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Orthognathic Case PresentationOrthognathic Case Presentation

State University of New York atState University of New York atStony BrookStony Brook

Department of OrthodonticsDepartment of OrthodonticsS. Mathew DDSS. Mathew DDS

ResidentResident--OrthodonticsOrthodontics

Jeff Drayer DDSJeff Drayer DDSResidentResident--OrthodonticsOrthodontics

Jose Vicens DMDJose Vicens DMDResidentResident--OrthodonticsOrthodontics

Benjamin Murray DMDBenjamin Murray DMDResidentResident--OrthodonticsOrthodontics

Richard Faber DDS, MSRichard Faber DDS, MSDirector Advanced Education Program in OrthodonticsDirector Advanced Education Program in Orthodontics

Salvatore Ruggerio DMD, MDSalvatore Ruggerio DMD, MDAssociate Professor Oral and MaxilloAssociate Professor Oral and Maxillo--Facial SurgeryFacial Surgery

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PatientPatients Historys History

Patient: J.O.Patient: J.O.

Age: 13 y.o. (7/28/2000)Age: 13 y.o. (7/28/2000)

Race/Ethnicity: GuatemalanRace/Ethnicity: Guatemalan

CC:CC: People make fun of my facePeople make fun of my facePMH: non contributory, No meds, NKDAPMH: non contributory, No meds, NKDA

PDH: WNL, seeks regular carePDH: WNL, seeks regular careTMJ: WNLTMJ: WNL

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Original Presentation

7/28/2000

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Original Presentation

7/28/2000

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TreatmentThe patient was followed with serial lateral

cephs and hand wrist films to evaluate growthcessation to begin pre-surgical orthodontics.

The patient was also evaluated for partial

glossectomy with an MRI by OMFS in 2001, andglossectomy was not performed.

Pre treatment records taken in Nov. 2004

Pre-surgical orthodontics began in January 2005

Pre-surgical orthodontic records taken in 2006

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Clinical ExamClinical Exam

SmileSmile

On smile, shows 60%On smile, shows 60%

of clinical crownof clinical crownMaxillary midline isMaxillary midline is

1.5mm R of mid1.5mm R of mid

sagittalsagittalTongue thrust uponTongue thrust upon

smilesmile

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Clinical ExamClinical Exam

Lateral ViewLateral View

Concave profileConcave profile

Acute nasolabialAcute nasolabialangleangle

Slightly deepSlightly deep

labiomental fold duelabiomental fold dueto everted lower lipto everted lower lip

MandibularMandibular

prognathismprognathism

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IntraIntra--oral Examinationoral ExaminationPermanent dentitionPermanent dentition

Lower midline 1mmLower midline 1mmright of mid sagittalright of mid sagittal

planeplane

4mm open bite with4mm open bite withtongue thrusttongue thrust

presentpresent

Anterior crossbiteAnterior crossbite

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InterdigitationInterdigitationRight Side (CR):Right Side (CR):

Canine : CL IIICanine : CL IIIMolar: CL IIIMolar: CL III

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InterdigitationInterdigitationLeft Side (CR):Left Side (CR):

--Canine: CL IIICanine: CL III

--Molar CL IIIMolar CL III

Centric Occlusion

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Maxillary ArchMaxillary Arch

Wide UWide U--shaped.shaped.

SymmetricSymmetric

mild spacingmild spacingIntermolarIntermolar

width=48mmwidth=48mm

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Mandibular ArchMandibular Arch

Wide U shapedWide U shaped

symmetric archsymmetric arch

ModerateModeratespacingspacing

IntermolarIntermolar

width= 49mmwidth= 49mmMild curve ofMild curve of

SpeeSpee

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Radiographic Analysis: PanoramicRadiographic Analysis: Panoramic

All permanent teeth present, no evident pathologyAll permanent teeth present, no evident pathology

11/9/04

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PA CephPA CephAsymmetric Skeleton, Dental: Mx midlineAsymmetric Skeleton, Dental: Mx midline1.5mm R, Md midline 1mm R1.5mm R, Md midline 1mm R

Apical bases: Mx midline 1.5mm R, MdApical bases: Mx midline 1.5mm R, Mdmidline 1mm Rmidline 1mm R

11/9/04

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LateralLateral

CephCeph

Skeletal Class III,Skeletal Class III,

ANB:ANB:--7, Wits:7, Wits:--1515

11/9/04

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Lateral CephLateral Ceph

Cranial base: mildlyCranial base: mildly

decreaseddecreased

Maxilla: Normal size,Maxilla: Normal size,Position WNLPosition WNL

Mandible: SeverelyMandible: Severely

increased in size withincreased in size withseverely increasedseverely increased

ramus and normal bodyramus and normal body

11/9/04

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Lateral CephLateral Ceph

Gonial angle: MildlyGonial angle: Mildly

increasedincreased

Mandibular plane: WNLMandibular plane: WNL

Y Axis: MildlyY Axis: Mildly

decreaseddecreased

Occlusal plane: WNLOcclusal plane: WNL

UFH: ModeratelyUFH: Moderately

increasedincreased

LFH Mildly increasedLFH Mildly increased

11/9/04

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LateralLateral

CephCeph

Upper incisor: FlaredUpper incisor: Flared

and protrusiveand protrusive

Lower incisor: slightlyLower incisor: slightlyflared and protrusiveflared and protrusive

Upper alveolus:Upper alveolus:

Moderately decreasedModerately decreased

Lower alveolus: WNLLower alveolus: WNL

11/9/04

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Lateral CephLateral Ceph

Convexity: decreasedConvexity: decreased

NLA: decreasedNLA: decreased

Incisor display:Incisor display:decreaseddecreased

Upper lip length: WNLUpper lip length: WNL

Upper lip thickness: WNLUpper lip thickness: WNL

Lower lip length:Lower lip length:

increasedincreased

Lower lip thickness: WNLLower lip thickness: WNL

Chin thickness: WNLChin thickness: WNL

11/9/04

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DiagnosisDiagnosisSkeletal Class IIISkeletal Class III

Dental Class IIIDental Class III

NormodivergentNormodivergent

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Problem ListProblem ListSkeletal Class III with large and protrusiveSkeletal Class III with large and protrusive

mandiblemandibleDental Class IIIDental Class III

Anterior crossbiteAnterior crossbite

Anterior open biteAnterior open biteDecreased OB and OJDecreased OB and OJ

Chin deviates to the leftChin deviates to the left

Large TongueLarge TongueMx and Md spacingMx and Md spacing

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ObjectivesObjectivesAdvance A point, retract B point surgicallyAdvance A point, retract B point surgically

Obtain Class IObtain Class I

Close open biteClose open bite

Close spacesClose spacesNormalize OB / OJNormalize OB / OJ

Rotate mandibleRotate mandible

Coordinate midlinesCoordinate midlines

Improve facial profileImprove facial profile

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General Treatment PlanGeneral Treatment Plan

Extract 8Extract 8ssPrePre--surgical Orthodonticssurgical Orthodontics

Differential IVRO SetbacksDifferential IVRO Setbacks

Le Fort 1,with posteriorLe Fort 1,with posteriorimpactionimpaction

Advancement GenioplastyAdvancement Genioplasty

PostPost-- Surgical OrthodonticsSurgical Orthodontics

Retention, U/L Hawley withRetention, U/L Hawley with

integrated tongue cribintegrated tongue crib

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Original VTOOriginal VTO

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Treatment sequenceTreatment sequence

Pt. banded and bonded 1/11/05Pt. banded and bonded 1/11/05Progress records taken 12/13/05Progress records taken 12/13/05

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Treatment sequenceTreatment sequence

Progress Radiographs 12/13/05Progress Radiographs 12/13/05

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Treatment sequenceTreatment sequence

Pt. had all 8s removed under IV sedation 5/17/06Pt. had all 8s removed under IV sedation 5/17/06

Post op radiograph belowPost op radiograph below

6/2/06

T t tT t t

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Treatment sequenceTreatment sequence

May 2006May 2006Obtained Surgical preObtained Surgical pre--approvalapprovalPre Surgical Records Taken 6/2/06Pre Surgical Records Taken 6/2/06

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Treatment sequenceTreatment sequencePrePre--Surgical Radiographs 6/2/06Surgical Radiographs 6/2/06

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Treatment sequenceTreatment sequence

PrePre--Surgical Radiographs 6/2/06Surgical Radiographs 6/2/06Hand Wrist SMI 11Hand Wrist SMI 11

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Treatment sequenceTreatment sequence

PrePre--Surgical Tracing 6/2/06Surgical Tracing 6/2/06

Model urgeryo e urgery

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Model urgeryo e urgeryprepre--surgical VTOsurgical VTO

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Treatment sequenceTreatment sequenceModel SurgeryModel Surgery

6/10/06Mounted Models

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S

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SurgerySurgery

IVROs and LeFort 1IVROs and LeFort 1

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SurgerySurgeryAdvancement GenioplastyAdvancement Genioplasty

Post SurgicalPost Surgical

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Post SurgicalPost Surgical

2 weeks post-op

P S i lP t S i l

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Post SurgicalPost Surgical

2 weeks post-op

Fi l R dFi l R d

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Final RecordsFinal Records

DebondedDebonded 9/16/08

Fi l R dFinal Records

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Final RecordsFinal Records

DebondedDebonded 9/16/08

C hCeph S i itiS perimposition

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CephCeph SuperimpositionSuperimposition

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Treatment ChangesTreatment Changes

Post TreatmentPre Treatment

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Profile ChangeProfile Change

Post TreatmentPre Treatment

Orthognathic Case PresentationOrthognathic Case Presentation

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Orthognathic Case PresentationOrthognathic Case Presentation

State University of New York atState University of New York atStony BrookStony Brook

Department of OrthodonticsDepartment of OrthodonticsS. Mathew DDSS. Mathew DDS

ResidentResident--OrthodonticsOrthodontics

Jeff Drayer DDSJeff Drayer DDSResidentResident--OrthodonticsOrthodontics

Jose Vicens DMDJose Vicens DMDResidentResident--OrthodonticsOrthodontics

Benjamin Murray DMDBenjamin Murray DMDResidentResident--OrthodonticsOrthodontics

Richard Faber DDS, MSRichard Faber DDS, MSDirector Advanced Education Program in OrthodonticsDirector Advanced Education Program in Orthodontics

Salvatore Ruggerio DMD, MDSalvatore Ruggerio DMD, MDAssociate Professor Oral and MaxilloAssociate Professor Oral and Maxillo--Facial SurgeryFacial Surgery