Surgical therapy

Surgical therapy

 Introduction:

The term orthodontic-surgical therapy covers interventions of a very diverse nature which fall within the framework of the therapeutic means of orthodontic treatment but are generally not carried out by the orthodontic specialist.

Intervention on dental units: extraction, germectomy, removal of odontoma or supernumerary teeth and also transplantation;

Soft tissue surgery: resection of labial frenum, resection of tongue frenum;

Surgical release of impacted teeth. 

Orofacial surgery: When the limits of orthodontics and orthopedics are exceeded, the achievement of therapeutic objectives requires recourse to orthognathic surgery.

1. Definition :

Orthognathic surgery, a specific activity of the maxillofacial surgery department, corresponds to obtaining harmonious maxillary relationships.

It allows the treatment of all dysmorphoses inaccessible to orthodontics while maintaining symbiosis between surgical and orthodontic treatment. 

2. Indications: 

• The major syndromes (Crouzon) 
• Severe sagittal, vertical and transverse skeletal shifts at the end of growth: 
• Strong dentoalveolar compensations 
• The major aesthetic disturbances 
• patients with unfavorable growth 

Even when the surgical indication is made early, orthognathic surgery only occurs at the end of growth, around 16 or 17 years of age in girls, 18 years of age in boys, in order to avoid the risks of relapse linked to unfavorable late mandibular growth, especially in class III and asymmetries.

3. Establishment of the therapeutic strategy 

Based on clinical observation and analysis of additional examinations, particularly imaging.

Pre-surgical set-ups make it possible to visualize the impact of the different therapies envisaged, to assess their feasibility and to coordinate them. 

1. Pre-surgical orthodontic preparation:

Carried out just before surgery. This preparation stage has the following objectives:

• Managing intra-arch issues
• Lifting alveolar compensations
• Ensure the concordance of the arches
• Provide anchorage to the post-surgical retention device 

Pre-surgical assessment: 

At the end of the orthodontic preparation, a new pre-surgical assessment is carried out based on the models and new X-rays or a CT scan of the patient. If the objectives of the orthodontic preparation have been achieved, the date of the intervention is set jointly by the orthodontist and the surgeon.

2. Surgical program:

The surgeon must respect the play of the temporomandibular joint, muscular balance, bone continuity and the vascular-nervous bundle.

Restoring functional balance and aesthetic harmony of the face sometimes requires a combination of contour surgery (profiloplasty) or muscle strap surgery. 

3. After surgery:

• It improves occlusal imperfections (parallelism of axes, closure of residual diastemas, correction of secondary dystopias). 
• It eliminates the parasitic movements maintained by the blockage. 
• He installs elastic tractions which curb relapses. 
• It stabilizes the result with glued retainers. 

4. Surgeries involving hard tissues:

Intended either to reduce or increase the dimensions of bone structures.

Osteotomy involving the entire body of the bone:

• The procedures: sliding osteotomy, rotation osteotomy.
• The two alternatives: 

In case of excess bone structure: resection of a bone fragment (ostectomy) 

In case of insufficient bone volume: osteotomy + interposition of a graft.

Osteotomy limited to the dento-alveolar region , “segmental osteotomy”.

1. Interventions on the maxilla: 1.1. Segmental osteotomies:
    

The intervention is limited to the anterior alveolar sector or the entire alveolar sector.

Directions:

• correction of a severe class II malocclusion (A NB > 10°, for some) 
• excess vertical height with gummy smile.
•  sometimes requires extraction of the upper first premolars.

Wassmund intervention: Correction of cases with overbite, posterior tilt and elevation of the resected block, which allows correction of the overbite.

Surgical therapy

SCHUCHARDT osteotomy:

Correction of a gap: Schuchart procedure: extraction of wisdom teeth. The section line passes above the molars and premolars. 

DAUTREY osteotomy:

A bone resection above this cutting plane allows the vertical dimension of occlusion to be reduced; Dautrey technique: extraction of the first premolar and segmental osteotomy, which allows the advancement and elevation of the fragment. 

Surgical therapySurgical therapy

2. Total osteotomies:

Lefort I low osteotomy:

The simplest path consists of 2 segments:

• One horizontal supra-apex, transverse and trans-septal
• The other vertical between: tuberosity and pterygoids 

Directions:

• maxillary advancement;
• a maxillary impaction;
• maxillary spacing with graft.

 Pre-orthodontic surgical intermaxillary disjunction:

2. Interventions involving the mandible:

2.1. Segmental osteotomies:

It affects the anterior alveolar sector.

— Correction of a class III malocclusion: distal block displacement of the anterior incisor-canine sector and extraction of the first premolar.

— Correction of an incisor overbite with lower supra-alveolus: bone resection under the roots of the teeth in the anterior sector and downward rotation. 

Segmental osteotomies are becoming increasingly rare in favor of total osteotomies.

KOELE osteotomy 

• Inferior proalveolism: setback osteotomy, involving the incisor-canine sector; 
• Inferior retroalveolism: In this case, an advancement movement is performed 
• Incisor-canine infra-alveolar osteotomy: This involves performing an alveolar elevation osteotomy, combined with a bone graft; 
• Anterior supraalveolism: bone resection under the roots of the teeth in the anterior sector and downward rotation.

2. Total osteotomies:

They concern the rising branch or the horizontal branch. 

Indications: true lower prognathia, micrognathia, laterognathia, vertical mandibular anomalies (posterior and/or anterior vertical excess).

The Dalpont-Obwegeser sagittal cleavage is the most commonly performed mandibular osteotomy. It allows the mandibular arch and symphysis to be moved forward, backward, elevated, lowered or derotated. The soft tissues follow the mandibular displacement

• Genioplasty and basilar border remodeling 

5. Soft tissue surgeries  :

• Glossotomy : reduction of tongue volume.

Indications: Class III cases, such as inferior prognathism, with or without associated osteotomy, incisor open bite , anterior and lateral open bite, biproalveolus .

Intervention technique: this is most often a median diamond resection at the tip.

The drop of water (to preserve the tip). 

• Deepening of the anterior gingivo-labial sulcus, which prevents gingival recession and reduces the pressure of the lower lip on the incisors,
• Cheiloplasty : reduction of the thickness of the lips.
• Rhinoplasty 

Surgical therapy

Conclusion :

Thanks to the close collaboration between surgeon-orthodontist teams, to advances in surgical techniques and diagnostic imaging, orthognathic surgery provides increasingly effective solutions in the treatment of facial dysmorphoses.

 It helps rebalance the facial skeleton, ensuring aesthetic reharmonization and functional normalization.

Surgical therapy

Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.
 

Surgical therapy