Orthognathic Surgery E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 2387

Veröffentlichungsjahr: 2016

Beschreibung

ORTHOGNATHIC SURGERY

Orthognathic Surgery: Principles, Planning and Practice is a definitive clinical guide to orthognathic surgery, from initial diagnosis and treatment planning to surgical management and postoperative care.

• Addresses the major craniofacial anomalies and complex conditions of the jaw and face that require surgery
• Edited by two highly experienced specialists, with contributions from an international team of experts
• Enhanced by case studies, note boxes and more than 2000 clinical photographs and illustrations
• Serves as an essential reference for higher trainees and practicing clinicians in cranio-maxillofacial surgery, orthodontics, plastic and reconstructive surgery and allied specialties

Leseprobe

Orthognathic Surgery

Principles, Planning and Practice

Edited by

Farhad B. Naini

BDS (Lond.), MSc (Lond.), PhD (KCL), FDS.RCS (Eng.),M.Orth.RCS (Eng.), FDS.Orth.RCS (Eng.), GCAP (KCL), FHEA

Consultant Orthodontist Kingston Hospital and St George’s Hospital and Medical School London, UK

Daljit S. Gill

BDS (Hons), BSc (Hons), MSc (Lond.), FDS.RCS (Eng.), M.Orth.RCS (Eng.), FDS (Orth) RCS (Eng.), FHEA

Consultant Orthodontist Great Ormond Street Hospital NHS Foundation Trust and UCLH Eastman Dental Hospital London, UK

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Dedication

Hugo L. Obwegeser

MD, DMD, FDS.RCS (Eng.), Hon. FRCS (Eng.), Hon. FDS.RCPS (Glas.), Hon. FFD.RCS (Ire.)

Emeritus Professor of Oral Diagnosis and Oral Surgery, Dental School, and Director of the Department of Cranio-Maxillofacial Surgery, University Hospital, Zürich, Switzerland

Pioneer of Maxillofacial and Reconstructive Surgery of the Facial Skeleton and father of modern Orthognathic Surgery

Contents

Foreword

Preface

Acknowledgements

Contributors

1 Introduction: Orthognathic Surgery – A Life's Work

Hugo L. Obwegeser

Introduction

Historical remarks

How did the sagittal splitting procedure come into being?

Trauner's inverted L-shaped osteotomy of the ramus

My first successful sagittal splitting of the mandibular ramus

My final technique for many years

International reaction

Transoral chin correction

The mobilization of the maxilla – its history

Operative technique for mobilization of the maxilla

Modifications of the procedures

New procedures

Segmental alveolar osteotomies

Problems of maxillary anomalies in secondary cleft deformity cases

The Le Fort III + I osteotomy

The correction of hypertelorism

Recurrence

Special instruments

Concluding remarks

Acknowledgements

References

Part I: Principles and Planning

2 Historical Evolution of Orthognathic Surgery

Farhad B. Naini

Introduction

Mandibular osteotomies

Maxillary osteotomies

Psychosocial implications of facial deformities

Conclusion

References

3 Orthognathic Surgery: Preliminary Considerations

Farhad B. Naini and Daljit S. Gill

Definition of orthognathic surgery

Aetiology of dentofacial deformities

Classification of dentofacial deformities

Terminology for orthognathic surgical procedures

Prevalence of dentofacial deformities

Objectives of orthognathic surgery

Effectiveness of orthognathic surgery

Treatment need – who will benefit from orthognathic surgery?

Scope of orthodontic treatment and growth guidance

Surgical camouflage

References

4 Orthognathic Surgery: The Patient Pathway

Farhad B. Naini and Daljit S. Gill

Introduction

The orthognathic team

Orthognathic treatment pathway – the clinician's role

Sequencing of treatment and coordination of care

References

5 Patient Evaluation and Clinical Diagnosis

Farhad B. Naini and Daljit S. Gill

Introduction

Patient interview

Clinical diagnostic records

Patient evaluation – the basics

Systematic clinical evaluation

Concluding remarks

References

6 Principles of Orthognathic Treatment Planning

Farhad B. Naini and Daljit S. Gill

Introduction

1. Preoperative diagnosis

2. Vectorial analysis

3. Prediction planning

4. Model surgery

Concluding remarks

References

7 Smile Aesthetics: Specific Considerations in the Orthognathic Patient

Daljit S. Gill and Farhad B. Naini

Introduction

The alignment of the teeth

Sagittal position and inclination of the maxillary incisors

The visibility of the dentition in the vertical dimension

The visibility of the dentition in the transverse dimension

Symmetry

Conclusions

References

8 Orthodontic and Orthognathic Surgery Planning Using CBCT

Lucia H.S. Cevidanes, Vinicius Boen, Beatriz Paniagua, Martin Styner and Tung Nguyen

Introduction

3D CBCT diagnosis and treatment planning

Longitudinal assessments using CBCT

Conclusions

References

9 Psychological Evaluation and Body Dysmorphic Disorder

Katharine A. Phillips and Canice E. Crerand

Introduction

Prevalence of BDD

Definition and clinical features of BDD

A patient with BDD

Treatment of BDD

Assessment of patients with BDD

How surgeons can approach patients with BDD

Conclusions

References

10 Patient Information Provision

Farhad B. Naini, Daljit S. Gill and Umberto Garagiola

Introduction

Effective communication

Information-seeking behaviour in patients

Methods of information provision

Conclusion

References

11 Consent and Medicolegal Considerations

Robert A.C. Chate

Introduction

UK perspective

International perspective

Informed consent essential requirements

Informed consent for orthognathic surgery

Who may legally give consent?

Adults who lack capacity

Conclusions

References

12 Preparatory and Postoperative Orthodontics: Principles, Techniques and Mechanics

Farhad B. Naini and Daljit S. Gill

Introduction

Preoperative orthodontics

Immediate preoperative appointment

Intraoperative orthodontic requirements

Immediate postoperative appointment

Postoperative orthodontics

Retention

Concluding remarks

References

13 Model Surgery

Farhad B. Naini, James McInnes, Daljit S. Gill and Andrew Stewart

Introduction

Definitions

Model surgery – principles

Model surgery – technique

Virtual model surgery

Conclusions

Acknowledgements

References

14 Perioperative Considerations and Anaesthesia for Orthognathic Surgery

Anne S. Blyth and Jelena Devic

Introduction

Preoperative assessment

Intraoperative care

Postoperative care

Conclusions

References

15 Postoperative Care, Nutritional Support and Oral Hygiene in the Orthognathic Surgical Patient

Richard Cobb, Kelly Wade-Mcbane and Mehmet Manisali

Postoperative care of the orthognathic surgical patient

Nutritional support

Oral hygiene measures

Conclusions

References

16 The Soft Tissue Effects of Orthognathic Surgery

Daljit S. Gill, Farhad B. Naini and Maarten Koudstaal

Introduction

The immediate response to orthognathic surgery

Soft tissue changes with maxillary surgery

Soft tissue changes with mandibular surgery

Genioplasty

Conclusions

References

17 Early Orthognathic Surgery: Considerations for Surgical Management

Pushkar Mehra and Larry M. Wolford

Introduction

Diagnostic considerations

Mandibular deformities

Maxillary deformities

Double jaw orthognathic surgery

Conclusions

References

18 Stability of Orthognathic Surgery

Tate H. Jackson and Brent A. Golden

Introduction

The principles of stability

Surgical planning using the hierarchy of stability

Conclusion

Acknowledgements

References

19 Management of Select Complications in Orthognathic Surgery

David S. Precious

Introduction

Orthodontic factors

Maxillary surgery

Mandibular surgery

Summary of orthognathic surgery complications

References

20 Patient Satisfaction and Patient-Centred Outcome Measures in Orthognathic Surgery

Ceib Phillips and Caitlin Magraw

Introduction

Immediate postoperative disturbances

Long-term disturbances and physical impacts

Long-term satisfaction and perception of improvement

Recommendations

Acknowledgements

References

Part II: Clinical Practice and Techniques

Section 1: Orthognathic Surgical Planning and Techniques

21 Introduction: Perspectives on Treatment Planning

Harvey M. Rosen

22 Le Fort I Osteotomy and Maxillary Advancement

Helen Witherow and Farhad B. Naini

Introduction

History of the Le Fort I osteotomy

Assessment of the maxilla

Anatomy

Surgical technique

Surgical technique – Le Fort I osteotomy

Variations of the Le Fort I osteotomy

Complications associated with the Le Fort I osteotomy – occurrence, prevention and management

References

23 Total Maxillary Set-Back Osteotomy

Joel Ferri and Romain Nicot

Introduction

Treatment planning

Surgical technique and considerations

General remarks

Case report

Acknowledgements

References

24 Sagittal Split Osteotomy and Mandibular Advancement

Christoph Huppa and Gavin Mack

Introduction

Indications

Treatment planning

Preoperative orthodontics

Surgical technique

Complications

Postoperative orthodontics

Case report

References

25 Mandibular Set-Back Procedures

Manolis Heliotis and Shamique Ismail

Introduction

Clinical assessment and planning

Preoperative orthodontic treatment

Surgical techniques

Postoperative management

Orthodontic retention

Case report

Reference

26 Surgical Correction of Vertical Maxillary Excess (VME)

Farhad B. Naini, Helen Witherow and Daljit S. Gill

Introduction

Diagnosis and aetiology

Principles in planning the surgical correction of vertical maxillary excess

Orthodontic preparation

Surgical technique

Postoperative orthodontics

Case examples

Alternative treatment options

Conclusion

References

27 Surgical Management of Vertical Maxillary Deficiency (VMD)

David J. David

Introduction

Pathology

Treatment planning

Surgical techniques

Ancillary surgical techniques

Outcomes and complications

Conclusions

Acknowledgements

References

28 Surgical Correction of Skeletal Anterior Open Bite: Segmental Maxillary Surgery

Johan P. Reyneke and Carlo Ferretti

Introduction

Development of the open bite malocclusion

Diagnosis

Treatment of growing patients

Treatment of skeletally mature patients

Combined orthodontic and surgical treatment

Surgery

Open bite secondary to short mandibular ramus with a normal condyle: mandibular surgery

Open bite secondary to a combination of vertical maxillary excess and short mandibular ramus

Open bite secondary to short mandibular ramus with condylar resorption

Conclusions

References

29 Surgical Correction of Anterior Open Bite: Differential Posterior Maxillary Impaction

Farhad B. Naini, Andrew Stewart and Daljit S. Gill

Introduction

Diagnosis and aetiology

Principles in planning the surgical correction of skeletal anterior open bite

Orthodontic preparation

Surgical technique

Postoperative orthodontics

Conclusion

References

30 Surgical Treatment of Anterior Open Bite with Mandibular Osteotomies

Dale Bloomquist and Don Joondeph

Introduction

Aetiology and description of skeletal anterior open bite

Treatment decisions for surgery

Techniques for maximizing stability when anticlockwise rotation of the mandible is used

References

31 Rotation of the Maxillomandibular Complex

Johan P. Reyneke

Introduction

Principles of conventional treatment designs

Principles of rotation of the maxillomandibular complex treatment design

Geometry and visualization of the rotation of the maxillomandibular complex

Indications and treatment designs using the constructed maxillomandibular triangle

Orthodontic treatment considerations

Rotation points and direction of rotation

Clockwise rotation of the maxillomandibular complex

Counterclockwise rotation of the maxillomandibular complex

Step-by-step development of a cephalometric surgical visual treatment objective

Stability after clockwise and counterclockwise rotation of the maxillomandibular complex

References

32 Specific Considerations in the ‘Low Angle’ Patient

Declan Millett

Introduction

Case assessment and treatment planning

Orthodontic management

Surgical aspects

Adjunctive procedures

Post-surgical stability and evidence of effectiveness

Acknowledgements

References

33 Osseous Genioplasty

Ali Totonchi, Sima Molavi and Bahman Guyuron

Introduction

Anatomy

Patient evaluation

Patient and procedure selection

Surgical technique

Postoperative complications

References

34 Asymmetries of the Maxilla and Mandible

Farhad B. Naini, Mehmet Manisali and Daljit S. Gill

Introduction

Aetiology and classification

Clinical evaluation

Principles in planning the surgical correction of maxillary and mandibular asymmetry

Orthodontic preparation

Surgical technique

Postoperative orthodontics

Case Examples

Conclusion

References

35 Temporomandibular Joint Replacement Surgery in the Orthognathic Patient

N. Shaun Matthews, Jonas Osher and Martyn T. Cobourne

Introduction

History of TMJ reconstruction

Guidelines for TMJ replacement

Surgical planning for TMJ reconstruction

Surgical procedure

Orthognathic procedures

TMJ pathology related to the orthognathic patient

Surgical ‘work-up’

Case studies

Acknowledgements

References

36 Surgically Assisted Rapid Maxillary Expansion

Nigel Taylor and Paul Johnson

Introduction

Rapid maxillary expansion

Treatment planning – surgical options to widen the maxilla

Patient selection and case assessment for SARPE

SARPE protocol

Evaluation of surgical techniques for SARPE

General complications

Dental complications

Postoperative management and appliance activation

Bone-borne appliance

Evidence for stability of expansion achieved with SARPE

The future

References

37 Mandibular Midline Osteotomy

Dale Bloomquist and Don Joondeph

Introduction

Literature review

Techniques

Conclusion

References

38 Segmental Surgery of the Maxilla

Jocelyn M. Shand and Andrew A. Heggie

Introduction

Treatment planning

Surgical technique

Case report

Acknowledgment

References

39 Total Subapical Mandibular Osteotomy

Jonathan Sandler, Alison Murray and Peter Doyle

Introduction

History of the technique

Case 1

Case 2

Discussion

Conclusions

References

40 Endoscopy in Maxillary and Mandibular Orthognathic Surgery

Katherine P. Klein, Natalie N. Tung and Maria J. Troulis

Introduction

Maxillary orthognathic surgery

Mandibular orthognathic surgery

Endoscopic orthognathic surgery for the orthodontist

Future directions

References

41 The Role of the Orthognathic Surgeon in Facial Feminization Surgery

Keith Altman

Introduction

Male and female faces: aesthetics

Surgical procedures of special interest to the orthognathic surgeon

Forehead reduction

Rhinoplasty

Cheek implants

Angle shave and taper

Genioplasty

Discussion

References

42 Contemporary Approach to Surgical Timing in Orthognathic Surgery: The ‘Surgery First’ Concept

Federico Hernández-Alfaro and Raquel Guijarro-Martínez

Introduction

Surgery first

Definition of the appropriate timing for surgery

References

43 Neurosurgical Access Surgery: The Role of the Orthognathic Surgeon

Helen Witherow, Daniel Archer and Simon Stapleton

Introduction

History of skull base surgery

Anatomy of the skull base

Pathology

Access osteotomies

General techniques

Complications

References

44 Obstructive Sleep Apnoea Syndrome

Ashraf Messiha, Ben Gurney and Piet Haers

Introduction

PCAV Risk Score Index

Pathophysiology

Treatment planning

Preoperative work-up

Surgical technique

Case report

Conclusions

References

45 Mandibular Intraoral Distraction Osteogenesis

Cesar A. Guerrero, Gisela I. Contasti-Bocco and Aura Marina Rodriguez

Introduction and history

Indications

Contraindications

Mandibular widening

Bilateral mandibular lengthening

Parasymphyseal osteotomy

Unilateral mandibular lengthening

Postoperative considerations

References

46 Maxillary Intraoral Distraction Osteogenesis

Cesar A. Guerrero

Introduction and history

Indications

Contraindications

Maxillary Le Fort I level advancement

Maxillary Le Fort I level advancement in clefts

Modified Le Fort III midface advancement

Subcranial Le Fort III midface advancement

Postoperative considerations

References

Section 2: Adjunctive Surgery

47 Introduction: Adjunctive Surgery

Foad Nahai

References

48 Rhinoplasty and Nasal Changes In Relation to Orthognathic Surgery

Mehmet Manisali and Leila Khamashta-Ledezma

Introduction

Nasal analysis

Basic steps in rhinoplasty

Nasal function following maxillary osteotomies

Aesthetic changes in the nose following orthognathic surgery

Intraoperative procedures to manage nasal changes with orthognathic surgery

Secondary nasal procedures following orthognathic surgery

Concluding remarks

References

49 Deep Plane Facelift

Farhad Ardeshirpour, Craig S. Murakami and Wayne F. Larrabee

Anatomy

Preoperative evaluation

Surgical technique

Postoperative care

Complications

References

50 Soft Tissue Resuspension

Alistair R.M. Cobb and Jonathan A. Britto

Introduction

Surgical technique

Discussion

Acknowledgements

References

51 Soft Tissue Augmentation and Fat Grafting

Mehmet Manisali and Rahul Jayaram

Introduction

Fat grafting

Biology of fat grafting

Surgical technique

Complications

Discussion

Conclusions

References

52 Aesthetic Surgery of the Submental-Cervical Region

Tirbod Fattahi

Introduction

Anatomy

Surgical options and evaluation

Surgical procedures

Discussion

Conclusion

References

53 Surgical Options for Aesthetic Enhancement of the Lips and Perioral Region

Joe Niamtu

Introduction

Patient assessment and communication – not everyone needs bigger lips

Mucosal reduction cheiloplasty procedure

Cutaneous lip reduction

Intraoral soft tissue surgery for excessive gingival display

References

Section 3: Orthognathic Surgery in the Cleft Patient and Orthognathic Aspects of Craniofacial Surgery

54 Introduction: Craniofacial Surgery

Jesse A. Taylor and Scott P. Bartlett

References

55 Developmental Disorders of the Craniofacial Complex

Martyn T. Cobourne and David P. Rice

Introduction

Development of the craniofacial region

Oro-facial clefting

Holoprosencephaly

Fetal alcohol syndrome

Ectodermal dysplasia

Pierre Robin syndrome

Hemifacial microsomia

Treacher Collins syndrome

Nager syndrome

Miller syndrome

Craniosynostoses

Single suture synostosis

Non-syndromic craniosynostosis

Syndromic craniosynostoses: Apert, Crouzon and Pfeiffer

Muenke syndrome

Saethre–Chotzen syndrome

Craniofrontonasal syndrome

Carpenter syndrome 1 and 2

Greig cephalopolysyndactyly syndrome

Chromosomal abnormalities causing craniosynostosis

Mouse models of craniosynostosis

Frontonasal dysplasias 1–3

Cleidocranial dysplasia

References

56 Orthognathic Surgery in the Patient with Cleft Lip and Palate

Alexander C. Cash and Alistair R.M. Cobb

Introduction

Prevalence

Treatment planning

Factors in planning orthognathic care

Facial features

Soft tissue approaches to the maxilla

Maxillary surgery

Segmental surgery

Distraction osteogenesis

Management of hard palate fistulas at the time of cleft orthognathic surgery

Adjunctive surgery to improve facial contouring following orthognathic procedures

Retention and outcomes

Psychological input

Speech and language input

Patient input

Acknowledgements

References

57 Craniofacial Asymmetry: Causes and Management

Pravin K. Patel, Ronald Jacobson and Linping Zhao

Introduction

Causes and classification of craniofacial asymmetry

Evaluation and assessment

Principles of symmetry reconstruction

Summary

References

58 High Level Maxillofacial Osteotomies

Stephen Dover

Introduction

Indications for midfacial osteotomies

Preoperative assessment

Surgical procedures

References

59 Le Fort-based Maxillofacial Vascularized Transplantation

Chad R. Gordon, Harlyn K. Susarla, Edward Swanson, Seenu Susarla, Mehran Armand, Gerald Grant, Leonard B. Kaban and Michael J. Yaremchuk

Introduction

Le Fort II-based allotransplantation

Le Fort III-based allotransplantation

Orthognathic planning for maxillofacial allotransplantation

Facial identity and cross gender transplants

Pre-clinical investigation in swine

Planning and practice

Conclusions

Disclosures

References

Section 4: Appendix

60 Orthognathic Surgery – One Patient's Perspective

Tania Murphy

Introduction

My orthognathic surgical treatment

Advice on preoperative patient preparation

Conclusions

References

61 Responding to Patients' Psychological and Social Needs Following Orthognathic Surgery

Henrietta Spalding

Introduction

Living with a disfiguring jaw condition

The cultural context

How do facial deformities affect patients and their families?

How to respond to patients' needs

How healthcare professionals can support their patients adjusting to their different appearance

The graded approach

References

Index

List of Tables

Chapter 2

Table 2-1

Chapter 3

Table 3-1

Table 3-2

Table 3-3

Table 3-4

Chapter 4

Table 4-1

Chapter 5

Table 5-1

Table 5-2

Table 5-3

Table 5-4

Table 5-5

Table 5-6

Chapter 6

Table 6-1

Table 6-2

Chapter 7

Table 7-1

Table 7-2

Chapter 12

Table 12-1

Table 12-2

Table 12-3

Chapter 15

Table 15.1

Table 15.2

Table 15.3

Chapter 16

Table 16-1

Table 16-2

Table 16-3

Chapter 19

Table 19-1

Chapter 28

Table 28-1

Chapter 29

Table 29-1

Table 29-2

Chapter 31

Table 31-1

Table 31-2

Table 31-3

Table 31-4

Table 31-5

Table 31-6

Table 31-7

Chapter 32

Table 32-1

Table 32-2

Table 32-3

Table 32-4

Table 32-5

Chapter 33

Table 33-1

Table 33-2

Chapter 34

Table 34.1

Table 34.2

Table 34.3

Table 34.4

Table 34.5

Chapter 35

Table 35-1

Table 35-2

Chapter 43

Table 43.1

Chapter 44

Table 44-1

Table 44-2

Chapter 51

Table 51-1

Table 51-2

Chapter 55

Table 55-1

Chapter 57

Table 57.1

Table 57.2

Table 57.3

Table 57.4

Chapter 61

Table 61.1

List of Illustrations

Chapter 1

Fig. 1-1 My teachers (anticlockwise): Professor Hermann von Chiari, Chief of the Institute of Pathology and Microbiology of the University of Vienna. Professor Richard Trauner, Chief of Dentistry and Maxillofacial Surgery, University of Graz, Austria. Professor Eduard Schmid, Chief of the Klinik für Gesichtschirurgie, Marienhospital, Stuttgart. Sir Harold Gillies, International founder of Plastic and Reconstructive Surgery, Basingstoke, England. Mr Norman Rowe, Chief of Department of Oral Surgery, Basingstoke, England. Dr Paul Tessier, Chief of the Department of Plastic Surgery, Military Hospital, Paris.

Fig. 1-2 Drawings of my sagittal splitting technique (from: Obwegeser, 1957).

3

Fig. 1-3 Intraoperative photographs (from: Obwegeser, 1957).

3

Fig. 1-4 My first successful sagittal splitting case (from: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001).

31

Fig. 1-5 My final technique for the sagittal splitting procedure for many years (from: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001).

31

Fig. 1-6 My technique and first case of transoral sliding chin procedure (from: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001).

31

Fig. 1-7 Drawings of my technique of Le Fort I anterior repositioning (from: Obwegeser, 1969).

28

Fig. 1-8 Drawings of my transoral angle osteotomy (from: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001).

31

Fig. 1-9 Schuchardt's procedure for correcting a maxillary open bite: (a) technique; (b) case before surgery; (c) occlusion after additional bridge work; (d) amount of relapse after one year.

Fig. 1-10 Some variations of lateral cortical cut for the sagittal splitting procedure by different authors (from: Obwegeser, 1968).

23

Fig. 1-11 H. Köle's technique for closing an anterior mandibular open bite: (a) The technique in a drawing; (b) Case before surgery; (c) Model operation; (d) Lateral skull radiographs before and after surgery; (e) Occlusion after one year. (From: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001.)

31

Fig. 1-12 Case of maxillomandibular long face plus open bite: (a) Before surgery; (b) Model operation plus drawings of planned surgery; (c) Result of surgery.

Fig. 1-13 Joachim Obwegeser's circular splitting of the mandible (from: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001).

31

Fig. 1-14 Case of secondary cleft deformity: Retromaxillism plus collapse of the maxillary arches: (a) Before surgery; (b) Model operation and drawings of planned surgery; (c) Lateral skull radiographs and occlusion before and one year and three months after surgery; (d) Profile view before and three months after surgery. (From: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001.)

31

Fig. 1-15 H.L. Obwegeser's technique for a combined Le Fort III+I operation. (From: Obwegeser, 1969.)

28

Fig. 1-16 Case of micro-retromaxillism: (a) Occlusion and lateral skull radiographs before and after surgery; (b) Profile and front views of case before and 2 years and 10 months after surgery. (From: Obwegeser HL. Mandibular Growth Anomalies. Springer, 2001.)

31

Fig. 1-17 Case of asymmetric hypertelorism. (a) Front view and semi-axial skull radiograph before surgery; (b) Planned operation and operation pictures; (c) Semi-axial radiographs of the skull before and after the correction; (d) Patients front views before and after the correction.

Fig. 1-18 Antonio – the case of my life. (From Obwegeser et al., 1978.)

29

Patient presented with midfacial duplication and medial facial cleft. Left: situation after birth; Right: at age of 10.

Fig. 1-19 Patients maxilla with two premaxillae plus skull semi-axial radiograph.

Fig. 1-20 Drawings of planned operation.

Fig. 1-21 Skeletal situation during and after correction plus excised part of forehead area.

Fig. 1-22 Patient after surgery plus radiograph.

Fig. 1-23 Patients lateral skull radiograph after removal of cranial plate due to infection plus view of reconstruction of skull defect with 14 half ribs.

Fig. 1-24 Lateral scull view with slight retromaxillism on the left side and 2.5 years later with severe facial deformity.

Fig. 1-25 Patients profile at age 17 years and 8 months and his lateral radiograph at age 18.

Fig. 1-26 Drawings of the skeletal situation and the planned correction.

Fig. 1-27 Profile before and after surgical correction.

Fig. 1-28 Reconstruction of the missing columella by a caterpillar flap and reconstruction of the framework of the septum by an L-shaped cartilage graft from the ribs.

Fig. 1-29 Profile view of patient at age 17 years and 8 months, and 20 years and 7 months.

Fig. 1-30 Presurgical and final lateral cephalometric radiograph of the skull.

Fig. 1-31 View of the nose before surgery and the final result.

Fig. 1-32 The patient and his surgeon again 25 years after surgery.

Chapter 2

Fig. 2-1 Simon P. Hullihen (1810–1857).

Fig. 2-2 (a)(i): Preoperative view of female patient, aged 20 years, following severe burns to the neck and chest 15 years earlier, and subsequent scar contractures and deformity of the anterior mandible. Hullihen undertook a wedge ostectomy and set-back of the anterior mandible via an intraoral approach, followed by two further surgical procedures for scar revision and lower lip revision. (a)(ii) 3 weeks postoperative result, following the final surgical procedure. (b)(i): Anterior subapical osteotomy and ostectomy; (b)(ii) Rotational set-back of the anterior mandibular dentoalveolar segment. (c): Diagram of the lip revision surgery. (After Hullihen,

3

).

Fig. 2-3 Edward Hartley Angle (1855–1930) (Courtesy of The University of Arizona).

Fig. 2-4 Vilray Papin Blair (1871–1955), through the ages.

Fig. 2-5 Blair's mandibular body ostectomy, undertaken in 1897.

Fig. 2-6 Cast gold splints for postoperative fixation, suggested by Edward Angle, (a): pre-mandibular body ostectomy, (b): postoperative.

Fig. 2-7 Rodrigues Ottolengui (1861–1937).

Fig. 2-8 Ottolengui surgical splint.

Fig. 2-9 Max Ballin (1869–1934).

Fig. 2-10 (a): Ballin's paper from 1908;

13

(b): Patient's dental models; (c): Patient's preoperative and postoperative facial appearance. Towards the end of his presentation, Ballin said: ‘The result, as you can see, is a very favorable one. The patient's facial expression is very much improved, and the young man, who formerly was shy and kept away from society, I am told, is now a favorite with young ladies.’

Fig. 2-11 Ottolengui's response to Ballin's paper. (From Ballin,

13

).

Fig. 2-12 Matthew Henry Cryer (1840–1921). (Courtesy of Historical Collections & Archives, Oregon Health & Science University).

Fig. 2-13 Cryer's semi-circular osteotomy (1913). (From Cryer,

14

).

Fig. 2-14 Aller's description of removal of a bony wedge via an intraoral approach (1917). (After Aller,

15

).

Fig. 2-15 Harsha's extraoral mandibular body resection, maintaining the integrity of the neurovascular bundle (1912). (After Harsha,

16

).

Fig. 2-16 (a): Kazanjian's use of a Gigli saw for a mandibular body ostectomy and set-back (1932). (b): measuring the amount of bone removal required using study models; (c): Orthodontic splint, cemented preoperatively; (d): Use of a surgical bur for an ostectomy (on a different patient), for mandibular set-back and closure of an anterior open bite. (e): Preoperative anterior open bite; (f): Postoperative result. Kazanjian achieved this by (a): ‘cut through the mandible at the molar region on each side and elevate the anterior segment to meet the maxillary teeth.’ This is an early description of closure of an anterior open bite with an isolated mandibular procedure. (After Kazanjian,

18

).

Fig. 2-17 (a): Anton Freiherr von Eiselsberg (1860–1939). (b): step-ostectomy. (After von Eiselsberg,

19

).

Fig. 2-18 Fickling and Fordyce technical note describing iliac crest bone graft (1955,

21

).

Fig. 2-19 John Herbert Hovell (1910–1988). (Courtesy of Journal of Medical Biography, Sage Publications).

Fig. 2-20 Hovell described the potential detrimental effects on the submental-cervical region from a significant mandibular set-back, and its surgical management by removal of a wedge of submental skin. (From Hovell,

22

).

Fig. 2-21 Hovell with his friend Hugo Obwegeser in Zurich. (Courtesy of Journal of Medical Biography, Sage Publications).

Fig. 2-22 Hofer's anterior mandibular subapical osteotomy to advance the mandibular labial dentoalveolar segment (1936) (After Köle,

26,27,28

).

Fig. 2-23 Heinrich Köle. (Courtesy of the Journal of Cranio-Maxillofacial Surgery).

Fig. 2-24 Köle subapical anterior mandibular advancement osteotomy (After Köle,

26,27,28

).

Fig. 2-25 Köle subapical anterior mandibular advancement osteotomy and closure of an anterior open bite, with bone graft taken from the inferior border of the chin, concomitantly reducing vertical chin height (After Köle,

26,27,28

).

Fig. 2-26 Sowray and Haskell Y-body ostectomy (1968) (After Henry,

30

): (a): Preoperative skeletal Class III with mandibular prognathism; (b): Extraction of mandibular first premolars and localized anterior alveolar osteotomy, permitting segmental set-back; (c): Midline symphyseal ostectomy, permitting anterior constriction; (d): Postoperative result.

Fig. 2-27 (a): Robert Bruce MacIntosh (Courtesy of Dr R. Bruce MacIntosh). (b): Total mandibular subapical (alveolar) osteotomy - original description by MacIntosh (1974,

32

); (i) Position of the osteotomy at the base of the alveolus, and another horizontal osteotomy of the osseous chin. (ii) The repositioned alveolar process supported by the transposed chin fragment and an augmenting iliac bone graft (After MacIntosh, 1974,

32

). (c): Subsequent description by MacIntosh (1985,

34

); (i) Describing the potential repositioning of the entire mandibular dentoalveolar segment in the direction of the desired correction, (ii) Diagram of the surgical procedure used to reduce lower face height and augment the chin, modified from Köle (After MacIntosh, 1985,

34

).

Fig. 2-28 Sir George Murray Humphry (1820–1896).

Fig. 2-29 Paul Berger (1845–1908).

Fig. 2-30 Mathieu Jaboulay (1860–1913).

Fig. 2-31 Léon Bérard (1870–1956).

Fig. 2-32 Robert Henry Ivy (1881–1974) (Courtesy of Professor Aron Wahrman and the Robert H. Ivy Society of Plastic Surgeons).

Fig. 2-33 Léon Dufourmentel (1884–1957).

Fig. 2-34 (a): František Kostečka (1893–1951) (Courtesy of Professor Daniel Hrušák). (b): Leonardo Gigli (1863–1908).

Fig. 2.35 (a): Kostečka's condylar neck osteotomy using an extraoral approach and Gigli saw (1928) (After Spilka,

42

), demonstrating insertion of aneurysm needle and the structures to be avoided; (b) Gigli saw in position; (c) Position of mandibular condyle and ramus after condylar neck osteotomy and set-back of the mandible. (d): Various approaches to closing an anterior open bite with mandibular surgery (From Kostečka, 1934,

41

). (e): Kostečka's technique, demonstrating insertion of the curved needle and the Gigli saw (From Kostečka, 1934,

41

). (f): Kostečka's technique, demonstrating the osteotomy of the mandibular ramus between the posterior ramal border and the centre of the sigmoid notch, and pushing the mandible up into occlusion after the osteotomy (From Kostečka, 1934,

41

).

Fig. 2-36 (a): An example of Kostečka's condylar neck osteotomy using an extraoral approach and Gigli saw. (b): Patient treated using Kostečka's technique (preoperative images above, postoperative images below). (From Bowdler Henry,

43

).

Fig. 2-37 Smith and Johnson's sigmoid notch ostectomy and condylar neck osteotomy to set-back the mandible (1940). (From Smith and Johnson,

44

).

Fig. 2-38 Sir William Arbuthnot Lane (1856–1943).

Fig. 2-39 (a): Blair's horizontal ramus osteotomy to advance the mandible (From Blair, 1907,

45

). (b): Blair's use of the Gigli saw for his horizontal ramus osteotomy (After Blair,

12

).

Fig. 2-40 William Wayne Babcock (1872–1963).

Fig. 2-41 Christian Bruhn (1868–1942).

Fig. 2-42 August Lindemann (1880–1970).

Fig. 2-43 Varaztad Hovhannes Kazanjian (1879–1974).

Fig. 2-44 (a,b): Kazanjian's horizontal osteotomy tapering obliquely from the medial to the lateral aspect of the ramus in order to obtain a wider area of bone contact (1951). (After Kazanjian,

53

).

Fig. 2-45 Alexander Limberg (1894–1974).

Fig. 2-46 (a): Limberg's ramus osteotomy to close an anterior open bite. (After Limberg,

56

). (b): Following ramus osteotomy. (After Limberg,

56

). (c): Patient before and after Limberg osteotomy (1925). (From Limberg,

56

).

Fig. 2-47 (a): Skaloud (1951) advocated a combined extraoral and intraoral approach to the horizontal ramus osteotomy using a Gigli saw and, (b): undertaking transosseous wiring of the bone segments. (From Skaloud,

57

).

Fig. 2-48 (a): Martin Wassmund (1892–1956). (b): Wassmund's textbook (1927).

Fig. 2-49 Wassmund's smoothly transitioning inverted ‘L’ type osteotomy of the mandibular rami via an extraoral approach, used to advance the mandible and potentially close an anterior open bite (1927). (After Wassmund,

58

).

Fig. 2-50 Georg Clemens Perthes (1869–1927).

Fig. 2-51 Schlössmann–Perthes oblique horizontal ramus osteotomy (1922). (After Perthes,

59

).

Fig. 2-52 Karl Schuchardt (1901–1985).

Fig. 2-53 Schuchardt's stepped osteotomy. (After Schuchardt,

61

).

Fig. 2-54 Richard Trauner (1900–1980).

Fig. 2-55 The author with Professor Hugo Obwegeser, Schwerzenbach, Switzerland, 23 March, 2012.

Fig. 2-56 (a): Obwegeser's original sagittal split osteotomy (1957); (i) Buccal osteotomy; (ii): Lingual osteotomy; (iii): Proximal and distal segment after split osteotomy; (iv) and (v): Mandibular set-back and advancement, respectively, with wire fixation in situ (After Obwegeser, 1957,

62

). (b): Obwegeser's modification (with Dal Pont) (After Obwegeser, 1964,

65

); (i) and (ii) buccal and lingual cuts; (iii) separation of the segments in the sagittal plane; (iv) set-back to correct mandibular prognathism; (v) advancement to correct mandibular retrognathia; (vi) correction of anterior open bite by rotation of the distal segment. (c): Hunsuck modification, (i) Buccal view; (ii) Lingual view.

Fig. 2-57 Trauner and Obwegeser's inverted ‘L’ osteotomy. (After Trauner and Obwegeser,

62

).

Fig. 2-58 Kurt H. Thoma (1883–1972) – Swiss-born American oral surgeon.

Fig. 2-59 Jack B. Caldwell (1914–1986).

Fig. 2-60 Caldwell and Letterman's vertical subsigmoid osteotomy (via an extraoral approach) for mandibular set-back (1954). (From Caldwell and Letterman,

71

). Hebert, Kent and Hinds later described the procedure via an intraoral approach (1970).

73

Fig. 2-61 Caldwell's C osteotomy. (After Caldwell et al.

72

).

Fig. 2-62 Iliac bone graft to the osseous chin placed via a submental incision and resection of submental adipose tissue (patient had orthodontic treatment to improve the dental occlusion prior to surgery) (From Kazanjian, 1952,

74

).

Fig. 2-63 Hans Pichler (1887–1949).

Fig. 2-64 Sigmund Freud (1856–1939), the ‘father of psychoanalysis’, in his study with his beloved Chow Chow, named Jo-fi (c.1936). Jo-fi was his constant companion. Freud admired the lack of pretension in the behaviour of dogs, which he felt was sadly lacking in humans.

Fig. 2-65 Greene Vardiman (GV) Black (1836–1915).

Fig. 2-66 First page of case history notes of Professor Sigmund Freud by Professor Hans Pichler (Courtesy of Freud Museum London).

Fig. 2-67 Varaztad Kazanjian in his laboratory.

Fig. 2-68 Hofer's advancement genioplasty of the osseous chin, undertaken via an extraoral approach on a cadaver (After Hofer, 1942,

75

) (Courtesy of Professor Hugo Obwegeser).

Fig. 2-69 (a): The ‘sandwich’ procedure, used to advance and increase the height of the chin; (b): Advancement genioplasty with resection of a bony segment to reduce chin height; (c): Oblique osteotomy to advance and reduce height of chin; (d): Correction of osseous chin asymmetry – the broken line outlines bone to be resected to obtain a smooth contour (After Converse and Wood-Smith, 1964,

79

).

Fig. 2-70 Neuner's double-step advancement genioplasty (1965). (After Neuner,

80

).

Fig. 2-71 Bernhard von Langenbeck (1810–1887).

Fig. 2-72 David W. Cheever (1831–1915) (c.1875, Courtesy of Harvard Medical School).

Fig. 2-73 René Le Fort (1869–1951).

Fig. 2-74 Georg Axhausen (1877–1960) (Courtesy of the National Library of Medicine).

Fig. 2-75 Norman Lester Rowe (1915–1980). Professor Rowe was appointed consultant in oral surgery at Rooksdown House in Basingstoke (1949-59) and worked there with Sir Harold Gillies. Norman Rowe's stature as a clinician and statesman grew after Rooksdown House was transferred to Queen Mary's University Hospital, Roehampton, in 1959. Roehampton became

the

centre for oral and maxillofacial surgeons throughout the world as a result of his reputation as a surgeon and his extensive writing, particularly the textbook

Fractures of the Facial Skeleton

. He made friends wherever he went and was affectionately known as ‘Uncle’ to both senior and junior colleagues, which reflected his perceived wisdom and his willingness to give help whenever it was asked of him. He became a lifelong friend to Professor Hugo Obwegeser. (Courtesy of Mr Peter Blenkinsopp, Consultant Oral and Maxillofacial Surgeon, and head of the former Norman Rowe Maxillofacial Unit at Queen Mary's University Hospital, Roehampton, UK).

Fig. 2-76 Obwegeser's first description of a simultaneous bimaxillary osteotomy (undertaken in 1969, published in 1970,

81

).

Fig. 2-77 (a): Josef Kufner (1924–1995) (Courtesy of Professor Daniel Hrušák). (b): Kufner's extended osteotomy of the maxilla, i.e. Kufner modification of the Le Fort III-type osteotomy (After Obwegeser).

Fig. 2-78 (a): Traditional Le Fort I-type osteotomy, from the piriform rim region, approximately 5 mm above the roots apices, to the pterygoid plate region. The osteotomy is designed to avoid the root of the canine and the maxillary buttress, and thereby tends to have an anterior-superior inclination. Advancement of the maxilla creates a ramping effect and inadvertent vertical movement. (b): Bennett and Wolford's Le Fort I ‘step’ osteotomy (1985), which prevents the potential ramping effect by keeping the horizontal cuts parallel to the true horizontal plane (or Frankfort plane if it is horizontal). The anterior cut is made from the piriform rim, approximately 4–5 mm above the root of the maxillary canine, to the zygomatic buttress. In the buttress region, a vertical step is created (approximately 5–8 mm), following which a further horizontal cut is continued at an inferior level towards the pterygoid plates. The osteotomy design eliminates the ramping effect. Significant maxillary advancement may require grafting of the step region.

Fig. 2-79 Günther Cohn-Stock (1889–1983) (Courtesy of Journal of Cranio-Maxillofacial Surgery – Elsevier).

Fig. 2-80 The first recorded maxillary anterior segmental osteotomy (Cohn-Stock, 1921). The greenstick type osteotomy of the anterior maxillary segment relapsed within a month of the procedure. (After Cohn-Stock,

99

).

Fig. 2-81 (a): Wassmund's two-stage segmental set-back of the anterior maxillary dentoalveolus (1935). (From Wassmund,

101

). (b): Wassmund's procedure increases the incisor overbite (After Köle, 1959,

26,27,28

).

Fig. 2-82 Ivo Čupar (1901–1981) (Courtesy of Professor Darko Macan).

Fig. 2-83 (a, b): Köle described variations of segmental maxillary osteotomies (After Köle, 1959,

26–28

).

Fig. 2-84 Wunderer's osteotomy is a single-stage procedure from a palatal approach that preserves a broad labial mucoperiosteal pedicle (After Converse).

Fig. 2-85 (a): Schuchardt's posterior segmental osteotomy was developed in the mid-1950s. Initially described as a two-stage procedure, (i) with bilateral palatal alveolar osteotomies performed, followed by reapplication of the palatal flap, and (ii and iii) buccal osteotomies undertaken as a second procedure after 3–6 weeks to elevate the posterior maxillary dentoalveolar segments. The posterior segment could also be inferiorly repositioned, and the residual space bone grafted, in the presence of a lateral open bite. (b): Kufner's one-stage modification of the Schuchardt posterior segmental osteotomy. (After Kufner,

97

).

Fig. 2-86 Schematic diagram of the blood supply to the anterior maxillary dentoalveolus from various anastomosing vessels, which permits maxillary osteotomies to be undertaken without compromising vascularity (After Bell, 1972,

112

).

Fig. 2-87 Bernd Spiessl (1921–2002).

Fig. 2-88 Sir Harold Gillies (1882–1960), through the ages.

Fig. 2-89 Gillies playing golf (Courtesy of Dr Aron D. Wahrman, Professor of Plastic Surgery, Temple University School of Medicine, Philadelphia, USA).

Fig. 2-90 Hippolyte Morestin (1869–1918).

Fig. 2-91 Henry Percy Pickerill (1879–1956).

Fig. 2-92 Robert Ivy and Varaztad Kazanjian (c.1950) (Courtesy of Countway Library of Medicine, Boston, USA).

Fig. 2-93 ‘Bossington on the Test’ – painting by Sir Harold Gillies (Courtesy of Dr Aron D. Wahrman, Professor of Plastic Surgery, Temple University School of Medicine, Philadelphia, USA).

Fig. 2-94 The ‘Big Four’ – Mowlem, Kilner, Gillies and McIndoe (from left to right).

Fig. 2-95 (a): McIndoe in the main operating theatre, with theatre Sister, Miss Mullens, behind. (b): McIndoe in the operating theatre (Courtesy of Mrs Jacquie Pinney, CEO, Blond McIndoe Research Foundation, Queen Victoria Hospital, East Grinstead, UK).

Fig. 2-96 Sir Winston Churchill with ‘the few’ (Courtesy of Mrs Jacquie Pinney, CEO, Blond McIndoe Research Foundation, Queen Victoria Hospital, East Grinstead, UK).

Fig. 2-97 Sir Archibald McIndoe playing the piano at a Guinea Pig Club dinner (Courtesy of Mrs Jacquie Pinney, CEO, Blond McIndoe Research Foundation, Queen Victoria Hospital, East Grinstead, UK).

Fig. 2-98 (a): Airman Bill Foxley on his wedding day. (b): Bill Foxley (photograph by Lucinda Marland, Courtesy of Mrs Jacquie Pinney, CEO, Blond McIndoe Research Foundation, Queen Victoria Hospital, East Grinstead, UK).

Fig. 2-99 (a): The Queen (later The Queen Mother) visiting Queen Victoria Hospital, with Sir Archibald McIndoe (left) and Sir William Kelsey Fry (right). (b): The larger than life bronze McIndoe Memorial Statue, unveiled on the 9 June 2014, by HRH The Princess Royal, is situated in a prominent location in front of Sackville College in East Grinstead on the route Sir Archibald took daily to the Queen Victoria Hospital. It is the work of the renowned British sculptor, Martin Jennings, who has created such masterpieces as ‘John Betjeman’ (Sir John Betjeman – 1906–84 – former Poet Laureate) now standing in all its glory in St Pancras railway station, London, and ‘Charles Dickens’ in Portsmouth. Martin's desire was to create a statue which visually captured not only McIndoe's physical appearance but also projected the content of his character. In order to achieve this Martin carried out extensive research. McIndoe is displayed wearing his surgeon's gown, and his hands are on the RAF soldier's shoulders – he was not just their surgeon, but acted as their guardian. The soldier is looking up both at Sir Archibald, and to the sky where he flew to defend freedom. This statue is particularly personal to Martin, as Sir Archibald had operated on Martin's father, Michael Jennings, who had sustained severe injuries when his tank caught fire after being hit by a shell towards the end of World War II. The RAF soldier's hands are based on Martin's memory of his father's hands. The statue is placed on an inscribed stone plinth with a semi-circular stone seat to enable visitors to interact and ‘be with’ the statue. (Courtesy of Mrs Jacquie Pinney, CEO, Blond McIndoe Research Foundation, Queen Victoria Hospital, East Grinstead, UK).

Fig. 2-100 Gillies performed the first elective Le Fort III-type advancement osteotomy on a patient with a severe developmental midfacial retrusion (From Gillies and Harrison, 1950,

141

).

Fig. 2-101 Paul Tessier (1917–2008).

Fig. 2-102 Professor Hugo Obwegeser and Dr Paul Tessier (in 2005).

Fig. 2-103 Fernando Ortiz-Monasterio (1923–2012).

Fig. 2-104 Gavril Abramovich Ilizarov (1921–1992).

Fig. 2-105 Frances Cooke Macgregor (1906–2001). (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission).

Fig. 2-106 John Marquis Converse (1909–1981) (Courtesy of the National Library of Medicine).

Fig. 2-107 Katharine Phillips (Courtesy of Professor Katharine Phillips).

Chapter 3

Fig. 3-1 (a): Anterior open bites predominantly in the incisor or canine-to-canine region are a problem for incising food. (b): Anterior open bites that extend further posteriorly will also be a problem for mastication.

Fig. 3-2 Andry's tree (1741).

Fig. 3-3 In an average growing individual, the average displacement of the maxilla and mandible is in a forward and downward direction away from the cranium.

Fig. 3-4 (a)–(c): Pretreatment photographs of a patient with Class II division 1 incisor relationship on a moderate Class II skeletal pattern. (d), (e): After 12-months of functional appliance treatment, demonstrating incisor overjet correction. The lateral open bites are to be expected with a Twin Block functional appliance, and will reduce with a period of part-time wear of the appliance. (f), (g): Following removal of fixed orthodontic appliances.

Fig. 3-5 (a): Norman Kingsley's headgear (1861) (After Goddard, 1897). (b): Edward Angle's headgear (After Goddard, 1897). (c): Edward Angle's headgear (1907).

Fig. 3-6 (a): Pretreatment photograph demonstrating an anterior open bite in a growing Class II patient. (b): Twin Block functional appliance for sagittal dental occlusal correction, with flying extraoral traction (EOT) tubes for attachment of the headgear facebow to the upper component of the appliance. (c): High pull headgear in situ. (d): End of functional appliance phase of treatment. (e): Patient in fixed appliances, and continuing with headgear to the maxillary first molars, with correction of the anterior open bite.

Fig. 3-7 Facemask.

Fig. 3-8 (a): Narrow maxilla, patient is displacing her mandible to her right to obtain maximum intercuspation of her teeth. (b): Undisplaced occlusion, demonstrating bilateral posterior crossbites. (c): Maxillary occlusal view. (d): (e): Rapid maxillary expansion (RME) appliance in situ at 3 weeks, demonstrating the diastema that will form. (f): Maxillary occlusal radiograph at 3 weeks demonstrating separation of the midpalatal suture. (g): At 3 months, RME appliance is removed and a transpalatal arch is placed. The diastema has closed spontaneously, due to the action of the transseptal fibres.

Fig. 3-9 Orthodontic camouflage treatment with partial occlusal correction in a patient with a Class II division 2 incisor relationship with mild to moderate mandibular retrognathia. The patient did not desire orthognathic surgery. The maxillary arch was aligned and the maxillary incisor inclination corrected to achieve an acceptable lip-incisor relationship. The increased incisor overjet and Class II buccal occlusion was accepted. (a)–(e): Pretreatment images. (f)–(j): End of treatment.

Fig. 3-10 Orthodontic camouflage treatment of a Class III patient, with missing maxillary lateral incisors. (a)–(e): Pretreatment photographs. Mandibular first premolars were extracted to permit alignment and retroclination of the mandibular incisors with fixed orthodontic appliances; the maxillary canines were aligned next to the central incisors, and reshaped. (f)–(j): End of treatment.

Fig. 3-11 Patient with Noonan syndrome, with severe bimaxillary dental proclination, anterior open bite, severe mandibular retrognathia and retrogenia, and reduced mandibular ramus height. The patient did not desire bimaxillary orthognathic surgery, but following camouflage orthodontic treatment to retrocline the incisor teeth and reduce the anterior open bite, decided on an advancement genioplasty, which in this case is a form of surgical camouflage. (a)–(g): Pretreatment. (h)–(n): Following orthodontic camouflage treatment, with extraction of first premolar teeth and retroclination of the anterior teeth. (o)–(r): 8-days following double-step advancement genioplasty. (s): Before and after genioplasty.

Chapter 4

Fig. 4-1 Sir William Osler (1849–1919).

Fig. 4-2 The orthognathic patient pathway. GDP, General Dental Practitioner; GMP, General Medical Practitioner.

Chapter 5

Fig. 5-1 Albert Einstein (1879–1955).

Fig. 5-2 (a) Head-holding device known as the cephalostat. (b) Modified technique for taking the lateral cephalometric radiograph, with the patient in natural head position (NHP), and using a plumb (shown with red arrow) and plumb line, which will appear on the cephalometric radiograph and act as the true vertical (see Figure 5-14).

Fig. 5-3 Angle's trimmed pretreatment study models.

Fig. 5-4 (a) Preoperative ‘snap’ study models of a Class III patient with an anterior open bite. (b) Hand articulating the ‘snap’ models to assess proposed postoperative arch coordination and potential occlusal interferences.

Fig. 5-5 Examples of anthropometric measurements: (a) The arms of spreading calipers are curved, allowing the instrument to fit round larger curved regions of the face. (b) The sliding caliper to measure total face height. (c) Measuring midfacial height with a sliding caliper. (d) Measuring nasal base width with a sliding caliper. (e) Measuring maxillary incisor crown width; the tips of the caliper have been thinned with a stone to improve the accuracy of measurements. (f) Measuring maxillary incisor crown height with a sliding caliper. (g) Measuring upper lip height and maxillary incisor exposure in repose with a ruler. (h) Measuring nasal base width with a divider caliper.

Fig. 5-6 Dentoskeletal subunits of the bimaxillary complex. 1. Nasomaxillary complex. 2. Maxillary dentoalveolus. 3. Maxillary incisors. 4. Mandibular incisors. 5. Mandibular dentoalveolus. 6. Mandibular ramus. 7. Mandibular body (corpus). 8. Mandibular symphysis (osseous chin). 9. Inferior border of the mandible. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; modified and reprinted with permission.)

Fig. 5-7 The facial planes. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-8 (a) The axes of rotation. (b) Maxillary rotation around the three axes of rotation. (c) Maxillary incisor rotation around the three axes of rotation. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-9 Rotation of the maxilla and maxillary occlusal plane round the axes of rotation: (a) Rotation round the sagittal axis, leading to a transverse cant of the maxillary occlusal plane. (b) Rotation round the vertical axis, leading to a maxillary dental midline deviation. (c) Rotation round the transverse axis, leading to a difference in the vertical level of the anterior and posterior regions of the maxillary occlusal plane.

Fig. 5-10 Hard tissue (skeletal) lateral cephalometric landmarks (see Table 5-1 for definitions).

Fig. 5-11 Soft tissue lateral cephalometric landmarks (see Table 5-2 for definitions).

Fig. 5-12 Angular profile parameters may be visually separated into upper and lower components and a

qualitative

decision made as to whether they are obtuse, average or acute. The patient should be in natural head position. The nasofrontal, nasolabial and mentolabial angles are demonstrated separated into upper and lower components by a true horizontal line.

Fig. 5-13 Two sets of arrows that exhibit the Müller–Lyer optical illusion. The set on the bottom demonstrates that all the shafts of the arrows are of the same length.

Fig. 5-14 A patient in natural head position (NHP), demonstrating the true facial vertical (TrV) and true horizontal (TrH) lines used to evaluate facial aesthetics. The true vertical may be taken as a line parallel to a plumb line hanging from the ceiling. The true horizontal will be at right angles to this. In some patients the Frankfort plane may be parallel to the true horizontal; however the inclination of the Frankfort plane is subject to individual variability. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-15 (a) Facial profile of a patient with a significant Class III jaw relationship in natural head position (NHP), demonstrating a marked downward inclination of the Frankfort plane in relation to the true horizontal. (b) Facial profile of a patient with a significant Class II jaw relationship in natural head position (NHP), demonstrating a marked upward inclination of the Frankfort plane in relation to the true horizontal.

Fig. 5-16 Leonardo's eye (c.1485) is the earliest example of a drawing using anamorphic perspective, and only appears as an eye when viewed from a specific position and angle.

Fig. 5-17 Facial height-to-width ratios. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-18 Facial divergence. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-19 Facial profile contours. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-20 (a) Pretreatment Class II patient with mandibular retrognathia, demonstrating a convex facial profile contour. (b) Following mandibular advancement osteotomy, demonstrating a relatively straight or orthognathic facial profile contour.

Fig. 5-21 (a) Preoperative Class III patient with maxillary retrognathism and mandibular prognathism, demonstrating a concave facial profile contour. (b) Following maxillary advancement at the Le Fort I level and mandibular set-back, demonstrating a relatively straight facial profile contour, within the norm for the ethnic background.

Fig. 5-22 Total vertical maxillary excess (total VME): (a) Excessive maxillary incisor exposure in repose (b) Excessive maxillary gingival exposure on smiling.

Fig. 5-23 (a–c) Anterior vertical maxillary excess (anterior VME) – this is due to excessive eruption of the maxillary incisor teeth and associated gingivae, i.e. the ‘gummy smile’ is only evident anteriorly.

Fig. 5-24 Total vertical maxillary deficiency (total VMD): (a–c) Preoperative photographs and lateral cephalometric radiograph demonstrating VMD and mandibular overclosure and reduced lower anterior face height (LAFH). (d–f) Following maxillary advancement and inferior repositioning, mandibular set-back and set-back genioplasty, with improved LAFH to total face height proportion.

Fig. 5-25 (a–d) Anterior vertical maxillary deficiency (anterior VMD), due to impeded eruption of the maxillary incisors and associated alveolus, with an adaptive tongue to lower lip swallow pattern secondary to a long-standing digit sucking habit. The lower anterior face height is normal.

Fig. 5-26 (a, b) Increased chin height, albeit on a tall face.

Fig. 5-27 (a–c) Reduced chin height.

Fig. 5-28 (a) Reduced mandibular plane angle. (b) Increased mandibular plane angle.

Fig. 5-29 Transverse facial proportions. The ‘rule of fifths’ states that transverse facial dimensions may be divided into equal fifths, each the width of an eye. The nasal alar base width should be equal to the intercanthal distance. The mouth width is equal to the distance between the medial iris margins. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-30 Increased bigonial width. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-31 Facial midline, connecting glabella and the mid-philtrum of the upper lip (midpoint of Cupid's bow).

Fig. 5-32 The midpoints of different structures may be marked on the patient's face with a skin pencil to demonstrate any deviations from the facial midline.

Fig. 5-33 (a) Significant asymmetry of the lower face, with the mandible and chin point to the patients left, and transverse cant of the rima oris (left and right commissures at different vertical levels) and the inferior chin plane. (b) Transverse cant of the maxillary occlusal plane evident, canted down on the patient's right. (c) Inferior view highlights asymmetry of the chin and lower lip in relation to the upper lip. (d) Dental mirror handle held against the maxillary dentition demonstrates a transverse cant in relation to the interpupillary plane.

Fig. 5-34 Maxillary dental midline shift of 2 mm to the right of the patient's facial midline: (a) Maxillary incisors are correctly angulated, with the mesial and distal contact areas of their crowns parallel to the facial midline. (b) Excessive maxillary incisor angulation to the patient's right and thereby a transverse cant of the incisal edge plane. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-35 (a) Maxillary advancement permits a wider part of the dental arch to move forward and reduce the lateral negative space. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.) (b, c) Maxillary advancement reduces the buccal corridors, ‘filling’ the corners of the smile.

Fig. 5-36 The ‘concealed premolar’ smile: it is likely that the parameter leading to the perception of smile attractiveness is not the presence or absence of buccal corridors, but the visibility of the posterior dentition distal to the maxillary canine teeth. (a) Narrow ‘canine to canine’ smile with the premolars ‘concealed’ behind the canine teeth. (b) Adequate visibility of the premolar teeth when observed in frontal view. In both situations, the percentage of visible dentition to buccal corridor is identical, but the visibility of the premolar teeth distal to the canines in (b) improves the smile aesthetics. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-37 (a–c) Incomplete lip seal (incompetent lip posture) – the posterior teeth are in occlusion, but there is an increased lower anterior face height, significant anterior open bite and bimaxillary incisor proclination, all of which have led to the observed lip posture in repose.

Fig. 5-38 Potentially competent lips, with maxillary incisors interposed between the upper and lower lips.

Fig. 5-39 (a) The subnasale vertical (SnV) line is a true vertical line through subnasale; labrale superius of the upper lip should be just anterior to SnV, and labrale inferius should be on or just behind. (b) A Class III patient with maxillary retrognathism and mandibular prognathism. Subnasale is retruded, therefore the SnV line will be posteriorly positioned, but it demonstrates the relative sagittal discrepancy between the prominence of the upper and lower lips. (c) Following maxillary advancement and mandibular set-back, the sagittal relationship of the upper and lower lips is improved. (The patient may have benefited from, but did not desire, an advancement genioplasty as a secondary procedure).

Fig. 5-40 The combined Burstone–Ricketts ‘triangle’ is formed between the Burstone line (Sn-Pog′) and Ricketts E-line (Pr-Pog′); the lips should fall within the triangle formed between the two lines, with the upper lip slightly ahead of the lower lip.

Fig. 5-41 The ‘lip–incisor relationship’ and maxillary incisor exposure (MIE) depends on the following factors: 1. Upper lip height. 2. Smile curtain – the muscular capacity to elevate the upper lip. 3. Vertical position of the anterior maxilla and incisor teeth. 4. Sagittal position of the anterior maxilla and incisor teeth. 5. Inclination of the maxillary incisor teeth. 6. Maxillary incisor crown height. 7. Vertical level of the labial maxillary incisor gingival margins. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-42 The most accurate measurement of maxillary incisor crown inclination is that of a tangent to the labial face of the maxillary central incisor in relation to the true horizontal plane (TrH), with the patient in natural head position. TrV, true vertical. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-43 Retroclination of proclined maxillary incisors towards the correct inclination increases the incisor exposure, as the teeth rotate around their centre of resistance.(From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-44 (a, b) Paranasal hollowing is a sign of maxillary retrognathism.

Fig. 5-45 (a, b) Post-treatment profile smiling view. A tangent to the labial face of the maxillary central incisor is approximately parallel to a true facial vertical line, which is the ideal inclination of the maxillary incisor crown. (c, d) Pretreatment profile smiling view. A tangent to the labial face of the maxillary central incisor is proclined relative to a true facial vertical line.

Fig. 5-46 (a) Preoperative profile smiling view of a Class III patient. The maxillary incisor crowns are significantly behind a true vertical line (TrV) dropped from glabella. (b) Following maxillary advancement at the Le Fort I level and mandibular set-back osteotomy. The sagittal position of the maxillary incisor crowns are very close to the TrV. (c) Pretreatment profile view of a Class II patient with maxillary dentoalveolar protrusion, vertical maxillary excess, mandibular retrognathia and retrogenia. The maxillary incisor crowns are significantly in front of a true vertical line (TrV) dropped from glabella. (d) Following orthodontic maxillary incisor retraction, maxillary incisor impaction and small set-back, mandibular advancement and advancement genioplasty. The sagittal position of the maxillary incisor crowns are very close to the TrV.

Fig. 5-47 The sagittal prominence of the soft tissue chin ideally should not be further ahead than the lower lip. The innermost point in the depth of the mentolabial fold (soft tissue B-point, also termed sublabiale) should be behind both the lower lip and chin, creating a smooth S-shape in the transition between the lower lip and chin. This shape also occurs in the dentoskeletal support, with the labial surface of the mandibular incisor on a vertical line with osseous pogonion, and skeletal B-point behind this line.

Fig. 5-48 Lower vertical height–depth ratio. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-49 Following a mandibular set-back osteotomy, submental fullness has increased and the submental–cervical angle become obtuse.

Fig. 5-50 The nasion perpendicular is a vertical line perpendicular to the Frankfort Horizontal (FH) plane, or ideally the true horizontal plane (TrH), dropped from bony nasion. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-51 An increase in the SNA angle

may

indicate protrusion of the maxillary dentoalveolus, assuming the SN plane has a normal inclination, and sella and nasion are in normal sagittal and vertical positions. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-52 The SNB, SND and SN-Pog angles provide an indication of the sagittal position of the mandibular apical base, mandible, and chin, respectively, in relation to the anterior cranial base and in relation to each other. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-53 The ANB angle represents the difference between the SNA and SNB angles, providing an indication of the sagittal discrepancy between the maxillary and mandibular apical bases. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-54 (a) According to the Sassouni analysis, in a well-proportioned face, the horizontal facial planes should

converge

symmetrically toward an approximate

area of intersection located near the occiput

. If any part of the face is vertically disproportionate, its associated plane will not converge with the others. (b) If the area of convergence of the horizontal facial planes is positioned well behind the occiput, the planes will be nearly parallel; this skeletal pattern is associated with similar anterior and posterior facial heights, and correlates with a deep overbite tendency, termed a ‘skeletal deep bite’. (c) If the area of convergence of the horizontal facial planes is positioned in front of the occiput, towards the face, the planes will diverge anteriorly; this skeletal pattern is associated with markedly different anterior and posterior facial heights, and correlates with an anterior open bite tendency, termed a ‘skeletal open bite’. MxP, maxillary plane; MnP, mandibular plane; FOP, functional occlusal plane; FH, Frankfort Horizontal plane; SN, sella–nasion plane. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-55 Anterior face height ratios (proportional relationship of lower to middle anterior face height). (TrV: true vertical plane). (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-56 Facial Height Index (FHI: Proportional relationship of anterior to posterior lower face height) is the ratio of LAFH to LPFH, and should be from 0.65 to 0.75. If the LPFH is less than 65% or more than 75% of the lower anterior face height, there is likely to be a vertical skeletal discrepancy. MxP, maxillary plane; MnP, mandibular plane. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-57 The maxillary–mandibular planes angle (MMPA) is the anterior angle formed by the intersection of the maxillary plane and the mandibular plane. The interincisal angle is the posterior angle formed by the intersection of the long axes of the maxillary and mandibular central incisors; the sum of the MMPA, maxillary incisor to maxillary plane inclination, mandibular incisor to mandibular plane inclination and interincisal angle should be 360°. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-58 The gonial angle may be divided into an upper and lower component in order to determine the relative contribution of the ramus and body inclination to mandibular morphology. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-59 Excessive maxillary incisor proclination may be evaluated on a profile smiling photograph and a lateral cephalometric radiograph taken with the patient in natural head position. TrH, true horizontal; TrV, true vertical. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)

Fig. 5-60 In individuals with good dentofacial aesthetics and good dental occlusions, the mandibular incisor edge lies on or close to the A-Pog line. (From: Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011; reprinted with permission.)