MANUAL AO CIRURGIA ORTOGNTICA

Planning of orthognathic surgery

Introduction
The key to proper planning is a precise diagnosis. To come to that diagnosis clinical examination, cephalometry, and standardized photography. Above that 3D-imaging (CT, 3D-reformatted CT, 3D-photography, 3D-models) may be indicated for complex asymmetric cases. Besides that, the expectations of the patients and the potential risks of the surgical procedures must be seen as well.

2 Facial proportions
The facial height is divided in three main thirds. The upper facial third goes from the hairline to the glabella, the middle third from the glabella to the base of the columella, and the lower third from the columella third to the deepest point of the chin prominence. The lower third is subdivided in an upper third from the columella base to the lip commissure and two lower thirds from the lower lip to the chin. The Frankfurt horizontal is an important line for facial measurements and goes through the porion (P) to the orbitale (Or). A vertical line can be drawn from the nasion (N) to and through subnasale (Sn). The most anterior chin point pogonion (Pog) is located slightly posterior to that line.

To analyze facial widths and symmetry, the face can be divided in to fifths according to the drawing.

3 Clinical examination

With the clinical examination the facial proportions, the balance, and the movements of the face are evaluated.

Profile evaluation Looking to the profile the following items are of importance:

antero-posterior position of the maxilla antero-posterior position of the mandible nasal size contours of the cheeks lip support/lip competence size of the mandibular angle (illustrated) facial soft tissues (amount, tension) Frontal view (en face) evaluation The following items are of importance:

Facial midline Symmetry Muscle activity of the lower lip and Tooth to lip relationship Lip length Facial contour Head to body proportion

chin

Documentations of findings It is recommended to record the clinical findings on standardized documentation sheets. Standard digital photography (profile, frontal view, three quarter view, bird's eye view) are taken and attached to the clinical documentation. Standard photos, especially profile pictures, are necessary to do a profile outcome prediction.

4 Cephalometry

Cephalometry is done to evaluate the proportions of the facial skeleton and to compare an individual patient with norm.

Standard skeletal analysis is based on plain X-Rays taken in the sagittal and frontal plane. Typically the X-rays are analyzed with the help of computer based programs. Protocols for analysis differ to some extent.

All of them are based on reference points, lines, and angles which are marked on the Xray. Today programs are developed to perform 3D cephalometry based on 3D reformatted CT scans.

5 Model analysis

Plaster of Paris models from the maxilla and mandible are taken and the actual centric occlusion of the patient is recorded. The models are oriented in a semi adjustable articulator after facebow transfer.

The models allow to analyze the:

occlusion shape of the dental arches position size and shape of the teeth position of the jaws in relation to the skull base

Usually two sets of models are used. One is kept to analyze and document the preoperative situation. The second set of models is used to perform mock surgery.

6 Mock surgery and fabrication of splints

Based on the results of the clinical and cephalometric analysis, a problem list and treatment plan are generated. The mounted models can then be moved into the planned position for correction of the skeletal disorder. Keeping in mind that treatment of facial bone abnormalities is usually a combined endeavor for both surgeon and orthodontist, this position has to be agreed upon by both parties. It is important that all movements become visible in a three dimensional fashion. This can be achieved using reference lines scribed on the models before performing the movements. The models are fixed in the new positions with wax or glue. Mock surgery is performed to mimic the planned surgical procedure. It is also a powerful tool to demonstrate the treatment plan to the patient. Finally the reoriented models after mock surgery are used to fabricate the surgical splints that will be used in the operating room to reposition the osteotomized segments. Mock surgery can also be performed using individual stereolithographic models. This is indicated for severe and mostly asymmetric deformities. Fabrication of splints Splints are made of acrylic and used in orthognathic surgery to intraoperatively position a mobile osteotomized jaw against the other stable jaw before an internal fixation procedure is performed. In case of two-jaw surgery two splints need to be fabricated. The first one is used after osteotomy of the first jaw as an intermediate splint, the other one after the second jaw has been osteotomized as a final splint. Usually the two splints are colour coded to avoid confusion.

7 Profile prediction

Planning is based on the clinical examination, evaluation of pictures and cephalometry. In order to visualize profile changes, X-Rays and pictures can be superimposed in commercially available planning software. If the bone is moved the soft tissues will follow (not in a 1:1 ratio) and a virtual image of the surgical result is created. The virtual images may be used to discuss treatment outcomes and alternatives with the patient. These pictures show the predicted soft tissue changes following mandibular advancement.

8 3D-Virtual planning
A cone beam or fan CT-scan is obtained and a virtual 3D-model of the patients skull is generated. The mandible is segmented (defined) in preparation for performing the virtual osteotomies.

enlarge A cephalometric analysis is performed. A problem list is then generated. Using the clinical exam and skeletal problem list, a treatment plan is formulated. A soft tissue overlay can be helpful in the analysis of the deformity. 3D virtual profile prediction Planning is based on the clinical examination, evaluation of pictures and cephalometry. In order to visualize profile changes, the virtual 3D-models and 3D pictures can be superimposed in commercially available planning software. If the bone is moved the soft tissues will follow (not in a 1:1 ratio) and a virtual image of the surgical result is created. The virtual video may be used to discuss treatment outcomes and alternatives with the patient.

MAXILA (DIAGNSTICO DE PROBLEMAS)

Sagittal disorders of the maxilla
Maxillary retrognathism Le fort I
Definition: Anterior position of maxilla with correct position of mandible. L The characteristics of maxillary retrognathism are:

Reversed dental overjet protruding lower lip Angle Class III malocclusion

Lefort I

Maxillary prognathism Le Fort I ou Subapical

Definition: Maxilla in anterior position with normal position of mandible. The characteristics of maxillary prognathism are:

Large overjet Deep labiomental sulcus Angle Class II malocclusion

Maxillary alveolar protrusion - Subapical

Definition: Isolated anterior position and/or tilting of maxillary anterior alveolar process. The characteristics of maxillary alveolar protrusion are:

Protrusion of maxillary teeth Lip incompetence Dental procumbency May have anterior open bite

Maxillary alveolar retrusion - Subapical

Definition: Isolated posterior position and/or tilting of maxillary anterior alveolar process. The characteristics of maxillary alveolar retrusion are:

No or negative overjet Prominent lower lip

Vertical disorders of the Maxilla 1 Vertical maxillary hyperplasia - Le Fort I ou Subapical

Definition: Increased vertical development of the maxilla. The characteristics of vertical hyperplasia of the maxilla may include:

Long midface Gummy smile Lip incompetence Anterior open bite (when hyperplasia occurs posteriorly)

2 Vertical maxillary hypoplasia - Subapical

Definition: Decreased vertical development of the maxilla The characteristics of vertical hypoplasia of the maxilla are:

Short midface decreased tooth show large distance between rest position and centric occlusion (increased freeway space)

Transversal disorders of the Maxilla Transverse hypoplasia of maxilla Expanso rpida

Definition: Narrow maxillary dental arch. The characteristic of transverse hypoplasia of maxilla is bilateral lingual crossbite, often associated with crowding

Transverse hyperplasia of maxilla Osteotomia de Dingman

Definition: Wide maxillary dental arch. The characteristic of transverse hyperplasia of maxilla is buccal crossbite.

MAXILA (TRATAMENTO CIRRGICO)

Approach to the Le Fort I level of the midface
Preparation The patient is positioned on the operating table supine with the head in a head holder. For corrective bone surgery, the whole face including the lower part of the forehead and eye brows, the auricles and the superior part of the neck need to be visible, and not covered with drapes. The nasal anaesthetic tube is covered with sterile adhesive tape and the cranium covered with two sterile drapes as illustrated. The eyes are protected with a bland eye ointment and the lips are lubricated. Anaesthesia To achieve a good hemostatic effect, local anaesthesia with a vasoconstrictor is injected into the labio-buccal sulcus from the midline to the maxillary tuberosities and pterygomaxillary areas. Hypotensive anaesthesia is routinely employed during all but the final stages of the surgery maintaining the systolic blood pressure around 80 mm Hg.

Vertical reference Many methods have been described for ensuring that vertical changes during orthognathic surgery especially Le Fort I osteotomy are accurate. In the authors experience a screw inserted into the glabella (the root of the bridge of the nose) provides a good vertical reference point. The procedure starts with the insertion of a 12-14 mm long screw with a cruciform head into a 6-8 mm hole drilled into the glabella. The distance between the middle of the cruciform head and the arch wire is measured with a caliper and recorded. All vertical changes are then measured against this reference distance.

Incision Pearl: Using the electrocautery, two vertical reference dots are made in the labial frenum

area of the maxillary midline to ensure that the incision is replaced accurately during suturing. For a Le Fort I osteotomy or SARPE the incision starts 5 mm anterior and 5 mm superior to the opening of the parotid duct and proceeds forwards and slightly downwards in the labio-buccal sulcus crossing the labial frenulum in the midline and proceeds upwards in the same manner on the contralateral side.

For supra-apical osteotomies preserving the nasal floor, the incision is made at the same level (upper sulcus approach), but with a length appropriate for the surgical procedure and not circumferential.

Alternatively vertical incisions combined with a subperiosteal tunneling can also be used The incision is made through the mucosa, submucosa, underlying facial muscles and periosteum. An electrocautery needle may be used to further reduce bleeding. Care should be taken with the electrocautery in the region of the nasal floor so as not to damage it and also on the bone if the tooth roots have perforated the buccal plate.

Subperiosteal dissections Sharp periosteal elevators are used to strip the soft tissues in the subperiosteal plane to expose the anterior maxillary wall, pyriform rims and nasal apertures, and zygomatico-maxillary buttresses. The periosteal dissection is performed in a systematic fashion.

Anterior midline and posterior (pterygopalatine fissure) The subperiosteal dissection continues behind the zygomaticomaxillary buttress into the region of the maxillary tuberosity and the pterygomaxillary fissure. The tip of the periosteal elevator is always kept in intimate contact with the bony surface.

Pitfall: A perforation of the periosteum and slippage into the soft tissues can either produce a herniation of the buccal fat pad obscuring the surgical field and/or bleeding from veins of the pterygoid plexus. enlarge Once exposed, a small curved up flat retractor (eg, a curved up Obwegeser retractor) is inserted behind the maxilla.

Nasal cavity The nasal mucosa should be elevated from the lateral wall and floor of the nose with a periosteal elevator The anterior nasal spine and the lower border of the cartilaginous septum are addressed by soft-tissue retraction if necessary with a forked retractor, and the perichondrium on top of the cartilaginous septal border is incised.

Closure Wound closure begins with the insertion of a single suture in the midline using the previous markings placed at incision. The rest of the incision is then subsequently closed. In cases of significant maxillary advancements or if the patients lip is short, a V-Y closure may be considered.

CORREO DE DEFEITOS SAGITAIS E VERTICAIS POR MEIO DA OSTEOTOMIA LE FORT I

Introduction

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The LeFort I osteotomy is designed to separate the tooth bearing maxillary component from the superior part of the maxilla. The segment always contains the bony palate.

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The mobilized segment can be moved in every direction. The procedure is a very versatile tool to correct maxillary deformities.

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If changes in vertical maxillary height are intended, it is of crucial importance to use a fixed skeletal marker (K-wire or screw) which will allow vertical measurements before and after the osteotomy is anchored into the nasofrontal junction.

2 Osteotomy

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A periosteal elevator is inserted between the nasal mucosa and the lateral wall of the nose on one side. A curved retractor is inserted behind the maxillary tuberosity. A further instrument is used to retract upwards the lip and mucoperiosteal flap, exposing the lateral maxilla.

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Horizontal osteotomies The horizontal osteotomy is usually made at the level of the nasal floor at a safe distance (~5 mm) from the apices of the teeth.

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When indicated, additional vertical interdental osteotomies to segment the dental arch are now performed. The osteotomies are completed after the downfracture. The segments should be designed to ensure adequate blood supply to the individual osteotomized segments.

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Posterior and vertical osteotomies A curved pterygoid chisel is placed with the curvature pointing medially and inferiorly between the tuberosity and the pterygoid plates. A mallet is used to drive the osteotome medially to complete the pterygomaxillary dysjunction. The position of the tip of the osteotome can be checked with a palpating finger.

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Pitfall: An upward and posteriorly oriented osteotome will not reliably separate the maxilla from the pterygoid plates. It is also associated with increased risk of bleeding from the pterygoid plexus and internal maxillary artery.

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Separation of the nasal septum from the palate The nasal septum has to be separated from the palate with either an osteotome or septum scissors. Special "guarded" osteotomes are used for this purpose to protect the nasal mucosa.

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Separation of the lateral nasal walls The lateral nasal wall is then separated using a nasal osteotome or saw. Special "guarded" osteotomes are used for this purpose to protect the nasal mucosa. Pitfall: This osteotomy should end anteriorly to the greater palatine vessels and nerve to prevent bleeding.

3 Downfracture and mobilization

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Downfracture The maxilla is downfractured anteriorly, with the help of a bone hook

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or manually.

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The downfracture maneuver allows for a complete visualization of the osteotomy lines. Remaining bony bridges at the posterior aspect of the maxilla can be transected under direct vision. To minimize bleeding when trimming bone close to the posterior maxilla, meticulous soft tissue protection should be employed. The downfracture technique allows good access to the nasal septum for septal corrections when indicated.

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It may be useful to use Tessier mobilizers (see illustration) or curved osteotomes which are inserted behind the maxilla on each side in order to pull the maxilla forwards. Rowe disimpaction forceps can also be used for this purpose. At this point the mobilized maxilla should be free and able to be moved by the surgeon's hand more than is actually required.

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Anterior movements can be facilitated with traction using a wire directly attached to the maxilla or to a bone screw in the maxilla.

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The interdental osteotomies and any additional palatal osteotomies to correct transverse discrepancies are now completed. Care should be taken to preserve adequate blood supply to the individual osteotomized segments.

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Positioning of the maxilla Mandibulo-maxillary fixation is performed to position the maxilla to the desired relationship with the mandible. A prefabricated surgical splint (or wafer) may be used to facilitate this. The maxillomandibular complex is now rotated around the condylar hinge until the desired vertical dimension has been attained.

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Control of vertical height The preplanned vertical position of the maxilla is then established against the fixed reference marker in the nasofrontal junction. When necessary, maxillary bone is removed with a drill until that vertical relationship is achieved passively. If the nasal septum or the inferior turbinates are preventing upward movement of the maxilla, they are reduced at this stage.

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Posterior movement (backward) Posterior movements are rarely indicated. If needed, a segment of bone must be removed usually from the posterior aspect of the maxilla. This is usually performed under direct vision from a downfracture approach.

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Superior (upward) movement Superior movement (shortening) of the maxilla requires an ostectomy of a bone segment. In an upward movement of the maxilla the septum needs to be vertically trimmed to avoid septal buckling deviation, which may lead to impaired airway flow and nasal deformation. In large impactions, the inferior turbinates should be trimmed to avoid airway obstruction.

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Inferior (downward) movement Inferior movement (lengthening) of the maxilla is possible, but results in a gap and a noncontact situation between the upper and lower part of the maxilla.

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The gaps need to be bone grafted, usually with free bone grafts from the iliac crest or the outer table of the skull, or allogeneic bone. The amount of lengthening is checked against the vertical reference mark at the nasofrontal junction.

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Asymmetric movement/rotations Asymmetric movements and rotations are also possible. In this case a bone gap may occur on one side and bone may need to be trimmed on the contralateral side.

4 Fixation

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Internal fixation Internal fixation is performed with four miniplates, usually L- or reversed L-shaped, along the pyriform aperture and the zygomaticomaxillary buttress. Care must be taken to passively adapt the plates to the bone surfaces. The screws in the mobilized maxillary segment must avoid the tooth roots.

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After osteosynthesis, the need for bone grafts (eg. by rotational movements) should be evaluated and if required, they should be placed at this time.

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Control of position After completion of osteosynthesis on both sides, the MMF is released and the resulting occlusion is checked against the pre-planned position. The splint may be fixed to the maxillary teeth with a few thin wires (especially when the maxilla is segmented) and left in place during the healing phase to allow for neuromuscular adaption and position control.

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Removal of glabellar reference screw The glabellar reference screw is removed.

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Special considerations Pearl: Extensive anterior movements of the maxilla will stretch the soft tissue envelope of the face and will lead to bilateral widening of the alar base and the nasal vestibules. This can be prevented by performing an alar cinch suture, which engages both alar bases in an attempt to approximate them towards the midline immediately before wound closure.

DEFEITOS ALVEOLARES SAGITAIS E VERTICAIS POR OSTEOTOMIA SUBAPICAL

1 Introduction

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Subapical osteotomies can be performed as isolated procedures or as part of total jaw osteotomies. They are indicated when the basal skeletal relationship is acceptable, and the malocclusion alveolar in origin. Subapical surgery can be performed in any region of the maxilla or mandible.

Subapical or block osteotomies are performed a safe distance (~5 mm) from the apices of the teeth, while maintaining the continuity of the mandible or maxilla.

2 Anterior maxillary osteotomy

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The anterior maxillary osteotomy is typically performed from a limited vestibular approach. If a posterior repositioning of the anterior maxillary segment is desired, a preexisting dental gap or simultaneous extraction of teeth at the time of surgery is necessary. The osteotomies can be combined with either bone resections (ostectomies) or bone transplantation depending on the individual problem.

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After marking of the osteotomy lines on the bone, the horizontal and vertical osteotomies are performed. Care must be taken not to injure tooth roots.

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When a retro positioning of the segment is planned, a bone segment must be removed. Care must be taken not to injure the palatal mucosa, because it provides the blood supply to the anterior segment.

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After completion of the osteotomy and ostectomy, the anterior maxillary segment is positioned into a splint. Some surgeons prefer to have the patient in MMF while performing internal fixation, others rely on a splint attached to the dentition. Osteosynthesis can be performed using small plates and screws if desired. Care should be taken not to injure the dental roots. The soft tissues are closed, and the splint is usually left in place during the healing phase.

3 Posterior maxillary osteotomy

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The posterior maxillary osteotomy is performed to treat posterior maxillary alvelolar hyperplasia. The typical indication is for closure of an anterior open bite. The osteotomy is typically performed from a limited vestibular approach. If a superior repositioning of the posterior maxillary segment is desired an ostectomy has to be performed.

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The posterior maxillary osteotomy is performed to treat posterior maxillary alvelolar hyperplasia. The typical indication is for closure of an anterior open bite. The osteotomy is typically performed from a limited vestibular approach. If a superior repositioning of the posterior maxillary segment is desired an ostectomy has to be performed.

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After marking the osteotomy lines on the bone, the horizontal and vertical osteotomies are performed. Care must be taken not to injure tooth roots or palatal mucosa.

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In case of a superior repositioning an ostectomy of the lateral maxillary wall must be performed. A transantral osteotomy of the palatal bone is then performed through the lateral maxillary ostectomy window. Care must be taken not to injure the palatal mucosa because it provides the blood supply to the osteotomized segment.

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After completion of the osteotomy and ostectomy, the posterior maxillary segment is positioned into a splint. Some surgeons prefer to have the patient in MMF while performing internal fixation, while others rely on the splint. Osteosynthesis can be performed using small plates and screws if desired. Care should be taken not to injure the dental roots. The soft tissues are closed, and the splint is usually left in place during the healing phase .

4 Anterior subapical mandibular osteotomy

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The anterior subapical mandibular osteotomy is performed to reposition the anterior mandibular alvelolar process. The osteotomy is typically performed from an anterior vestibular sulcus approach. It can be used to position the anterior mandibular alveolar element in almost every dimension but is particularly indicated for vertical or tilting movements.

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After marking of the osteotomy lines on the bone, the horizontal and vertical osteotomies are performed. Care must be taken not to injure tooth roots or the lingual mucoperiosteum.

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Before any internal fixation is performed, the anterior mandibular segment is positioned into a splint. Some surgeons prefer to have the patient in MMF while performing internal fixation, while others rely on the splint Osteosynthesis can be performed using small plates and screws if desired. Care should be taken not to injure the dental roots. The gap is filled with autogenous bone, eg, from the iliac crest. The soft tissues are closed, and the splint is usually left in place during the healing phase.

5 Complete osteotomy of the alveolar ridge

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Complete alveolar ridge osteotomies can be performed in both the mandible and maxilla. The goal is to reposition the complete alvelolar process. The osteotomy is typically performed from a vestibular approach. In the maxilla it is indicated for patients with a high alveolus/palate. The osteotomies can be combined with either bone resections (ostectomies) or bone transplantation depending on the individual problem.

DEFEITO (Hiperplasia Transversal de Maxila) POR OSTEOTOMIA DE DINGMAN

Introduction

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A mandibular body ostectomy is an osteotomy with a segmental resection of a defined section of the mandibular body. The inferior alveolar nerve typically crosses the osteotomy sites and the bony piece which has to be resected. In order to avoid damage to that nerve it is recommended to free and mobilize it from the inferior alveolar canal before the osteotomies and the resections are performed.

This osteotomy can only be used to shorten the mandibular body.

2 Osteotomy

In dentate patients some surgeons extract the tooth/teeth in the segment which is going to be resected before performing the osteotomies.

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A transoral surgical approach is routinely used. The inferior alveolar nerve can be identified and mobilized after removing the lateral cortical bone overlying the nerve. This can be facilitated by the use of a piezoelectric cutting device.

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After the alveolar nerve is identified and mobilized, two parallel vertical osteotomy lines are marked with a pen or drill on the bone surface. The lingual mucoperiosteal layer is detached from the bone with a periosteal elevator. The osteotomy is then performed with either a saw, drill or piezoelectric saw. While performing the osteotomies care must be taken to protect the nerve, for instance with a freer elevator.

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After completion of both osteotomies the segment of bone is removed.

3 Mobilization/positioning

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After bilateral resection, the anterior segment of the mandible is moved posteriorly into the preplanned position. Mandibulo-maxillary fixation is performed to position the mandibular segments to the desired relationship with the maxilla. A prefabricated surgical splint (or wafer) may be used to facilitate this.

4 Internal fixation

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Internal fixation is usually performed with two straight miniplates one above and one below the inferior alveolar nerve. The plate placement and drilling is usually performed from the transoral route.

6 Release of MMF and position control

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After completion of osteosynthesis on both sides, the MMF is released and the resulting occlusion is checked against the pre-planned position. The splint may be fixed to the maxillary teeth with a few thin wires and left in place during the healing phase to allow for neuromuscular adaption and position control.

DEFEITO (Hipoplasia Transversal de Maxila) POR EXPANSO RPIDA DE MAXILA

Introduction

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The surgically assisted rapid palatal expansion (SARPE) is a procedure designed for skeletal transverse widening of the basal maxilla, the palate, and the dental arch. The widening itself is done with either a tooth born or bone born distraction device in the days following the osteotomy.

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Various types of osteotomies have been described to facilitate maxillary and palatal expansion. Today, usually a subtotal Le Fort-I osteotomy (without downfracture) and a sagittal osteotomy of the maxilla and palate either on one or both sides of the septum is performed.

2 Osteotomy

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A periosteal elevator is inserted between the nasal mucosa and the lateral wall of the nose on one side. A curved retractor is inserted behind the maxillary tuberosity. A further instrument is used to retract upwards the lip and mucoperiosteal flap, exposing the lateral maxilla.

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Horizontal osteotomies The horizontal osteotomy is usually made at the level of the nasal floor, a safe distance (~5 mm) from the apices of the teeth.

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Posterior and vertical osteotomies A curved pterygoid chisel is placed with the curvature pointing medially and inferiorly between the tuberosity and the pterygoid plates. A mallet is used to drive the osteotome medially to complete the pterygomaxillary dysjunction. The position of the tip of the osteotome can be checked with a palpating finger.

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Pitfall: An upward and posteriorly oriented osteotome will not reliably separate the maxilla from the pterygoid plates. It is also associated with increased risk of bleeding from the pterygoid plexus and internal maxillary artery.

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Separation of the nasal septum from the palate The nasal septum has to be separated from the palate with either an osteotome or septum scissors. Special "guarded" osteotomes are used for this purpose to protect the nasal mucosa.

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Separation of the lateral nasal walls The lateral nasal wall is then separated using a nasal osteotome or saw. Special "guarded" osteotomes are used for this purpose to protect the nasal mucosa. Pitfall: This osteotomy should end anteriorly to the greater palatine vessels and nerve to prevent bleeding.

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Sagittal osteotomy of the anterior alveolar crest and the palate The sagittal osteotomy is usually made between the roots of the central incisors. To avoid iatrogenic damage of those roots it is recommended to first mark the position and penetrate the outer cortex with a small burr or with a piezoelectric device.

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The osteotomy is continued posteriorly through the alveolus and the palate, usually with a thin straight scaled osteotome. Care must be taken not to penetrate the palatal mucosa. The course of the chisel tip as it goes posteriorly is monitored with a palpating finger, which is difficult with a tooth borne expansion device in place.

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Check of segment mobility After completion of the osteotomies, the mobility of the segments must be checked. The palatal expansion device can now be inserted, if not already in place.

3 Expansion

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Insertion of the device A tooth borne expansion device is fixed to at least two teeth on either side of the palatal osteotomy.

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A bone borne device is fixed to the palate on either side of the palatal osteotomy with screws or pins. The expansion device is activated to assure that bilateral symmetric expansion occurs. The device is then deactivated (returned to starting position) prior to wound closure.

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Expansion and retention After a suitable latency period, the palate is distracted at a rate of 0.5 -1.0 mm per day. During the distraction phase, a diastema will form between the two incisors (at the osteotomy site). Movement of the teeth into the regenerate will occur spontaneously unless the teeth are prevented from doing so by orthodontic appliances. After reaching the desired expansion the device is left in place to retain the expansion and to allow for bone consolidation for at least 3 6 months before removal. Even after removal of the distraction device, it may be necessary to stabilize the expansion with an orthodontic appliance or an acrylic splint for an extended period of time.

MANDBULA (DIAGNSTICO DE PROBLEMAS)

Sagittal disorders of the mandible Mandibular prognathism

Definition: Anterior position of mandible with correct position of maxilla. The characteristics of mandibular prognathism are:

Reversed dental overjet Anterior over-projection of chin (increased chin prominence) Protruding lower lip Angle Class III malocclusion

Mandibular retrognathism

Definition: Posterior position of mandible with correct position of maxilla The characteristics of mandibular retrognathism are:

Increased overjet Posterior position of chin Short, normal or long lower face Angle Class II malocclusion

Mandibular alveolar protrusion

Definition: Isolated anterior position and/or tilting of mandibular anterior alveolar process. The characteristics of mandibular alveolar protrusion are:

Protrusion of mandibular anterior teeth Possible lip incompetence

Mandibular alveolar retrusion

Definition: Isolated posterior position and/or tilting of mandibular anterior alveolar process. The characteristics of mandibular alveolar retrusion are:

Retrusion of mandibular anterior teeth May have deep labiomental sulcus