Fundamentals of Orthognathic Surgery and Non Surgical Facial Aesthetics

Contributors
Preface and Acknowledgements
1. General Assessment
	Introduction
	History
		The Medical History
		Body Dysmorphic Disorder (Formerly Dysmorphophobia)
	Evaluation of the Patient
		Introduction
	Clinical Examination
		Frontal Assessment
		Profile Assessment
		Temporomandibular Joint Examination
		Intraoral Examination
	Investigations
		Radiographic Imaging
		Study Models (Casts)
		Photographs
		Lateral Skull Tracing
	The Diagnosis
2. Radiographic Analysis and Imaging
	The Need
	The Tracing
	The Analysis
	Vertical Values
		Linear
		Angular
		Anteroposterior Relationships
			Analysis of the Incisor Angulations to the Maxillary and Mandibular Bases
	The Surgical Application of Cephalometry
	Computerised Cephalometrics
	Posteroanterior Radiograph Tracings
	Orthopantomogram Tracing
3. Computerised Cephalometrics for Orthodontic and Orthognathic Planning
	Treatment Planning with Digital Images
	Patient Education is Important
	Interactive and Simulation Programmes
	Limitations
4. Orthodontic Preparation
	Timing and Duration
	Presurgical Orthodontics
		Alignment of the Dentition — The Technology
		Arch Levelling
		Segmental Levelling
			a) In cases of reduced vertical dimension
			b) In cases of increased vertical dimension
		Incisor Decompensation
		Decompensation in Class II Cases
		Arch Coordination
		Methods of Orthodontic Arch Expansion
			Quadhelix
			Hyrax Screw
			Expansion Arch
			Alternative Arch Expanders
		Monitoring Arch Coordination During Treatment
		Facilitating Surgical Correction
	Postsurgical Orthodontics
		Retention
5. The Definitive Treatment Plan
	Manual Planning of the Maxillary Move
	Planning the Mandibular Move
		Autorotation
		Anterior Movements
		Posterior Movements
		Horizontal Rotation
		Chin Position
		Cephalometric Tracing Planning
		Imaging Simulations
6. The Recording and Transfer of Orthognathic Planning Data
	Introduction
	The Planning Process
		1. Clinical Measurements
		2. Impression Procedure
		3. Recording the Occlusal Relationship
	The Registration of Supine Centric Relation
		4. Facebow Recording
		5. Facebow Transfer to the Articulator and the Mounting of the Casts
			Facial Asymmetry
			The Transfer of the Facebow Record of a Maxillary Asymmetry
		6. Model Surgery
			The Ericsson Table for Model Surgery (Great Lakes Orthodontics)
		7. Occlusal Wafers
			Wafer Fabrication
		The Construction Technique Using Quick Cure Acrylic
7. Computer-Aided Surgical Simulation (CASS) for Orthognathic Surgery
	Introduction
	The Virtual (Stereolithic) Dental Cast (STL)
	In House CASS Processing
	The Remote CASS Service Centre
	The CASS Programme
	The Alternative CASS Treatment Plan
	The CASS Remote Service Centre
	Exploring the Possible Operations
	Example — The Le Fort 1 osteotomy
	Surgical Cutting Guides
	Establishing Facial Dimensions for an Anterior Open Bite
	3D Printing Technology for Surgical Guides and Wafers
	The Case Presentation
	Cephalometric Data
	CASS and the Operative Methodology
	Postoperative
	Conclusions
	Acknowledgements
8. Fixation Techniques
	Introduction
		Fixed Orthodontic Appliances
			Advantages
			Disadvantages
			Cortical Screws
		Arch Bars
			Prefabricated Flexible
			Advantages
			Disadvantages
		Ligating Arch Bars
		Eyelet Wires
			Advantages
			Disadvantages
		Occlusal Wafers
	Internal Fixation
		Transosseous Wiring
		Miniature Bone Plates and Cortical Screws
		Bioresorbable Fixation Plates and Screws
9. Osteotomies and Bone Grafts
	General Preoperative Considerations
		Preoperative Investigations
		Blood Replacement
	Antibiotics
		Preoperatively
	Antioedema Medication
		Preoperatively
		Postoperatively
		Operating Considerations
		Instruments
	Postoperative Care
		Immediate
		Analgesics
		Postoperative Care
		Second Postoperative Day
		Follow-Up
	The Operative Procedures
		The Obwegeser Sagittal Split Osteotomy
			Indications
			Technique
			Additional Notes
	The Subsigmoid (Subcondylar) Osteotomy
		Indications
	Subsigmoid Osteotomy (Extraoral)
		Technique
	Intraoral Subcondylar Osteotomy
		Technique
			Buccal Ramus Approach
			Medial Ramus Approach
	Body Osteotomies
	The Inverted L Osteotomy
		Indications
		Technique
	The Lower Labial Segmental Osteotomy (Kole Subapical Osteotomy)
		Indications
		Technique
		Forward Movement
		Upward Movement
	The Anterior Mandibulotomy
		Indications and Technique
	Genioplasty or Mentoplasty
		Indications
	The Augmentation Genioplasty
		Technique
	The Reduction Genioplasty
	Maxillary Osteotomies
		Anterior dentoalveolar osteotomy (Wassmund/Wunderer)
			Indications
			Limitations
			Technique
	The Le Fort I Osteotomy
		Indications
		Technique
	The Posterior Dentoalveolar Segmental Osteotomy of Schuchardt
		Indications
	Le Fort II Osteotomy
		Indications
		Technique
	The Kufner Modification of the LeFort III Osteotomy
		Indications
		Technique
	Tongue Reduction
		Indications
		Technique
	Bone Grafts
		Orthognathic Indications
	Iliac Crest
		1. Open harvesting
		2. Trephine harvesting
		3. Non operative bone substitutes with recombinant human bone morphogenetic protein 2. (rhBMP-2)
	Rib
		Technique
10. Distraction Osteogenesis
	Introduction
	The Cell Biology of Distraction Osteogenesis
	The Distraction Technique
	The Procedure
	The Vector of Distraction
	Types of Distractor
	1. The Hypoplastic Mandible
	2. Temporomandibular Joint (TMJ) Ankylosis
	Summary and Conclusion
	3. Maxillary Hypoplasia Due to Cleft Surgery
	4. Distraction for Dento-Alveolar Atrophy
	5. Restoration of a Maxillofacial Trauma Defect
	Treatment plan
	Summary
11. The Surgical Correction of Common Deformities
	Operative Timing
	Single Jaw Deformities
		Mandibular Prognathism
			Treatment
		Mandibular Asymmetry (Unilateral Hyperplasia and Hypoplasia of the Mandible)
			Introduction
		Hemimandibular Elongation
			Treatment
				Presurgical Orthodontics
				Surgery
		Hemimandibular Hyperplasia
			Treatment
				Early
				Late
		Condylar Hypoplasia
			Treatment
		Mandibular Retrognathism or Hypoplasia
			Treatment
				The Occlusion
			Lengthening the Mandible and the Chin
		The Chin
		Lower Lip Sag: A Warning
		Mandibular Incisor Proclination
			Treatment
		The Maxilla
			Maxillary Hypoplasia
			Treatment
		Nasomaxillary Hypoplasia
		Malar-Maxillary Hypoplasia
		Maxillary Protrusion
	Bimaxillary Deformities
		Gross Mandibular Prognathism
		The Deep Overbite
		Class II Division 1
			Treatment
		The Class II Division 2
		The Long Face Syndrome (“Vertical Maxillary and Chin Excess”)
			Treatment Planning
			Vertical Chin Excess (VCE)
			Bimaxillary Proclination
			Treatment
			The Open Bite Deformity (Apertognathia)
			The Skeletal Open Bite
		The Dento-Alveolar Open Bite
			Treatment
		The Skeletal Open Bite: Classes I and II
			Treatment
			Variations
		The Skeletal Open Bite Class III
			Treatment
		The Large Tongue
		The Short Face
			Treatment
		Operative Procedure
		Maxillary Asymmetry
			Treatment
12. Secondary Cleft Lip and Palate Deformities
	Introduction
	Important Factors
	Surgical Instrumentation
	The Surgical Procedures
		Harvesting the alveolar bone graft
		The Problems
		Surgical Management
		Postoperative care
		Segmental Surgery
			The Problems
			The Surgical Treatment
			Bilateral Clefts
			Presentation 1 — The Problems
			The Surgical Treatment
			Presentation 2 — The Problems
			The Surgical Treatment
			Presentation 3 — The Problems
			The Surgical Treatment
		Lesser Segment Alveolar Distraction
	The Surgical Preparation for Distraction
	Residual Fistulae
		Small Fistulae
			The Surgical Treatment
	Closure of Large Fistulae in Cases Presenting Late
		The Problem
		The Surgical Treatment
	The Surgical Treatment
		The Lateral Tongue Flap
		The Anterior Based Dorsal Tongue Flap
		Extraoral Flaps
			Residual Oronasal Fistulas in the Soft Palate
			Residual Nasolabial Fistulae
	Orthodontic Considerations
		Orthognathic Surgery
		Specific Problems in Cleft Patients
		Preparation of the Patient for Surgery
			Dental Care and Preparation
			Treatment Planning
		The Choice of Osteotomy Operation
			Maxillary Hypoplasia
			Implications for the Mandible and/or Chin
			Maxillary Advancement in the Previously Bone Grafted Maxilla
			Special Considerations — The Osteotomy Cuts and the Down-Fracture
		Ancillary Surgical Manoeuvres
			Segmental Maxillary Surgery
		Airway Considerations
		Postoperative Manoeuvres
		Effects on Speech
		Lip and Nose Changes with Maxillary Surgery
		Achieving Stability
			Skeletal Relapse
			Dentoalveolar Relapse
		Mid Face Distraction Osteogenesis
			Indications
			Severe Maxillary Deficiency and Complex Three-Dimensional Deficiency
		Stability and Effects on Speech
			Disadvantages
		Method and Choice of Distraction Device
		Internal Distractors
		Extra-Oral Distractors
			LeFort I Distraction
			LeFort II Distraction
			LeFort III (Kufner) Distraction
13. Ankylosis of the Temporomandibular Joint
	Introduction
	Aetiology
	Presentation
	Treatment Principles
	Treatment Choices
	Preoperative Imaging
	Timing
	Surgical Approach
	Complications
	Summary
14. Rhinoplasty Surgery
	Introduction
	Nasal Anatomy
	Assessment
		History
	Examination
	Documentation
	Photography and Computer Imaging
	Surgical Approaches
		Endonasal Approach
		External Approach
	Operative Techniques
		Anaesthesia
		Incisions
			1. Intercartilaginous
			2. Cartilage Splitting (Intracartilaginous, Transcartilaginous)
			3. Marginal Incision
			4. External Approach
		The Operative Sequence
			1. Septal Surgery
		Correction of the Osseocartilaginous Dorsum
			1. Hump Reduction
			2. Osteotomies
				Medial osteotomy
				Lateral osteotomy
		Intermediate Osteotomy
		Nasal Tip Surgery
		Volume Reduction
		Rotation Deformities
		Projection Deformities
			1. Domal Sutures
			2. Grafts and Struts
		Alar Base Reduction
			Nostril Size
			Alar Flare
			Combination
		Sequential lowering of the cartilaginous dorsum
		Postoperative Care
	Revision Surgery
	Case Reports
	Patient Examples
		Patient 1 — Dorsal Hump and Tip Ptosis
		Patient 2 — Post-Traumatic Saddle Deformity
		Patient 3 — Shallow Dorsal Hump and Boxy Tip
	Conclusions
15. Emergencies and Complications
	Introduction
	Medical Monitoring
	Complications
		1. Oedema and Infection
		2. Bleeding Problems
			a) Minor Haemorrhage
			b) Persistent Haemorrhage
			c) Investigations and Management
			d) Ligation of the External Carotid Artery
			e) Coagulation Defects
			f ) Secondary Haemorrhage
			g) Gastric Haemorrhage
		3) The Airway
			h) Emergency Airway Procedures
		4. Drainage of a Pneumothorax
			Vomiting
			Prevention
			Management
		5. Iliac Crest Problems
		6. Catheterisation
			Technique
		7. Deep Vein Thrombosis
		8. Fixation Problems
		9. Relapse
			a) Operative Structural Causes of Relapse
			b) Postoperative Functional Causes of Relapse
			c) Nerve Damage
		10. Emotional and Psychiatric Problems
16. The Psychosocial Aspects of Facial Deformity
	Introduction
	1. Social Aspects of Facial Deformity
	2. The Psychological Assessment
	3. Satisfaction and Dissatisfaction with Treatment
	Subjective Disorders of Appearance
		Body Dysmorphic Disorder (BDD)
			Presenting Features
			Treatment Options
				Surgery and BDD
				Medication management
				Counselling and psychological therapy
		Racial/Ethnic Dysphoria
		Gender Dysphoria or Gender Reassignment Surgery
	Conclusions
	The Eastman Consent Process
17. Non Surgical Facial Aesthetics — Part 1 Clinical Anatomy and the Aging Face
	Introduction
	The Structure of the Skin
	The Aging Process and the Skin
	Racial Aging Differences
	Facial Aging and the Integument
	The Muscles of Facial Expression
	The Origin and Function of the Muscles of Facial Expression
	The Muscular Control of Emotional Facial Expression
	Clinical Segmental Aging Changes
		1. Aging of the upper third of the face
		2. Aging of the midface
	The Nose and Ears
		3. Aging of the lower face
18. Non Surgical Facial Aesthetics — Part 2 Injectable Neuromodulators and Fillers
	Introduction
	Facial Rejuvenation with Injectable Neuromodulators
	Mechanism of Action
		1) Dynamic wrinkles
		2) Static wrinkles
	Neuromuscular Physiology
	Case Studies
		1) Forehead wrinkles
		2) Frown lines
		3) Crow’s feet
		4) Bilateral masseteric hyperplasia (hypertrophy)— The square jaw
		5) The “gummy smile”
		6) “Cobble stone” wrinkles of the chin
		7) Drooping of the mouth corners
		8) Peri-oral wrinkles
		9) Cervical dystonia
		10) Opening the palpebral fissure
		11) Platysma
		12) Intra-dermal BTX-A
		13) Botox and the treatment of idiopathic myofascial pains including the Temporo-Mandibular Joint Pain Dysfunction Syndrome (TMJPDS/Facial Arthromyalgia FAM)
	Conclusion
	Dermal Fillers
	Introduction
	Fat Compartments and Ligaments of the Face
	The Nerves and Arteries of the face
	Arteries of the Face
	The Clinical Applications of Dermal Fillers
		1) Wrinkles
		2) Eyebrow fillers
		3) The temporal fossae (the temples)
		4) Cheeks
		5) Tear trough deformity
	Tear trough deformity fillers require experienced assessment and management
		6) Naso-labial folds
		7) Marionette lines
		8) The chin
		9) Lips
	Cosmeceuticals
	Sunscreen
	Retinoids
	L-Ascorbic Acid
	Tocopherol
	Hyaluronic Acid
	Peptides
	Conclusion
19. Non Surgical Facial Aesthetics — Part 3 Radiofrequency versus Ultrasound Therapy
	Introduction
	Non-ablative High Radiofrequency Treatment (RF)
	The Application of Non-ablative Radiofrequency
		Radiofrequency therapy — Contra indications and complications
	Radiofrequency Summary
	Micro focused Ultrasound Therapy
		Introduction
	The Collagenesis Process
		Ultrasound versus nonablative radiofrequency
	The Psychological Aspects of NSFA Treatments
	Clinical Governance in Aesthetic Practice
20. Nutrition Support for Osteotomy Patients
	Introduction
	Nutritional Guidelines
	Immediate Postoperative Nutrition
		0–24 Hours Postoperation
		After 24 Hours
		After 48 Hours
	Philosophical and Religious Dietary Restrictions
	Nutrition After Discharge
	Written Instructions for the Patient and Family
		Appropriate Diet Guidance
		The Carnivore (Meat and Fish)
		The Vegetarian
		The Vegan
Information for Patients Undergoing Orthognathic Surgery
	Orthodontics
	The Operation
		Problems
		Oral hygiene and diet
	Postoperative Orthodontics
Index
Contents