use other teeth, ie the premolars, to determine the transverse maxillary plane.

Frontal view with photo cheek retractors

For this view (Fig 1-14), refer to the frontal view requirements above.

Fig 1-14 Frontal view with photo cheek retractors with tabs.

If canine tips 13 and 23 are not visible in the spatula photo, an additional photo should be taken with photo cheek retractors to determine if the maxilla is parallel to the interpupillary line (Fig 1-14).

Alternatively, a photo can be taken without photo cheek retractors, but with the mouth open, showing the canine tips (Fig 1-15).

Fig 1-15 Frontal view with open mouth.

This view is important to assess whether the transverse maxillary plane (line connecting the canine tips 13 and 23) is parallel to the interpupillary line.

With the photo cheek retractors, it is additionally possible to see whether the patient has a “jaw” rotation of the maxillary molar region that requires correction.

The photographic example with the photo cheek retractors (Fig 1-16) shows the following:

Fig 1-16 Determination of whether the transverse maxillary plane (lower horizontal line) is parallel to the interpupillary line (yellow line).

Determination of the correct position of the transverse maxillary plane (see Fig 1-13)

Target: The line connecting canine tips 13 and 23 should be parallel to the interpupillary line, ie the maxilla is parallel to the interpupillary line.

There should be no jaw rotation of the posterior maxilla, ie the molars are visible equally on both sides, as seen in the example case.

Frontal view from below

In this frontal view (Fig 1-17), the head is tilted backward until the tip of the nose is just below the level of the supraorbital rim.

Fig 1-17 Frontal view from below.

This view is important for the following assessments:

symmetry of the nostrils

documentation of the width of the base of the nose

basal nasal septal deviation

symmetry of the zygomatic prominences

symmetry of the mandibular rim/angles.

The photographic example (Fig 1-18) shows measurement of the width of the nose.

Fig 1-18 Measurement of the alar width.

Target: equal values of the width of the nose pre- and postoperatively, symmetrical nostrils, symmetrical and prominent zygomatic prominences, symmetrical mandibular rim and angles.

Profile view (90 degrees, right and left)

These views are shown in Figs 1-19 and 1-20. For all profile/ semi-profile views, the following applies:

Fig 1-19 Profile view from the right (90 degrees).

Fig 1-20 Profile view from the left (90 degrees).

The Frankfort horizontal should be parallel to the floor (Fig 1-21).

The entire head with neck front and back/neck area and upper base of shoulder should be included.

Teeth should be in resting position (let the patient hum “Mmmm” if necessary).

Lips should be relaxed (if necessary, have the patient moisten their lips with the tongue); in case of lip closure insufficiency, lips are open accordingly.

In the case of mandibular retrognathia, the patient should push the mandible backward to be able to document the extent of mandibular retrognathia.

Fig 1-21 Orientation of the patient’s head to the Frankfort horizontal plane (red line).

In addition, the eyebrow on the other side should not be visible. However, there is a risk that the photo will be taken too far from the back and not enough of the face will be visible. If necessary, have the patient’s head turned slowly or move around the patient on the chair until the eyebrow of the other side is no longer visible, and then take the photo directly.

This view is important for profile planning (eg, nasolabial angle, prominence of upper and lower lip, chin, later corrections of the nose, shape of jaw angle, documentation of masseter hypertrophy, neck contour, midface hypoplasia, position and shape of the ears). The photographic example (Fig 1-22) shows the measurement of the nasolabial angle.

Fig 1-22 Measurement of the nasolabial angle.

Target: women 100 degrees, men 90 degrees.

Half profile view (45 degrees, right and left)

For this view, turn the patient with their entire body 45 degrees to the side; this is sometimes difficult to reproduce. Alternatively, two images can be created, as these are easier to reproduce individually:

Half profile view I (approx. 45 degrees, right and left)

For this view (Figs 1-23), turn the patient with the entire body 45 degrees to the side and then move around the patient until the tip of the nose coincides with the contour of the face; this is easy to reproduce individually (exception: if necessary, postoperatively after correction of the tip of the nose).

Fig 1-23a Half profile view from the right (approx. 45 degrees) – the tip of the nose on the contour of the face.

Fig 1-23b Half profile view from the left (approx. 45 degrees) – the tip of the nose on the contour of the face.

This view is important for the shape assessment of the jaw angle, asymmetries of the skull shape, and ears/position of the ears.

Half profile view II (approx. 45 degrees, right and left)

For this view (Figs 1-24), turn the patient with entire body 45 degrees to the side and then move around the patient until the opposite median eyelid angle is just visible behind the bridge of the nose; this is also easy to reproduce individually (exception: possibly postoperatively after correction of the bridge of the nose).

Fig 1-24a Half profile view from the right (approx. 45 degrees) – bridge of the nose on the median corner of the eyes (approx. 45 degrees).

Fig 1-24b Half profile view from the left (approx. 45 degrees) – bridge of the nose on the median corner of the eyes (approx. 45 degrees).

This view is important for assessment of the zygomatic bone contour and to reveal asymmetries of the skull shape.

1.3 Intraoral photos

The general guidelines for taking intraoral photos are as follows:

Photograph in a sitting position, eg, place the patient crosswise on the dental practitioner’s chair so that the patient’s legs hang down to the side (Fig 1-25).

The necessary equipment is shown in Fig 1-26.

Acquire intraoral images before taking the impression, as otherwise impression material residue could remain in the oral cavity.

Use intraoral mirrors, possibly also in oversize.

Warm up the mirrors so that they do not fog up; if necessary, blow dry with a multifunctional syringe such as Sprayvit (Dentsply Sirona) shortly before taking the photo.

Let the patient breathe through the nose.

Use cheek retractors to retract the lips; the teeth and marginal gingiva should be fully visible and not covered by the lips.

Carefully aspirate saliva and blow saliva bubbles from the occlusal surfaces/out of the vestibule.

Even in the case of asymmetric dental arches or partial dentition, the complete alveolar ridge should be acquired laterally.

The display should include the alveolar ridge, aspect ratios, mucogingival border, gingiva, and alveolar ridge width.

If the tongue is large and partially covers the teeth, one image should be taken with the tongue covering the teeth and one should be taken with the tongue held back over the mirror to image the entire occlusal surfaces.

Fig 1-25 Positioning of the camera and head of the patient for intraoral photography.

Fig 1-26 Equipment required for intraoral photography.

1.3.1 Terminal occlusion, frontal view

This view (Fig 1-27a) is taken with the photo cheek retractors in situ. The patient or the dental hygienist pulls lightly on the tab on the cheek retractors from both sides (Fig 1-27b).

Fig 1-27a Terminal occlusion, frontal view.

Fig 1-27b Positioning of the camera at the same height as the mouth of the patient (red line).

Fig 1-27c Focusing of the camera on the canines (yellow stars).

The focus should be on the canines for maximum depth of field (Fig 1-27c). The occlusal plane should be photographed horizontally or slightly from above. The patient should guide the mandible backwards into maximum Angle Class II occlusion, if they have an Angle Class II retrognathia with Sunday (dual) bite. The aim is to achieve a symmetrical view, with the dental arch center in the middle of the photo. Hold the lips away from the teeth, especially in the anterior mandible. The view should show the complete maxillary and mandibular arch and the maxillary and mandibular vestibules.

This view is important to show the course of the gingiva, the overview periodontal status, mucosal bands, mucosal thickness, recessions, the canine position (to assess whether one canine is higher than the other or if the entire maxilla is crooked), and abrasion.

If the patient has a constrained terminal occlusion, take one picture in their terminal occlusion and one with the first occlusal contact.

1.3.2 Terminal occlusion, left lateral view

This view (Fig 1-28a) is taken with the photo cheek retractors in situ. The patient turns their head slightly to the right and pulls the tab on the cheek retractors to the left posteriorly.

The focus is on the first premolars (Fig 1-28b). The occlusal plane should be photographed horizontally or slightly from above. The patient should guide the mandible maximally backward in Angle Class II patients, especially in the case of Sunday bite, to show the original dimension of the mandibular retrognathia.

Fig 1-28a Terminal occlusion from the left.

Fig 1-28b Focusing of the camera on the first premolars (yellow star).

This view should show the approach of the canines of the opposite side to at least the first molars of the same side.

It is important for assessment of occlusion, gingival conditions, mucosal bands, and periodontal conditions.

1.3.3 Terminal occlusion, right lateral view

For this view (Fig 1-29a) see the left lateral view above. The patient turns their head slightly to the left and pulls the tab on the cheek retractors to the right posteriorly (Fig 1-29b). The focus is again on the first premolars (Fig 1-29c).

Fig 1-29a Terminal occlusion from the right.

Fig 1-29b Positioning of the camera and patient for documentation of lateral terminal occlusion.

Fig 1-29c Focusing of the camera on the first premolars (yellow stars).

1.3.4 Maxillary view

Using an intraoral mirror, and retracting the upper lip with lip retractors or dental mirrors, this view is taken at maximum mouth opening (Fig 1-30a and 1-30b).

The focus is on the second premolars (Fig 1-30c). The aim is for a symmetrical view. If possible, do not let the mirror rest distally on the maxillary teeth, but press it down so that there is some space between the mirror and the teeth. The entire dental arch should be seen as vertically as possible, from above. This view is important to show the presence of the teeth, symmetry of the dental arch, and position of the dental midline to the palatal raphe.

Fig 1-30a Maxillary top view.

Fig 1-30b Positioning of the camera and patient for documentation of maxillary top view.

Fig 1-30c Focusing of the camera on the second premolars (yellow stars).

1.3.5 Mandibular view

For this view (Fig 1-31a), the patient should pull their head into their neck, and hold the lower lip with a lip retractor, contrastor, or dental mirrors, to show maximum mouth opening (Fig 1-31b). The neck can be supported by the dental assistant if necessary.

Fig 1-31a Mandibular top view.

Fig 1-31b Positioning of the camera and patient for documentation of mandibular top view using a contrastor and dental mirror.

Fig 1-31c Focusing of the camera on the second premolars (yellow stars).

The focus is on the second premolars (Fig 1-31c). The aim is for a symmetrical view. The tongue should be held back over the mirror or pressed back with the mirror to relax the tongue, keep the floor of the mouth free, and ensure that no teeth are hidden from view. If possible, do not allow the mirror to rest distally on the teeth, but press it cranially. Also vacuum carefully.

The entire dental arch/alveolar ridge with marginal gingiva should be seen as vertically as possible from above, including the floor of mouth with the lingual frenulum.

If the patient has an excessive pharyngeal (gag) reflex, leave the tongue on the floor of the mouth and make sure that the teeth are not covered occlusally by the tongue.

This view is important to show the presence of teeth, and the symmetry of the dental arch.

2

Initial documentation of a dentofacial malformation

Caroline Fedder

2.1 General information and medical history

2.1.1 Introduction

The following findings survey contains the anamnesis and clinical examination of the head, neck, and oral cavity including the functional analysis of the temporomandibular joints, the tongue, and the swallowing cycle. The significance of the findings obtained for surgical planning is explained.

2.1.2 General data

The documentation sheet is shown in Fig 2-1.

Fig 2-1 Preoperative documentation sheet.

Patient

Attending physicians

For interdisciplinary treatment of the patient and for queries, the data of the treating orthodontists and dental practitioners are requested.

Date of diagnosis and admitting physician

The day of admission of the set-up is recorded and the oral and maxillofacial surgeon performing the survey is documented. If the surgical planning is carried out by a person other than the surgeon performing the planning of the operation, queries about the clinical findings can be made in this way.

Diagnostics

The documents are checked for completeness and that they are up-to-date.

Current models, photos (see guidelines for photographic documentation; Chapter 1), and a panoramic radiograph, which are either already available or, like the functional MRI (fMRI), are created during setup, are obligatory for surgical planning. A cranial periapical scan or digital volume tomography (DVT)/CT should be available for transverse problems to check the width of the bony base of the arches and the axial inclination of the teeth. The 3D examination also provides information about the positioning of the temporomandibular joints (TMJs). The radiologic images must be up to date in order to be able to detect, for example, dental foci preoperatively and to treat them in time.

If there are previous temporomandibular joint disorders (TMDs), an MRI of the TMJs in occlusion and at maximum mouth opening should be available or, if there is macroglossia, an MRI to size the tongue. The findings must be included in the surgical planning.

Patient’s reason for treatment

Documentation of the reason for treatment from the patient’s point of view is important, since many different aspects develop in the course of long interdisciplinary treatment, which can cause the original reason to be forgotten. However, this should be recalled, especially before surgical interventions, in order to realistically bring the extent of the operation planned by the practitioner into line with the patient’s original and actual wishes. In this way, subsequent changes in the timing of treatment or new treatment goals can be discussed and the patient’s expectations can be converted into postoperative satisfaction.

2.1.3 Anamnesis

General anamnesis

When taking a general medical history, special attention is paid to allergies (eg, to antibiotics), the use of blood-thinning medications or those with an effect on bone metabolism (eg, antiresorptives), and known anemia, so that preoperative treatments can be initiated if necessary. A current anemia, eg due to a vegetarian diet or a bleeding tendency, is excluded or diagnosed by means of current laboratory values (hemoglobin value, red blood cell count, coagulation values, platelet function test) and treated accordingly pre-, intra-, and/or postoperatively.

Thrombosis or embolism in the patient’s own and/or family history must be additionally inquired about and then further clarified and included in the treatment planning as well as perioperatively.

Orthodontic/maxillofacial surgical history

If orthodontic palatal expansion or excessive transverse expansion of the maxillary dental arch has been performed so that the palatal molar cusps have been lengthened or periodontal lesions have developed in the buccal molar region, this is an indication of a discrepancy between the dental and skeletal transverse width of the maxilla. This can be seen in the analysis of the posteroanterior cephalometric radiograph and the 3D images.

Consequence

To avoid a postoperative transverse recurrence due to a too-narrow maxilla, the skeletal discrepancy should be corrected by a multi-part division of the maxilla with widening of the apical base and bony torque of the posterior teeth. However, this is only possible up to a skeletal transverse deficit of approx. 5 mm with low recurrence. Larger discrepancies should already have been treated by means of transverse maxillary distraction before the maxillomandibular realignment osteotomy.

The extraction of third molars in the mandible should have taken place more than 6 months prior to mandibular sagittal split osteotomy in order to avoid complications due to incomplete bony regeneration processes during sagittal splitting (eg, nerve damage, bad split). Transverse maxillary distraction and transverse mandibular distraction should have been performed at least 12 months prior to maxillomandibular realignment osteotomy for the same reasons in order to prevent transverse bony instabilities.

2.2 Clinical examination

2.2.1 Introduction

The following standardized procedure has proven effective for the clinical examination of the patient.

Examination of the face

Examination of the face includes assessment of:

proportions and symmetries of the face

soft tissue and outer skeletal frame in frontal view (Fig 2-2a)

soft tissue and outer skeletal frame in profile view (Fig 2-2b).

Figs 2-2a and 2-2b Soft tissue and outer skeletal frame (a) in frontal view and (b) in profile.

These are divided into:

upper face

midface

lower face

Examination of the TMJs/functional analysis

The TMJs are examined, with functional analysis.

Examination of the oral cavity

Examination of the oral cavity includes:

bony/skeletal base

occlusion

teeth

soft tissue and pharynx.

2.2.2 Examination of the face: frontal view

The frontal view is used and the preoperative data collected as shown in Fig 2-3.

Fig 2-3 Preoperative appraisal of dentofacial malformation – examination of the face in the frontal view.

Habitual head posture

A conspicuous habitual head posture can be an indication of a scoliotic malposition of the cervical spine, shoulder girdle obliquity, muscular asymmetries of the spine, or errors in the overall posture.

In pronounced mandibular retrognathia, the head is partially raised or the mandible and thus the chin are habitually pushed forward in order to unconsciously achieve a more favorable occlusion, which then conceals the underlying malocclusion.

Consequence

In the case of habitual head malposition, refer to an orthopedist for diagnosis and therapy of concomitant orthopedic diseases, if necessary.

For centric bite registration, the shortened mandible is manually returned to the central position of both condyles. In the case of severe tension, it may even be necessary to relax the masticatory muscles by means of general anesthesia in order to be able to perform centric bite registration in complete muscle relaxation. In this case, preoperative splint therapy should be considered.

Proportions and symmetries

Face type

The facial type ethnicity is collected at the beginning of the diagnostic process.

Consequence

When planning a maxillomandibular rearrangement osteotomy, different normal findings/harmonies must be considered depending on the ethnic face type. In the following explanations, the Caucasian face type is assumed.

Proportions/facial third

To examine the proportions, the facial thirds (upper, mid-, and lower face) are measured vertically:

In a harmonious face, the three proportions are ⅓ to ⅓ to ⅓. In women, a slightly shorter midface is also considered harmonious.

Short and long face refer to a shortening or lengthening of the entire face from the hairline to the tip of the chin. However, the shortened or lengthened components can affect all three parts of the face – upper face, midface, and lower face. Thus, in the case of a short or long face, it should be indicated which facial component is shortened or lengthened: upper face, midface, or lower face. This differentiated information determines the surgical indication and causal surgical planning (Fig 2-4). Since the upper face is usually not surgically altered, only vertical height changes of the midface or lower face portion can be performed, such as extrusion of the maxilla with bony augmentation by interpositional osteoplasty, intrusion of the maxilla with transmaxillary septorhinoplasty, and/or vertical augmentation or reduction of the mandible by chin osteotomy. In the case of a deep or open bite, the clinically imposing short or long face may be due to occlusion and can be eliminated by surgical adjustment of a normal occlusion.

Fig 2-4 Schematic presentation of different face proportions and their descriptions.

Facial asymmetries are characterized by a lateral deviation of facial parts from the facial midline. They can occur on both sides and in mild manifestations are only noticeable by a lateral displacement of the chin or mandible. Sometimes, with closed lips, the mouth area is also oblique, and with open lips, an obliquity of the transverse occlusal plane is noticeable. In more severe manifestations of facial asymmetry, a unilateral decreased or increased facial growth component occurs. A unilateral hypoplastic component due to congenital growth retardation exists, for example, in hemifacial microsomia, and a partially hyperplastic side of the face due to a pubertal growth spurt exists, for example, in hemimandibular hyperplasia.

Consequence

The upper, middle, and lower face should be harmoniously proportioned (see also section 2.3 Clinical correction planning).

Center line

The facial midline is determined in frontal view with the mouth slightly open (Fig 2-5). The interpupillary line (connecting the pupil centers) is used as a guide and the median vertical is constructed as the facial midline. Lateral deviations of the tip of the nose, anterior nasal spine, maxilla, mandible, and chin are taken into account in clinical surgical planning.

Fig 2-5 Determination of the facial midline.

Consequence

The anterior nasal spine, maxilla, mandible, and chin midline should be placed in the facial midline during maxillomandibular osteotomy.

Special features arise in the case of a crooked nose with nasal tip deviation, lowering of one eye, or facial asymmetry (see also section 2.3 Clinical correction planning).

Midface

Intercanthal distance and alar base (Fig 2-6): In a Caucasian face, the intercanthal distance roughly corresponds to the alar base.

Fig 2-6 Measurement of intercanthal distance and alar base.

Consequence

Since the alae nasi are detached from the bony base during Le Fort I osteotomy, they move latero-cranially if appropriate refixation of them is not performed. The patient complains of a “wide nose” postoperatively (Figs 2-7 and 2-8).

Fig 2-7 Anatomy of alar base, levator labii superioris alaequae nasi muscle, and levator labii superioris muscle (Reprinted with permission © AO Foundation, Switzerland, https://surgeryreference.aofoundation.org.)

Fig 2-8 The alae nasi are detached from the bony base during Le Fort I osteotomy, and move latero-cranially if appropriate refixation of them is not performed. This results in a “wide nose” postoperatively. (Reprinted with permission © AO Foundation, Switzerland, https://surgeryreference.aofoundation.org)

Therefore, before suturing the mucosa in the maxilla, the attachment of the levator labii superioris muscles and the levator labii superioris alaeque nasi muscles should be grasped with a suture and sutured bilaterally (“alar cinch suture”) in order to symmetrize the nasal wings, to narrow them to their initial level, and to fix them caudally (Fig 2-9).

Fig 2-9 The “alar cinch suture” prevents widening of the alar base. (Reprinted with permission © AO Foundation, Switzerland, https://surgeryreference.aofoundation.org)

Visible sclera

If a strip of sclera is visible between the iris margin and the lower eyelid edge (Fig 2-10) when looking straight ahead with a normal eyelid fissure width, this may indicate midface hypoplasia. The receding midface lacks optimal bony support of the overlying soft tissue and lower lid edge. This sinks back and exposes part of the sclera.

Fig 2-10 Visible sclera due to midface hypoplasia.

Other causes of a scleral show include exophthalmos or lower eyelid retraction (Graves disease), which should be evaluated ophthalmologically.

Consequence

See “infraorbital rim” below.

Infraorbital rim

A flat infraorbital rim (Fig 2-11) may also be indicative of midface hypoplasia with accompanying scleral show.

Fig 2-11 A flat infraorbital rim indicates a midface hypoplasia with accompanying scleral show.

Consequence

If the scleral show or the flat infraorbital rim is based on midface hypoplasia, a forward displacement of the maxilla – if necessary combined with a more cranial osteotomy line – is useful in the Le Fort I osteotomy to give the midface additional volume. The patient should be informed about the postoperative changes, since an increase in volume in the midface is often perceived as “swelling” from the patient’s side.

Especially with a concave facial profile, the type change is obvious to the patients and they occasionally have difficulty adjusting postoperatively to the additional volume in the midface (Fig 2-12).

Fig 2-12 With an originally concave facial profile, the postoperative type change is obvious due to the additional volume in the midface.

Zygomatic region

A flat or asymmetrical zygomatic region (Fig 2-13) is sometimes perceived as non-ideal by the patient.

Fig 2-13 Bilateral flat zygomatic regions.

Consequence

In the case of maxillomandibular rearrangement osteotomy, unilateral or bilateral augmentation of the zygomatic prominences with consecutive zygomatic arch augmentation can be performed simultaneously, since a bone block graft required here for interposition can be harvested distolingually from the tooth-bearing mandibular portion during sagittal splitting.

Paranasal soft tissue contour

A pronounced paranasal contour results, for example, from protrusion of the maxilla, or, in older age, as an involution process combined with deep nasolabial folds due to a descent of the soft tissue mantle (Fig 2-14).

Fig 2-14 A pronounced paranasal contour.

A flattened paranasal contour may be caused by midface hypoplasia combined with low expression of the nasolabial folds (Fig 2-15).

Fig 2-15 A flattened paranasal contour caused by midface hypoplasia combined with low expression of the nasolabial folds.

Consequence

Paranasal overlay plasty from autologous bone resorbs for the most part. By advancing the maxilla during Le Fort I osteotomy, flattening of a deep nasolabial fold is possible. Additional advanced osteotomy techniques with individualized nasolateral wings can also be used for this purpose (Fig 2-16).

Figs 2-16a and 2-16b In this case, a maxillomandibular osteotomy with a 3-piece maxilla with individualized nasolateral wings was performed.

Nose shape

The shape of the nose is documented preoperatively to identify postoperative changes.

Consequence

The width of the nostrils may change during maxillomandibular surgery, eg widen, if no alar cinch suture is applied.

Nasal axis

The nasal axis can be moved slightly to the right or left in its caudal portion by a movement of the anterior nasal spine. The bridge of the nose does not change significantly even after maxilla relocation.

Nasal wings

The nasal wings are detached from their bony support during the Le Fort I osteotomy (release of the levator labii superioris muscle and levator labii superioris alaequa nasi muscle) and shift cranio-laterally in the absence of refixation.

Consequence

Nasal septum and nasal breathing

Causes of nasal obstruction may include a deviated septum or septal spur, nasal valve stenosis, turbinate hypertrophy, or a narrow nasal base based on a transversely narrow maxilla.

Consequence

In the case of a deviated septum, the septum can be partially straightened during Le Fort I osteotomy and shortened if necessary. However, complete correction can only be achieved with subsequent septoplasty after maxillomandibular osteotomy, eg with scarification for straightening. Nasal valve stenosis is also correctable only with rhinoseptoplasty in a subsequent operation.

A septal spur is removed during Le Fort I osteotomy after down fracture, and hypertrophic inferior nasal concha must also be shortened via submucosal concha resection when the maxilla is cranially displaced to preserve unobstructed nasal breathing and avoid the development of an “empty nose.” Sometimes, hypertrophic inferior nasal concha are even a mechanical obstacle to the planned sufficient cranialization of the maxilla and must be shortened intraoperatively.

If the nasal airway obstruction is caused by a low intranasal airway volume emanating from a narrow nasal base due to a transversely narrow maxilla, a transverse maxillary expansion already brings a significant increase in volume and thus nasal airway improvement.

Lower face

Measurements of the lower face are discussed below.

Mouth gap width

The mouth gap width is defined as the distance from the right to the left corner of the mouth when the lips are relaxed. The corners of the mouth should be in the area between the perpendicular of the medial canthi and the perpendicular on the pupils (Fig 2-17). A very narrow and also a very wide oral fissure is considered inharmonious.

Fig 2-17 The mouth gap width is the distance from the right to the left corner of the mouth when the lips are relaxed. The corners of the mouth should be in the area between the perpendicular of the medial canthi and the perpendicular on the pupils.

Consequence

The oral cleft is enlarged by advancing the maxilla and mandible.

Upper lip

Upper lip shape relaxed

If the upper lip is thin when relaxed, this is due to either a lack of volume or a lack of bony/dental support. In addition, with age, there is a lengthening of the lip white with inversion of the lip red due to the increasing slackening of the upper lip. The visible upper lip red narrows (Fig 2-18).

Fig 2-18 Thin upper lip when relaxed.

Consequence

Advancement of the maxilla/protrusion of the maxillary anterior teeth to create a bony/dental base. If necessary, additionally various suture techniques during wound closure of the maxillary vestibule to “pad” the upper lip, eg median or bilateral paramedian V-Y technique.

Likewise, subsequent autologous fat grafting into the upper lip is possible if needed.

Asymmetry of the upper lip

The cause of an asymmetry of the upper lip should be determined and corrected according to the cause, if desired by the patient. Causes could be, for example, lip cleft, vestibular scarring due to previous surgery, syndromal disorders, and neurological pre-diseases.

Upper lip length

The total length of the upper lip depends on many factors and is on average 2.5 cm. The ratio of the total length (lip white and lip red) of the upper lip to the lower lip should be ⅓ (upper lip) to ⅔ (lower lip). In a reduced visible incisor length, for example, this can indicate whether the upper lip is too long (soft tissue cause) or whether its cause is maxillary vertical hypoplasia (skeletal cause) (Fig 2-19).

Fig 2-19 Facial proportions. The ratio of the total length (lip white and lip red) of the upper lip to the lower lip should be ⅓ (upper lip) to ⅔ (lower lip).

Lip closure insufficiency

To measure lip closure insufficiency, the patient should moisten the lips slightly and then hold them relaxed. Often it can already be seen from the mentalis habit (“curled” chin) whether the lower lip can really be relaxed or not. A mentalis habit is found when the lower lip is pulled cranially by tensing the mentalis muscles – the lip closure is thus brought about by muscle tension (Fig 2-20). The patient’s chin can then be gently smoothed downward by the practitioner while telling the patient to relax the lips, even if they do not come to rest on each other. In this way, the distance between the lower edge of the upper lip and the upper edge of the lower lip can be measured.

Figs 2-20a and 2-20b A mentalis habit because of lip closure insufficiency due to vertical maxillary excess and mandibular retrognathia.

Consequence

Lip closure insufficiency results from a mismatch of the encasing soft tissue to the position of the skeletal base and dentition. There are either vertical or sagittal discrepancies.

Vertical discrepancies: The maxilla is too far caudal (maxillary anterior view > 4 mm) or the anterior mandible is too high (exposure of the incisal edges of the anterior mandibular teeth with relaxed lips, see below). The maxilla should therefore be cranialized to achieve an ideal anterior tooth show of 3 to 4 mm. If the anterior mandible is too high, sufficient lip closure can be achieved by vertical shortening of the mandible with cranialization of the chin apex.

Sagittal discrepancies: In the case of a large sagittal positional difference between the maxilla and mandible, eg mandibular retrognathia, maxillary protrusion, or even mandibular prognathism, an Angle Class II occlusion with its almost vertical skeletodental base should be created for the overlaying soft tissue to rest with the occlusal plane at the level of the lip closure line.

In rare cases, the jaws are orthognathic and only the soft tissue mantle is too short.

Visible incisor length