Combined Surgical-Orthodontic Therapy
Facial deformities can be so great that normal orthodontic treatment cannot provide a satisfactory remedy, even when incorporating facial orthopedic techniques for patients who are young enough. In such situations it is only by using surgical treatment that the form of the facial skeleton can be so changed that a more acceptable condition will result. Usually the surgery is combined with orthodontic treatment.
Surgical-orthodontic therapy requires the consideration of several specific matters. These include indications, psychological aspects, diagnosis and treatment planning, preferred patient age at operation, treatment procedures, operative corrections, retention and relapse, and risks of operation.
Orthodontic anomalies often disturb facial harmony. Most are best treated conservatively. Sometimes, however, the deformity is so great that without surgical reconstruction of the facial skeleton it will not be possible to secure a good result.
Disproportion in the craniofacial skeleton can be present from the beginning of morphogenesis (i.e., be congenital). It can also occur as the result of trauma (e.g., condyle fracture), early ankylosis of the temporomandibular joint, tumours, sequelae to radiotherapy, and also from growth disorders that distort an originally normal face. Extreme growth of the mandible giving rise to a disturbing degree of mandibular prognathism is a good example of the latter.
In serious deformities of the craniofacial skeleton the dentoalveolar compensatory mechanism fails and a severely deviant occlusion with abnormal positions of the teeth, particularly the anterior teeth, will result.
Most patients for whom surgical-orthodontic treatment is considered will in the first place have asked their dentist or family physician about the possibilities for treatment. They would usually then have been referred to an orthodontist or oral surgeon. The initiative for combined surgical-orthodontic treatment generally does not come from the patient, though in the case of people seeking cosmetic improvements (plastic surgery) that certainly is not so.166
Surgical-orthodontic therapy should also be contemplated when it is possible to achieve good occlusion with normal orthodontic procedures but an acceptable appearance cannot be attained. On the one hand this applies to situations in which facial esthetics would in fact be made worse as a consequence of securing a good occlusion. For example, in retracting maxillary and mandibular incisors over a considerable distance the lips may fall inwards excessively particularly in patients with a marked chin, or the nasolabial angle might become unacceptably great. On the other hand, there are patients who after orthodontic treatment, still need surgical correction outside the immediate dentomaxillary area. Examples of this are the provision of paranasal onlays where the canine fossae are excessively hollow, and correction of the form and position of the bony chin.
Functional disturbances such as inadequate lip seal, indistinct speech, and poor mastication can indeed influence a decision to institute surgical-orthodontic treatment for severe facial deformities. The most important influence, however, is of psychological origin.
Indeed, the patient’s desire to improve his or her appearance is the essential deciding factor. Those who are satisfied with the condition of their teeth and facial appearance and do not suffer from social or psychological disadvantage connected with those factors do not need surgical-orthodontic treatment. Such treatment is only appropriate when the patient, after being made fully aware of all the treatment difficulties, still emphatically wishes to go ahead.
Improvement of appearance brings with it increased self-confidence and inner well-being.74 This is particularly so for patients for whom a serious deformity has been corrected.
The social climate in which we live sets great store by physical attractiveness; the face is the focus of this attention. The form of the face has a great influence on the feeling of self-esteem and on establishing and maintaining interpersonal contacts.91
A patient with a serious facial deformity, to whom the possibilities of surgical-orthodontic treatment have been explained, will build up an image of how he or she will fit into society once the handicap has been corrected. Of course this sometimes exceeds the limits of reality. However, the majority of patients who have experienced such an improvement are indeed very satisfied with the result. They are delighted by the improvement in their appearance, feel better accepted by other people, make friends more easily, and have a more positive outlook on their own potential. As a result they have a tendency to quickly forget the seriousness of their former deformity.91, 148
Children with a severe facial deformity also suffer psychologically and socially. The significance increases sharply once they leave their own sheltered environment in order to attend school. The psychological pressure can be so great that an operation at an early age can be justified even if that leads to a less satisfactory physical result than would be achieved at a later age. There may also be a need for further surgery later, but the immediate benefits counter any such disadvantages.
The improvements that can be achieved with surgical-orthodontic treatment are often so pronounced that the patient subsequently encounters many obvious reactions from other people. The patient must learn to live with a new appearance; this demands a certain ability to adapt, not only from the patient but from his or her family and friends also. Not every patient who undergoes substantial physical changes is able to manage it without emotional problems. Therefore it is essential to assess the patient beforehand and take all the steps necessary to inform and prepare him or her for what is involved. To undertake surgical-orthodontic treatment without giving full consideration to the psychological consequences is irresponsible. The patient must be strongly motivated but not desperate. Most importantly, the patient’s feet should be firmly on the ground.
The orthodontist and oral surgeon should jointly establish a diagnosis and choose the treatment for patients who are potential candidates for surgical-orthodontic therapy. In doing so, consideration has to be given not only to psychological aspects and facial esthetics, but also to occlusion and function.235
For diagnosis, comprehensive records are necessary in addition to the history and detailed clinical examination of the patient. The latter should involve dynamic and static features. The records should include well-extended plaster models of the teeth and surrounding structures, radiographs of the skull and teeth such as might be needed to give unambiguous information, and standardised facial photographs. For treatment planning, montages of facial photographs (preferably life-size) and cephalometric and soft tissue tracings are essential aids.58 In patients where displacement of jaws or segments thereof is being considered, a “trial operation” using plaster models properly mounted on a fully adjustable articulator is indispensable in order to properly simulate the changes being sought.
Over 100 different approaches have been presented for surgical correction of major facial deformities.15, 49 Which approach is most appropriate and which methods of operation are most suitable for the situation can only be determined after careful diagnosis and deliberation. Moreover, different teams have diverse viewpoints on these matters.121 Fortunately there usually is more than one approach that will reach a satisfactory result.
In theory, dentofacial deformities can be divided into sagittal, vertical, and transverse components. Where there is no asymmetry the deformity usually is restricted to the sagittal and, to a lesser degree, vertical components. Besides, transverse elements are difficult to quantify.
The practical situation, however, is that although patients usually see their faces from the front in a mirror, their judgement of their deformity generally places the anteroposterior aspects of the profile at the top of the list of undesirable characteristics.123 In planning />