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Aesthetic Considerations in Orthognathic Surgery Mr Paul Johnson Guildford, England XX1 COBRAC Vitoria-ES 2011

Is Orthognathic Surgery Cosmetic Surgery?

Yes and No

Orthognathic Surgery The Treatment of Dentofacial Deformity

Aims Correction of dentofacial deformity To give a functional occlusion To achieve the best aesthetic result

Paradox Indication is usually occlusal Result usually judged by the aesthetic outcome

Mandibular Procedures Maxillary Procedures Chin Rhinoplasty Cheek implants

• Bilateral Sagittal Split • Le Fort 1 • Sliding Genioplasty


Pertaining to beauty

A quality which delights the senses

Place Time Fashion


Beauty is in the eye of the beholder But are their any rules?

Treatment planning So how do you decide what the correct operation is?

Cephalometric analysis. Yes but what is really important?

Cephalometics •Skeletal pattern •Incisor angulation •Face Height •Maxillary Mandibular Plane Angle

Think aesthetics Starting point End point What to do What not to do

 Assess the patient.  Consider the immediate effects of planned movements.  Consider long term effects.

Mosby 2003

Chapter 4. Evaluation Of Facial Soft Tissues David Sarver, William Profitt, James Ackerman

Clinical assessment of facial form • • • • •

Facial balance. Thirds and fifths Lips Chin\Nose balance Nose Cheekbones and inferior orbital rims.

Facial thirds and fifths

Facial fifths

The Lips • Lip growth lags behind skeletal growth. Therefore lip competence cannot be assessed until growth complete. • Lip thickness greater in females than males. • Lip thickness decreases with age. • Lip balance.

Upper lip â&#x20AC;&#x201C; incisor relationship Incisal show with the upper lip at rest  0 â&#x20AC;&#x201C; 4 mm. Female > male  If > 4mm vertical maxillary excess  If < 0mm vertical maxillary insufficiency But must assess in conjunction with mandibularmaxillary plane angle and facial thirds. Beware of the short upper lip and short clinical crowns.

Chin â&#x20AC;&#x201C; nose balance

Nasal aesthetics  Nasolabial angle  Alar width  Paranasal fullness

Nasolabial Angle 100-120 degrees Female > male

So What effects do osteotomies have on facial appearance?

Mandibular movements

Advancement • Pogonium forward • Pogonium downward (if curve of Spee maintained) • Labio-mental angle becomes more obtuse • Improved soft tissue support over jaw and neck

Mandibular Setback • Chin point back • Labiomental angle more acute • Decreased soft tissue support

Nasal Aesthetics and Le Fort 1 • • • • • • •

Nose forward Nose tip angulation Nares exposure increased Upper lip forward and flattened Subnasale forward Columella forward Increased alar width

Adverse Aesthetics following treatment of AOB by maxillary impaction. The ‘Miss Piggy’ deformity

Facial Age Changes Loss of soft tissue volume and skin elasticity and gravitational effects. Loss of lip fullness Loss of curve of upper lip Loss Increase Increase in upper lip length Loss of face height Decrease in upper incisor show Increase in lower incisor show Nasal tip moves inferiorly and nasolabial angle becomes more acute Deepening of nasolabial grooves and marionette lines

Compensation for Age Changes Leave soft tissues oversupported. – Maintains upper lip support – Decreases nasolabial fold development and marionette lines

Conservative maxillary impaction. – Maintains incisal show


Clinical Assessment Nasal hump Zygomatic insufficiency Acute nasolabial angle Undersupported upper lip Oversupported lower lip

Orthodontic Plan Decompensation Alignement Coordination

Surgical Plan Maxillary advancement Cheek implants Rhinoplasty

Bird-face deformity

Bird-face deformity BirdPost distraction

Conclusions Think aesthetics in orthognathic surgery Anticipate age changes

Is orthognathic surgery cosmetic? Yes and no.

Thank You

Mr Paul Johnson

08-09-2011-14H30_PAUL JOHNSON  

XX1 COBRAC Vitoria-ES 2011 Mr Paul Johnson Guildford, England Is OrthognathicSurgery Cosmetic Surgery? Cosmetic Surgery? Yes and No The Trea...

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