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Contributors

CONSULTINGEDITOR

RUIP.FERNANDES,MD,DMD,FACS, FRCS(Ed)

ClinicalProfessorandChief,DivisionofHead andNeckSurgery,DepartmentsofOraland MaxillofacialSurgery,Neurosurgery,and OrthopaedicSurgeryandRehabilitation, UniversityofFloridaHealthScienceCenter, UniversityofFloridaCollegeofMedicine, Jacksonville,Florida,USA

EDITORS

MICHAELR.MARKIEWICZ,DDS,MPH,MD, FACS

ProfessorandChair,DepartmentofOraland MaxillofacialSurgery,WilliamM.Feagans EndowedChair,AssociateDeanforHospital Affairs,SchoolofDentalMedicine,Clinical Professor,DepartmentofNeurosurgery, DivisionofPediatricSurgery,Departmentof Surgery,JacobsSchoolofMedicineand BiomedicalSciences,UniversityatBuffalo, Co-Director,CraniofacialCenterofWestern NewYork,JohnR.OisheiChildren’sHospital, Buffalo,NewYork,USA

AUTHORS

SHELLYABRAMOWICZ,DMD,MPH,FACS

AssociateProfessor,OralandMaxillofacial SurgeryandPediatrics,Departmentof Surgery,DivisionofOralandMaxillofacial Surgery,EmoryUniversitySchoolofMedicine, AssociateChiefofOralandMaxillofacial Surgery,Children’sHealthcareofAtlanta, EmoryUniversity,Atlanta,Georgia,USA

VEERASATHPURUSHALLAREDDY,BDS, PhD

BrodieCraniofacialEndowedChair,Professor andHead,DepartmentofOrthodontics, CollegeofDentistry,TheUniversityofIllinoisat Chicago,Chicago,Illinois,USA

VEERASATHPURUSHALLAREDDY,BDS, PhD

BrodieCraniofacialEndowedChair,Professor andHead,DepartmentofOrthodontics, CollegeofDentistry,TheUniversityofIllinoisat Chicago,Chicago,Illinois,USA

MICHAELMILORO,DMD,MD,FACS ProfessorandHead,DepartmentofOraland MaxillofacialSurgery,CollegeofDentistry,The UniversityofIllinoisatChicago,Chicago, Illinois,USA

SHARONARONOVICH,DMD,FRCD(C) DepartmentofOralandMaxillofacialSurgery, UniversityofMichigan,AnnArbor,Michigan, USA

JENNIFERCAPLIN,DMD,MS

AssociateDirector,Post-Graduate Orthodontics,AssistantProfessor, DepartmentofOrthodontics,Collegeof Dentistry,TheUniversityofIllinoisatChicago, Chicago,Illinois,USA

RICHARDSCOTTCONLEY,DMD PrivatePracticeofOrthodontics,Washington, Pennsylvania,USA

MOHAMMEDH.ELNAGAR,DDS,MS,PhD

DepartmentofOrthodontics,Collegeof Dentistry,TheUniversityofIllinoisatChicago, Chicago,Illinois,USA

BRIANFARRELL,DDS,MD,FACS

PrivatePractitioner,CarolinaCenterforOral andFacialSurgery,Charlotte,NorthCarolina, USA;ClinicalAssistantProfessor,Department ofOralandMaxillofacialSurgery,Louisiana StateUniversity,SchoolofDentistry,New Orleans,Louisiana,USA

MICHAELD.HAN,DDS

AssistantProfessor,DepartmentofOral andMaxillofacialSurgery,TheUniversity ofIllinoisatChicago,Chicago,Illinois, USA

CHESTERS.HANDELMAN,DMD

ClinicalProfessor,Departmentof Orthodontics,CollegeofDentistry,The UniversityofIllinoisatChicago,Chicago, Illinois,USA

JASONP.JONES,DDS,MD

DepartmentofOralandMaxillofacialSurgery, UTHealthSanAntonio,SanAntonio,Texas, USA

LEONARDB.KABAN,DMD,MD

WalterC.GuralnickDistinguishedProfessor ofOralandMaxillofacialSurgery,Chief Emeritus,DepartmentofOraland MaxillofacialSurgery,Massachusetts GeneralHospital,HarvardSchoolof DentalMedicine,Boston,Massachusetts, USA

KATHERINEP.KLEIN,DMD,MS Director,OrthodonticsandDentofacial Orthopedics,MassachusettsGeneral Hospital,InstructorinOraland MaxillofacialSurgery,HarvardSchoolof DentalMedicine,Boston,Massachusetts, USA

BUDIKUSNOTO,DDS,MS

DepartmentofOrthodontics,Collegeof Dentistry,TheUniversityofIllinoisatChicago, Chicago,Illinois,USA

MICHAELR.MARKIEWICZ,DDS,MPH, MD,FACS

ProfessorandChair,DepartmentofOral andMaxillofacialSurgery,WilliamM.Feagans EndowedChair,AssociateDeanfor HospitalAffairs,SchoolofDentalMedicine, ClinicalProfessor,Departmentof Neurosurgery,DivisionofPediatricSurgery, DepartmentofSurgery,JacobsSchoolof MedicineandBiomedicalSciences,University atBuffalo,Co-Director,CraniofacialCenterof WesternNewYork,JohnR.OisheiChildren’s Hospital,Buffalo,NewYork,USA

MOHAMEDI.MASOUD,BDS,DMSc Director,AdvancedGraduateOrthodontics, AssistantProfessorofDevelopmentalBiology, HarvardSchoolofDentalMedicine,Boston, Massachusetts,USA

DANIELJ.MEARA,MS,MD,DMD, MHCDS,FACS

Chair,DepartmentofOralandMaxillofacial SurgeryandHospitalDentistry,Christiana CareHealthSystem,Wilmington,Delaware, USA;AffiliateFaculty,DepartmentofPhysical Therapy,UniversityofDelaware,Newark, Delaware,USA

LOUISG.MERCURI,DDS,MS

VisitingProfessor,Departmentof OrthopaedicSurgery,RushUniversityMedical Center,Chicago,Illinois,USA;Clinical Consultant,TMJConcepts,Ventura,California, USA

MICHAELMILORO,DMD,MD,FACS ProfessorandHead,DepartmentofOraland MaxillofacialSurgery,CollegeofDentistry,The UniversityofIllinoisatChicago,Chicago, Illinois,USA

SVENERIKNØRHOLT,DDS,PhD

DepartmentofOralandMaxillofacialSurgery, AarhusUniversityHospital,ClinicalProfessor, SectionofOralMaxillofacialSurgery,Aarhus University,Aarhus,Denmark

PETRAOLIVIERI,MD,DMD

Resident,DepartmentofOralandMaxillofacial Surgery,CaseWesternReserveUniversity, Cleveland,Ohio,USA

THOMASKLITPEDERSEN,DDS,PhD

ClinicalProfessor,SectionofOrthodontics, AarhusUniversity,DepartmentofOraland MaxillofacialSurgery,AarhusUniversity Hospital,Aarhus,Denmark

DANIELE.PEREZ,DDS

DepartmentofOralandMaxillofacialSurgery, UTHealthSanAntonio,SanAntonio,Texas, USA

FAISALA.QUERESHY,MD,DDS,FACS Professor,DepartmentofOraland MaxillofacialSurgery,Director,Residency Program,DepartmentofOralandMaxillofacial Surgery,CaseWesternReserveUniversity, UniversityHospitalsClevelandMedicalCenter, Cleveland,Ohio,USA

CORYM.RESNICK,DMD,MD,FACS AssistantProfessor,DepartmentofPlasticand OralSurgery,BostonChildren’sHospital,Oral andMaxillofacialSurgery,HarvardSchoolof DentalMedicine,HarvardMedicalSchool, Boston,Massachusetts,USA

JOHANP.REYNEKE,MChD,FCOMFS(SA), PhD

PrivatePractice,DirectoroftheCenterfor OrthognathicSurgery,Mediclinic; ExtraordinaryProfessor,DepartmentofOral andMaxillofacialSurgery,FacultyofHealth Sciences,UniversityoftheWesternCape,

CapeTown,SouthAfrica;ClinicalProfessor, DepartmentofOralandMaxillofacialSurgery, UniversityofOklahoma,OklahomaCity, Oklahoma,USA;AssociateProfessor, DepartmentofOralandMaxillofacialSurgery, VNAIFacultyofDentistry,Universidad NacionalAutonomadeMexico,SanSalvador, Mexico

PETERSTOUSTRUP,DDS,PhD

AssociateProfessor,SectionofOrthodontics, AarhusUniversity,Aarhus,Denmark

FLAVIOA.URIBE,DDS,MDentSc

CharlesBurstoneProfessor,ProgramDirector andInterimChair,AssociateProfessor, DivisionofOrthodontics,Departmentof CraniofacialSciences,Universityof Connecticut,UConnHealth,Farmington, Connecticut,USA

LARRYM.WOLFORD,DMD

ClinicalProfessor,DepartmentsofOraland MaxillofacialSurgeryandOrthodontics,Texas A&MUniversityCollegeofDentistry,Baylor UniversityMedicalCenter–PrivatePractice, Dallas,Texas,USA

SUMITYADAV,MDS,PhD

AssociateProfessor,Departmentof CraniofacialSciences,Universityof ConnecticutSchoolofDentalMedicine, Farmington,Connecticut,USA

Preface:OrthodonticsfortheOralandMaxillofacialSurgeryPatient xiii

MichaelR.Markiewicz,VeerasathpurushAllareddy,andMichaelMiloro

DigitalWorkflowforCombinedOrthodonticsandOrthognathicSurgery

MohammedH.Elnagar,SharonAronovich,andBudiKusnoto

ThisarticleprovidesanoverviewofthedigitalworkflowprocessforCombinedorthodonticsandOrthognathicsurgerytreatmentstartingfromdataacquisition(3dimensionalscanning,cone-beamcomputedtomography),datapreparation,processingandCreationofathree-dimensionalvirtualaugmentedmodelofthehead. EstablishingaProperDiagnosisandQuantificationoftheDentofacialDeformityusing3Ddiagnosticmodel.Furthermore,performanceof3-dimensionalVirtualorthognathicsurgicaltreatment,andtheconstructionofasurgicalsplint(via3dimensionalprinting)toallowtransferofthetreatmentplantotheactualpatient duringsurgery.

OrthodonticandSurgicalConsiderationsforTreatingImpactedTeeth

VeerasathpurushAllareddy,JenniferCaplin,MichaelR.Markiewicz,andDanielJ.Meara

Impactedteethoccurinasignificantnumberofpatients.Theirmanagementrequires coordinatedeffortsoforthodontistsandoralandmaxillofacialsurgeons.Specifically,optimalresultsrequireapromptorthodonticdiagnosisandtreatmentplan withexecutionofeitherclosedoropenexposureofimpactedteethbytheoral andmaxillofacialsurgeon.Failuretoconsiderorthodonticmechanicsandproper surgicaltechniquecanleadtosuboptimalresults.Thus,orthodontist/oralandmaxillofacialsurgeoncommunicationisessentialforsuccessandpatienteducationand shareddecision-makingismandatorybeforeinitiatingtreatment.

TemporarySkeletalAnchorageTechniques

JasonP.Jones,MohammedH.Elnagar,andDanielE.Perez

Asorthodontictreatmenthasadvancedincomplexityandinfrequency,morerecent techniques,usingtemporaryskeletalanchorage,weredevelopedtohelpcorrect moresevereocclusalanddentofacialdiscrepanciesthatweretreatedwithorthognathicsurgeryalonepreviously.Thesetechniqueshaveallowedtheorthodontistto moveteethagainstarigidfixation,allowingformorefocusedmovementsofteeth andfororthopedicgrowthmodification.Thesetypesoftreatmentsusingrigidfixationhaveallowedforgreaterinteractionbetweentheorthodontistandtheoraland maxillofacialsurgeon,andhavevastlyenhancedthetreatmentplanningforthe orthodontistintoday’ssociety.

InterceptiveDentofacialOrthopedics(GrowthModification)

JenniferCaplin,MichaelD.Han,MichaelMiloro,VeerasathpurushAllareddy, andMichaelR.Markiewicz

Althoughalldentofacialdeformitiesinvolvedeviationofskeletalanddentalunitsthat requirecorrection,thetimingandmethodoftreatmentcanvaryconsiderably.

1

15

27

39

Growthisakeyconsiderationwhenmanagingdentofacialdeformities,becauseit hasadirectimpactonthetimingandmethodofmanagement.Somedeformities maybeinterceptedandmanagedduringgrowth,whereasotherscanonlybedefinitivelymanagedaftercessationofgrowth.Thisarticlefocusesonclinicalconsiderationsofgrowthinmanagingdentofacialdeformities,anddiscussesmethodsof growthevaluationandinterceptiveorthodonticmanagementstrategiesindifferent typesofdentofacialdeformities.

Surgical/OrthodonticCorrectionofTransverseMaxillaryDiscrepancies

JohanP.ReynekeandRichardScottConley

Thetransversedimensionisacriticalcomponentofcomprehensivetreatmentinorthognathicsurgery.Severaltreatmentapproachesexistandtheteammustconsider thepatient’sneeds,desires,andlimitationswhenworkingtocorrectthemalocclusion.Treatmentapproachesmayincludeonlyorthodonticexpansionorrapidpalatal orthodonticexpansion;however,inadults,theorthodontistmayrequiresurgical assistancetoexpandthebonymaxilla.Segmentalmaxillaryexpansionmaybeindicatedinseveretransversedeficienciesofthemaxillaryarchordentofacialdeformity patientsalsorequiringverticalandsagittalcorrections.Thevarioustreatmentoptions,advantages,anddisadvantages,andindicationsforeachsurgicalapproach arediscussed.

OrthognathicSurgeryandOrthodontics:InadequatePlanningLeadingtoComplications

KatherineP.Klein,LeonardB.Kaban,andMohamedI.Masoud

Complicationsinorthognathicsurgeryarecommonlyaresultofinadequatepreoperativeplanningandcommunicationbetweenthesurgeonandorthodontist.Unfavorableoutcomescanoftenbeavoidedwhenoveralltreatmentgoalsalongwitha surgicalandorthodonticplanaredevelopedandagreeduponbytheorthodontist, surgeon,andpatientbeforethestartofactivetoothmovementoranysurgicalprocedures.Continuousevaluationofthepatient’sprogressthroughouttreatmentand subsequentcommunicationbetweenthesurgeonandorthodontistarerecommendedtopreventfrequenterrors,suchasinadequatedentaldecompensation,poor applianceselectionormanagement,andoccasionalcontraindicatedorthodontic elastictractionortoothmovements.

DentoalveolarDistractionOsteogenesisforRapidMaxillaryCanineRetraction:An OverviewofTechnique,Treatment,andOutcomes83

SumitYadav,MichaelR.Markiewicz,andVeerasathpurushAllareddy

Patientsandorthodontistsseektoreducetreatmenttimeinbraces.Rapidcanine retractionthroughdentoalveolardistractionosteogenesisisoneofseveraltreatmentapproachestoreducetreatmentinbraces.Thisarticleprovidesanoverview oftechniqueofdentoalveolardistractionosteogenesistoaccomplishrapidcanine retractionandassociatedoutcomes.Whenthistreatmentprotocolisimplemented well,rapidcanineretractionisachievedpredictablywithminimalsideeffects. Althoughcurrentevidencesuggeststhatadversesequelae,suchasrootresorptionsandpulpdevitalization,arerare,prospectiveclinicalstudiesthatare adequatelypoweredanddocumentinglong-termfollow-upoftheseoutcomes arelacking.

FlavioA.UribeandBrianFarrell

Thesurgery-firstapproach(SFA)hasbecomearecentalternativetotheconventional3-stageapproachtoorthognathicsurgery.Skeletalanchorageinorthodontics hasfacilitatedtheresurgenceofthistreatmentsequence.Byeliminatingthepresurgicalphaseoforthodontictreatment,patientshaveimmediateresolutiontotheir facialdeformity.Treatmentdurationhasbeenshowntobereduced;thedifference withtheconventionalapproachbeingapproximately5months.Patientsatisfaction withthisapproachisveryhighasmeasuredbyquality-of-lifesurveys.Thisarticle describestheindicationsandstep-by-stepapproachofthistechniqueinconjunctionwithvirtualsurgicalplanning.

IdiopathicCondylarResorption:WhatShouldWeDo?

LouisG.MercuriandChesterS.Handelman

Idiopathiccondylarresorption(ICR),alternativelycalledprogressivecondylar resorption,isanuncommonaggressiveformofdegenerativediseaseofthetemporomandibularjointseenmostlyinadolescentandyoungwomen.ICRoccurring beforethecompletionofgrowthresultsinashortermandibularcondyloidprocess, ramusandbody,compensatorygrowthatthegonialangleandcoronoidprocess,as wellasanincreaseinanteriorfacialverticaldimension.Managementoptionsdiscussedincludeoralappliances,orthodontics,medicalmanagement,orthognathic surgerywithandwithoutdiscrepositioning,andalloplastictemporomandibularjoint replacement.

105

InterdisciplinaryManagementofDentofacialDeformityinJuvenileIdiopathicArthritis117 PeterStoustrup,ThomasKlitPedersen,SvenErikNørholt,CoryM.Resnick, andShellyAbramowicz

Temporomandibularjoint(TMJ)arthritisimpactsmandibulargrowthanddevelopment.Thiscanresultinskeletaldeformity,suchasfacialasymmetryand/ormalocclusionasymmetry.ThisarticlereviewstheuniquepropertiesofTMJanddentofacial growthanddevelopmentinthesettingofjuvenileidiopathicarthritis(JIA).Specific orthopedic/orthodonticandsurgicalmanagementofchildrenwithJIAandTMJ arthritisisdiscussed.Theimportanceofinterdisciplinarycollaborationishighlighted.

ComprehensivePostOrthognathicSurgeryOrthodontics:Complications, Misconceptions,andManagement135

LarryM.Wolford

Postorthognathicsurgerypatientmanagementiscriticalforhigh-qualityandpredictableoutcomes.Surgeonsandorthodontistsmusthavetheknowledgeandabilitytoimplementpostsurgicalmanagementprotocolsandstrategiestoprovidethe bestcareandoutcomespossible.Thisarticlepresentsbasicconcepts,philosophies,treatmentprotocols,risks,andpotentialcomplicationsassociatedwithpostsurgicalpatientmanagement.Postsurgicalorthodonticgoalsaretomaximizethe occlusalfitandprovidepredictablemeanstoretaintheocclusion.Aggressiveorthodonticmechanicsmayberequiredtoprovidethebestocclusalfit.Complications canoccur,butearlyrecognitionofcomplicationsandimplementationofcorrective tacticsshouldminimizeadverseoutcomes.

AestheticFacialSurgeryandOrthodontics:CommonGoals

PetraOlivieri,FlavioA.Uribe,andFaisalA.Quereshy

Manyoftheaestheticfacialprocedurescanbeperformedsimultaneouslyatthetime ofinitialorthognathicsurgery.Correctionofanyresidualdeformitiesaftersurgery, suchasmandibularnotching,malarasymmetry,labiomentalcrease,andanycamouflagetreatment,shouldbeperformedasadelayedprocedure,whentheoutcome ismorepredictable.Additionally,theseprocedurescouldbeusedtoenhancethe orthodonticresult,withouttheneedofosteotomiestorepositionthebones.

ORALANDMAXILLOFACIALSURGERY

CLINICSOFNORTHAMERICA

FORTHCOMINGISSUES

May2020

OrthodonticsfortheCraniofacialSurgery Patient

MichaelR.Markiewicz,Veerasathpurush Allareddy,andMichaelMiloro, Editors

August2020

GlobalOralandMaxillofacialSurgery

ShahidAziz,StevenRoser,and JoseM.Marchena, Editors

November2020

DentoalveolarSurgery SomsakSittitavornwong, Editor

RECENTISSUES

November2019

AdvancesinOralandMaxillofacialSurgery

JoseM.Marchena,JonathanW.Shum,and JonathonS.Jundt, Editors

August2019

DentalImplants,PartII:Computer Technology

OleT.Jensen, Editor

May2019

DentalImplants,PartI:Reconstruction

OleT.Jensen, Editor

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www.oralmaxsurgeryatlas.theclinics.com

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www.dental.theclinics.com

THECLINICSARENOWAVAILABLEONLINE!

Accessyoursubscriptionat: www.theclinics.com

Preface

OrthodonticsfortheOraland MaxillofacialSurgeryPatient

MichaelR.Markiewicz,DDS, MPH,MD,FACS

VeerasathpurushAllareddy, BDS,PhD

Editors

ThespecialtiesofOralandMaxillofacialSurgery andOrthodonticsareintimatelyrelated.Infact,it canbestatedthat,inmanycases,“anOraland MaxillofacialSurgeon(OMFS)isonlyasgoodas theirOrthodontist.”Thisrelationshipandcollaborationbetweenthese2specialtiesarecriticalto thesuccessoftheorthodontistandsurgeon, and,inturn,thesuccessoftheirpatient.Thiscould notbemoreevidentthaninthefieldoforthognathicsurgery,wheretheoutcomes,and,inactuality,thefrankabilityofthesurgeontoperformthe procedurearedictatedbythelevelofappropriate orthodonticpreparationofthatpatient,based uponantheinitial,andevolving,treatmentplan determinedbythesurgeon,orthodontist,and patient.

However,thebasicprinciplesandclinicalrelevanceoforthodonticstoorthognathicsurgery areoftenoverlookedinanOralandMaxillofacial Surgeryresidencytrainingprogram.Therationale, planning,andexecutionoftheorthodontic componentofacombinedorthodontic-oraland maxillofacialtreatmentareoftenlackinginthe

educationofanOMFSsurgeonandisoftensecondarytotheattainmentofsurgicalknowledge. Thelackofappreciationforthiscrucialcollaborationbetweenspecialtieswouldbesimilarfor dentalimplantsurgeryinwhichtheOMFStrainee whodoesnotunderstandorappreciatetheprosthodonticcomponentsofthosecombinedtreatmentapproaches.Therefore,thedevelopmentof thiscriticalrelationshipmaybedelayedor inhibitedfromtheoutsetanddifficulttoincorporateintothetreatmentparadigmatalatertime. Thisrelationshipandknowledgeofeachother’s specialtiescapabilitiesandlimitationsareessential,notonlyfororthognathicsurgeryandmanagementofdentofacialdeformitiesbutalso,for example,inthecaseofmanagementofimpacted teeth,theuseoftechniquesforskeletal anchorage,thediagnosisandrelevanceof obstructivesleepapnea,andtheneedforadjunctiveprocedures,suchasaestheticfacialsurgery. Inaddition,aknowledgeofdentofacialorthopedicsandothercommonorthodonticmaneuvers andtechniqueswillallowtheOMFSsurgeonto

MichaelMiloro,DMD,MD,FACS

makemoreinformedandappropriatedecisionsin themanagementofthe“growing”patient.Therefore,wesetouttoproduceaclinicalreference fororthodontistsandOMFSsintrainingandinclinicalpractice.

Thisissueofthe OralandMaxillofacialSurgery ClinicsofNorthAmerica isthefirstofa2-partseries.Thesecondissue,“Orthodonticsforthe CraniofacialSurgeryPatient,”isintendedtobuild uponthefoundationalframeworkoftheinformationpresentedinthisissue,however,withafurther applicationoftheseprinciplestoamorecomplex patientpopulation—thosepatientswithcraniofacialanomalies,facialclefts,craniofacialdysostoses,andothercongenitalandacquired anomaliesoftheheadandneck.

Toaccomplishourgoalofprovidingcurrent collaborativepracticeguidelinesandengaging thoseindividualswhowedeemedtobeauthorities ontheorthodonticandsurgicalaspectsoftheproposedtopics,weutilizedauniqueapproachin authorrecruitment.WesolicitedbothanorthodontistandanOMFS,deemedtobeanexpertineach oftheirrespectivefields,tocoauthoreacharticlein acollaborativefashion.Theseindividualswere chosenwithoutconcernoftheirinstitutionalorigin toavoidpotentialsingle-institutionalbiasinpracticephilosophies.Thiswasanincrediblychallengingendeavorsincemostcliniciansaremost experiencedinpublishingtheirliteraturewiththe teamwithwhomtheypractice.Despitethepotentialrisksofnotidentifyingcompatibleauthors,all oftheauthorsgraciouslyandenthusiastically acceptedtheinvitationtobepartofthisproject andlookedforwardtoestablishinganewrelationship,andworkingwith,anotherauthorwithwhom theymayormaynothavehadthechanceto interactwithinthepast.Webelievethatthis uniqueapproachtoauthorshipforthisissuehighlightstheimportanceofthecollaborationbetween

theorthodontistandOMFSandledtotheproductionofthisuniquetextproducedherein.Wethank allofthosewhohavecontributedastheyarethe valueofthisuniquetext.

MichaelR.Markiewicz,DDS,MPH,MD,FACS DepartmentofOralandMaxillofacialSurgery SchoolofDentalMedicine UniversityatBuffalo 3435MainStreet,112SquireHall Buffalo,NY14214,USA

DepartmentofNeurosurgery DivisionofPediatricSurgery DepartmentofSurgery JacobsSchoolofMedicineandBiomedical Sciences

CraniofacialCenterofWesternNewYork JohnR.OisheiChildren’sHospital Buffalo,NY,USA

VeerasathpurushAllareddy,BDS,PhD DepartmentofOrthodontics CollegeofDentistry UniversityofIllinoisatChicago 801SouthPaulinaStreet 138AD(MC841) Chicago,IL60612-7211,USA

MichaelMiloro,DMD,MD,FACS DepartmentofOralandMaxillofacialSurgery CollegeofDentistry UniversityofIllinoisatChicago 801SouthPaulinaStreet M/C835 Chicago,IL60612-7211,USA

E-mailaddresses: mrm25@buffalo.edu (M.R.Markiewicz) sath@uic.edu (V.Allareddy) mmiloro@uic.edu (M.Miloro)

DigitalWorkflowfor CombinedOrthodontics andOrthognathicSurgery

MohammedH.Elnagar, DDS,MS,PhDa,*,SharonAronovich, DMD,FRCD(C)b, BudiKusnoto, DDS,MSa

KEYWORDS

Computer-aidedsurgery 3Dorthognathicsurgerysimulation Virtualmodelsurgery Digitalworkflow

KEYPOINTS

3DDataAcquisitionandProcessingfordiagnosticandquantificationofthedentofacialdeformities. Developing3DVirtualtreatmentplanningandorthognathicsurgery. Transferthe3DVirtualtreatmentplantoOperatingroom. FutureofComputer-assistedsurgicalplanning. Teledentistry-RemoteMonitoringandFollowup.

INTRODUCTION

Dentofacialdeformitiesaffectqualityoflife,selfimage,socialbehavior,andpublicperception, leadingtoaperceptionthattheindividualisless attractive,lesssuccessful,andlesssocially acceptablebasedonsocietalnorms.Thetreatmentapproachusingcombinedorthodonticsand orthognathicsurgeryisconsideredtobeavery powerfultooltocorrectfunctionalabnormalities, butalsotoaltersofttissuesandfacialforminorder toimproveoverallfacialesthetics.1,2

Theestablishmentofacorrectdiagnosisand treatmentplanisoneofthemostcriticalpartsin themanagementoftheorthognathicsurgicalpatient.Computertechnologyhascertainly enhancedtheabilityofthecliniciantodelivera moreprecisetreatmentoutcome,reducerisk, andachievebetteroutcomes.

Manysoftwarepackagesforcomputer-assisted surgery(CAS)areavailable,andsomeofthem allowin-houseCAStobeperformedfromthe database(cone-beamcomputedtomography

[CBCT],intraoralscans)andthentransferredto theoperatingroomwiththegenerationofasurgicalsplint(eg,Dolphin3D;DolphinImaging11.9 Premium,Chatsworth,CA,USA).Furthermore, thereareseveralcommerciallyavailablesystems, includingMedicalModeling(3DSystemsHealthcare,Littleton,CO,USA)andMaxilim(Medicim, Mechelen,Belgium)thatcanhelptofacilitatethe processofvirtualsurgicalplanning(VSP).Fora servicefee,thecommercialcompaniesconstruct surfacemodelsfromCBCTimagesanddigital dentalcastsregisteredtotheCBCT,performthe virtualsurgeryviaWebinarswiththesurgeonand orthodontist,onoccasion,andprinttheactualsurgicalsplints.Thevariouscomponentsofthedigital workflowprocessarecoveredinthisarticle.

DataAcquisition

Inordertobuildanaccuratemodelthatcan representarealisticdigitalsimulation,itmust beginwithproperdataacquisition.Eachofthe endusers,includingthecliniciansand

DisclosureStatement:Theauthorshavenothingtodisclose. a DepartmentofOrthodontics,CollegeofDentistry,UniversityofIllinoisatChicago,801SouthPaulinaStreet, Room131,Chicago,IL60612-7211,USA; b DepartmentofOralandMaxillofacialSurgery,UniversityofMichigan,1500EMedicalCenterDr,AnnArbor,MI48109,USA

*Correspondingauthor.

E-mailaddress: melnagar@uic.edu

OralMaxillofacialSurgClinNAm32(2020)1–14 https://doi.org/10.1016/j.coms.2019.08.004 1042-3699/20/ 2019ElsevierInc.Allrightsreserved.

technicians,shouldhavetheknowledgeofhow variousmethodsofdataacquisitionmightinfluencetheoutcomesofthetreatmentsimulation. Dataacquisitionmethodscanbecategorized intoseveralmethods,suchas(a)surfacescans, (b)volumetricscans,and(c)4-dimensional(4D) videoscans/movements.Eachmethodofdata acquisitionmustleadto1commongoal,thatis, tocreateprecisereplicasofthepatientforthe purposeofestablishingacomprehensivediagnosis,treatmentplanning,treatmentsimulation, anddesignanddeliveryoforthodonticandsurgicaltreatment.Tobeclear,accurate3Dvirtual treatmentplanningfororthodonticsandorthognathicsurgeryrequiresappropriateandaccurate imageacquisitiontoestablishtheproper database.

Imageacquisitionofthemaxillofacialregion (cone-beamcomputedtomography)

CBCThasbecomeanincreasinglyimportanttool intreatmentplanninganddiagnosisinimplant dentistry,endodontics,orthodontics,andother dentalandmedicalspecialties.Thebenefitsof CBCTinorthodonticsincludeincreasedaccuracy ofimagegeometryandimprovedabilitytorecord accuratemeasurementsbyeliminatingimage magnification,anatomicstructureoverlap,andimagedistortioncommonlyencounteredwith2dimensional(2D)radiographs(traditionalcephalometry).3 Oneoftheconcernswiththeroutine useofCBCTistheeffectsofincreasedexposure toionizingradiation.Themedicalimagingindustry hasimproveduponthistechnologyoverthepast 2decadesofitsincreasinglywidespreadusein dentistry.Withtechnologicadvances,suchas theuseofflatpaneldetectors,theavailabilityof different/limitedfieldsofview,andtheadvances incomputerscience,improvementshavebeen madetowardthereductionofunnecessaryradiationexposurebyCBCTtechnology.3,4

Forproperimageacquisitionofthemaxillofacial region,thejawrelationshipshouldbescanned withthemandiblein“centricrelation(CR),”and, ideally,ina“naturalheadposition(NHP).”Fora propercombinedorthodonticandorthognathic surgeryvirtualplanning,thepatient’slipsshould berelaxedinreposewiththeteethinanormal occlusalrelationship(CR).Withtheadventof CBCTimaging,thishasbecomefeasibleand reproducible.ToensurethattheCBCTisacquired withthemandibleinCR,thepatientshouldbe scannedwhileoccludingintoabiteregistration material.Alargefieldofviewshouldbeconsidered toincludeallanatomicstructuresrequiredtoplan theorthognathicsurgery.5,6 CBCTimagingisa3D volumeofDigitalImagingandCommunicationsin

Medicine(DICOM)data,consistingofacollection of“cubelikeblocks”called“voxels.”7

TheCBCTDICOMdatacanbe“rendered”to generatea3Dvirtualimageofthepatient’shead by(1)“surfacerendering”or(2)“volume rendering.”“Surfacerendering”isareconstruction of3Dstructuresurfacesbysegmentationbased ongrayscales,anditallowsdigitizationof3D cephalometriclandmarks,planningof3Dvirtual osteotomies,definitionofthe3Dvirtualocclusal relationship,maxillaryandmandibularbonymovementswithadditionalsofttissuesimulation,and 3Dsuperimpositionofdatasets.8 Moreover,itallowsintegrationof3Ddigitaldentalcastsand3D facialphotographsintotheCBCTscan.9,10 “Volumerendering”isadirectreconstructionof3D structuresbyrenderingavolumeofvoxels.With regardstoeachvoxel,colorandopacityare assignedbasedonvariousshadingalgorithms. Volumerenderingallowsmoredetailedanatomy oftheteethandinterdentalspaces.However,it doesnotallowuseractionsandinteractions, suchas3Dvirtualosteotomies,bonefragment movements,oradditionalsofttissuesimulation or3Dintegrationofdatasets.Foroptimal3Dvirtual treatmentplanningoforthognathicsurgery,both “surfacerendering”and“volumerendering”are usuallyusedincombination.11

Imageacquisitionofthedentitionand occlusion

ImagesderivedfromasingleCBCTscancannot provideaccuratedetailedinformationregarding thedentitionorinterocclusalrelationships,which aremandatoryforproperorthodonticpreparation andsurgicaltreatmentplanningandappropriate generationofsurgicalsplints.10 Additionalimage acquisitionofthepatient’sdentitionintheform of3Ddigitalmodelsisrequiredinordertoobtain accurateocclusalandintercuspationanalysis.In addition,3Ddigitalmodelsfacilitatethemeasurementoftoothpositionin3dimensions,canbe manipulatedeasily,maybesegmentalizedto analyzespecificteeth,andallow3Dmappingof toothmovementsinvarioustreatmentplans.12

Thesedigitalmodelsmaybeobtainedviaanindirectmethodthatrequiresdigitalscanningofpreviouslyobtainedplastercastsorviaimpressions ofthedentition.Variousextraoral3Dscanners havebeendesignedtocapture3Dimagesfor dentalimpressionsorphysicalcastsandthen create3Ddigitalmodels.Thescanningtechnology usesanondestructivelaserbeamandseveraldigitalcamerastoreproducehigh-resolution3Dimagesofthetargetsurfaces.Dentalimpressions, models,orbiteregistrationsarepositionedinside achamberplatform,whichisautomaticallyrotated

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