O il
CLINICAL REPORTS
Coordination of the goals of orthodontic, surgical, and prosthetic dentistry: anterior maxillary osteotomy Claude Wood, Jr., D D S Byron H arrison, D D S David Ackerson, D D S Ted M cCurdy, D D S , K n o x v ille , T e n n
This p a p e r dem o n stra tes the n e c e s s ity o f a team a p p ro a ch in co m p lica ted ca s e s ; in tro d u ces an in e x p e n s iv e y e t sta b le a p p lia n c e f o r p o stsu rgica l in tra -a rch fixa tio n ; a n d w arns o f the d a n g ers o f reha bilitation b e fo r e total tem p o ro m a n d ib u la r joint resolutio n.
T
B o su ccessfu lly treat any patient w ho has com plex dental problem s, a team approach is essential. One den tist or dental sp ecialist is not capable of diagnosing, m uch less treating, som e o f the cond itions that confront today’s practitioners. W henever this is attem pted on an individual basis, the case is usu ally com prom ised to som e degree. W e strongly urge, therefore, the use o f a team effort w hen it is practical. W ith increased know ledge and tech n ica l advance m ents in treating adult patients orth o d ontically w ith the aid o f orthog nathic surgery., patients w ho previ ously had required com plete dental prostheses are now able to receive com plete and com prehensive oral rehabilitation . 650 ■ JADA, Vol. 97, October 1978
M eth od Careful diagnosis and treatm ent planning is essential for the su ccess ful restoration of m ouths that have the m utilated conditions so often seen. T h e team approach, although help ful in m ost instances, m ay easily becom e a detrim ent, leaving the pa tien t confused and w ith a question ing attitude concerning the com pe ten ce of several or all m em bers of the dental team . To m inim ize this em barrassing situation, all m em bers of th e dental team m ust agree on certain basic p rin cip les of dentistry. T h e philosophy we use in these cases is to attem pt to give the patient a m outh free from dental disease. T his in cludes not only a caries-free m outh, but also a healthy periodontium , teeth positioned suitably over the basal supporting bone, harm onious bony relationsh ip in w ell-balanced faces and, m ost of all, a cen trically related occlu sion . It has been our ex perien ce that if the last prin ciple of occlu sio n is overlooked or ignored, failu re w ill result to som e degree in nearly all cases.
R e p o rt of c a s e A 34-year-old white woman had diffi culty with mastication and had protru
sion of the maxillary anteriorteeth (Fig 1). The patient had lost a number of teeth in previous years, which resulted in supraeruption of the remaining teeth and overclosure of the bite. The condition was diagnosed as a severe, Class II, Division I malocclusion with a skeletal basis. The patient recently had had frequent head aches, difficulty in chewing, and gradual worsening of the protrusion of the m axil lary anterior teeth. The orthodontist obtained cephalometric radiographs, photographs, and dental cases mounted on a semiadjustable Whip-M ix articulator with use of the Whip-mix Centric-Ceph1 face-bow and centric registration. Because of the symp toms in the temporomandibular joint, three centric relations were recorded by the orthodontist; two additional centric registrations had been previously ob tained by the general dentist. All five rec ords of centric relation were identical. By use of the Centric-Ceph face-bow tech nique, the cephalometric tracings were made both in centric occlusion and in centric relation. Although the case showed an extreme deflective m alocclu sion clinically and on the mounted casts, little change was seen in the two ceph alometric tracings. This was due to the extreme subluxation of the condyles over the dental interferences. The following plan for treatment was developed: □ Preliminary adjustment of the oc clusion to close the centrically related
C L IN IC A L
REPORTS
Fig 1 ■ Facial photographs: frontal view, lateral view; in traoral photographs in centric occlusion: frontal view, right, left.
vertical dimension to 4 mm of bite open ing rather than the original 6 mm. □ Construction of a maxillary Hawley-type appliance to accom plish the following goals: close the maxillary an terior diastemas; open the bite in centric relation to the 4 mm determined previ ously, but also afford the patient full con tact of the posterior teeth at the vertical dimension and good anterior disclusion; and test the patient’s tolerance of the new vertical dimension, and elim inate the preexisting temporomandibular joint dysfunction syndrome. □ Construction of a maxillary surgical splint. □ Maxillary segmental osteotomy in volving the edentulous maxillary right second premolar and left first premolar areas. (Argument could be made for man dibular advancement rather than for the maxillary procedure, but the presence of the existing space, the elim ination of maxillomandibular fixation during heal ing, and the desire to reduce pain for the patient made the prescribed surgical site advisable in this case.) □ Fabrication of the necessary crown and bridge work.
T re a tm e n t c o u rs e After the preliminary adjustment of the occlusion, the Hawley-type
appliance was inserted (Fig 2 ). The appliance was worn full time by the patient and was checked by the or thodontist at four-week intervals for space closure, reduction of symp toms in the temporomandibular joint, and accuracy of centric rela tion. In the next four months, space clo sure, tolerance of the newly estab lished vertical dimension, and relax ation of the mandibular musculature were seen. A week before surgery, the orthodontist noticed an extreme change in the centric relation (Table 1 , Fig 3,4). After occlusal adjustment to the predetermined 4 mm of bite opening, the maxillary appliance was adjusted to accommodate the
change in centric relation, and surgery was postponed. The change in the position of the centric relation was attributed to res olution of the pain in the tem poromandibular joint or of the mus cle pain dysfunction syndrome. Dur ing resolution of the problem of the temporomandibular joint, more ver tical repositioning occurred than did posterior repositioning of the con dyles in the glenoid fossa. The change in the centric relation was producible on recordings of the cen tric relation during the ensuing four-month period. Furthermore, the patient said she had a reduction of symptoms with “unbelievable com fort and freedom of my lower jaw ,”
T able 1 ■ Cephalometric analysis preoperatively. Angle
N orm
C entric occlusion
C entric relation 1°
C entric rela tio n 2°
N AP F H -N P SNA SN B AN B M P-SN M P -FH U l-S N L l-M P U 1 to L I N to A N S
0 87.8° 82° 80° 2° 32° 25° 104° 93° 130° 7
11 87° 85 79 6 36 29 110 94 116 6.6
12 86° 85 78 7 37 30 110 94 115.5 6.6
13.5 85° 85 77 8 38 31 110 94 115 6.6
A N S to GN
9
7.0
7.0
7.0
W ood-others : ANTERIOR MAXILLARY OSTEOTOM Y ■ 651
C L IN IC A L
REPO RTS
Fig 2 ■ Top: anterior discluder wax-up; bottom (left to right): custom acrylic guide table, completed Hawley-type appliance, intraoral cen trically related occlusion.
i
^ JS im
Fig 4 ■ Intraoral photographs showing change in centric relation: right, left, frontal.
At that time, surgery was resched uled. FABRICATION OF THE SPLINT. A
vacuum-formed
plastic
maxillary
652 ■ JADA, Vol. 97, October 1978
splint was constructed (Fig 5). The vacuum-formed acrylic splint has been used since 1970 on at least 25 similar osteotomy procedures to offer a quick, inexpensive, yet stable
applian ce for fixation of the m obile segm ents. OPERATION. On the first hospital day, the patient was placed under
C L IN IC A L
REPORTS
Fig 5 ■ Top: m odel surgery on articulator: right, left. M iddle: trim m ing excess O m nivac m aterial with stiff Robinson b ristle brush; splint with occlu sal buildup; m aterials used for adjusting splint to centric relation. Bot tom: centric stops in powder spray; finished splint right view; finished splint left view (Om nivac .080 clea r m aterial).
Fig 6 ■ Postoperative intraoral photographs: right, left, frontal.
general anesthesia and was prepared and draped for the operation in the usual manner. An anterior maxillary osteotomy with a midline split was performed. The technique was sim i lar to that described by Wunderer .2 The preformed acrylic splint was in serted and was held in position with periodontal wires (Fig 6 ). The pa
tient’s condition remained stable throughout the surgery. POSTOPERATIVE COURSE. Steroid and antibiotic therapy was given dur ing and after the surgery. The patient responded in the usual manner to the operation without complications, and she was discharged on the third
hospital day. Postoperative cephalometric analysis disclosed a dis tinct improvement in facial and dental balance (Table 2, Fig 7). RESTORATIVE DENTISTRY. After the orthodontic and surgical phases of treatment, new models were ob tained with face-bow transfer centric
W ood-others : ANTERIOR M AXILLARY OSTEOTOM Y ■ 653
C L IN IC A L
REPORTS
T ab le 2 ■ Cephalometric analysis preoperatively and postoperatively. Angle
C entric preoperatively
C entric postoperatively
NAP F H -N P SN A SN B ANB M P-SN M P -FH U l-S N L l-M P U1 to LI N to AN S
13.5 85 85 77 8 38 31 110 94 115 6.6
0 85 79 77 2 38 31 105 94 125 6.5
A N S-G n
7.0
7.5
maxillary canine and lateral incisors were restored with use of Nuva-Fil for esthetic reasons; the anterior teeth were reshaped and were rounded slightly for a more pleasing and feminine effect. On com pletion, we believe that we have been able to provide th e patient w ith an extrem ely b en eficial result, esthetically and fun ctionally (Fig 9).
S u m m a ry a n d c o n clu s io n
and lateral bite registrations for mounting on a Whip-mix articulator. A complete occlusal equilibration that was performed to obtain the best possible anterior guidance gave satisfactory results. Because the re sulting plane of occlusion was still irregular, new models were made. The casts were then modified to give the desired plane of occlusion, with the understanding that the ideal tooth form was not completely ob
tainable because of the position of the teeth. The amount of desired reduc tion on the extruded teeth was noted on the original casts and was marked with hard-base, plate wax cores for transfer to the mouth to allow accu rate reduction during preparation (Fig 8 ). The resultant partial dentures produced a comfortable, satisfactory centric relaxation with well-functioning excursions and with no inter ferences with balance. Finally, the
This case shows what dentistry has to offer if dentists work together. No one area of dentistry could possibly have achieved the results that were seen in this case. Although the intro duction of a splint that is easily con structed and sound in usage for seg mental osteotomies is important, the overwhelming value of this experi ence was in the use of a team effort to resolve the temporomandibular joint dysfunction syndrome before further treatment. Often dentists are hasty in diagnosis and treatment. If a patient had undergone the surgical proce dure before total resolution of the joint, coupling or approximation of the anterior teeth would have been impossible. The available recourses of treatment would have been to give further orthodontic treatment; place restorations and partial dentures dis regarding centric relation and thereby encouraging symptoms in the temporomandibular joint to reappear; or repeat the surgical pro cedure. Alternatives like these lead to poor relationships between pa-
Fig 8 ■ W ax cores, left, right.
654 ■ JADA, Vol. 97, October 1978
C L IN IC A L
REPORTS
F ig 9 ■ T o p : fa c ia l p h otog rap h s, fro n ta l a n d la te ra l; p re o p e ra tiv e c e n tric a lly re la te d ca sts: rig h t, left. M id d le: p o sto p e ra tiv e c e n tr ic a lly re la te d o cclu s io n c a s t, rig h t, left; fin a l in tra o ra l w o rk in g view , rig h t. B o tto m : fin a l in tra o ra l v iew s: left b a la n cin g , rig h t b a la n cin g , le ft w o rk in g .
tients and doctors, hard feelings, and possibly legal complications. The purpose of this report has been to advise dentists to proceed cauti ously, seek consultation, be as cer tain as possible of the diagnosis, and be aware of the possibility of a change in centric relation. Failure, although always a possibility, will be
greatly minimized; your fellow prac titioners w ill thank you, and your pa tients will be grateful for the extra effort to ensure the best possible re sults that dentistry has to offer. 1. Wood, C.R., Jr. Centrically related cephalometrics. Am J Orthod 71:156 Feb 1977. 2. W underer, S . Profile correction in the m id facial area w ith the help o f the pedunculated
m axillary fragment method. Trans Fourth Int Conf Plastic Reconstr Surg Rome, O ct 1976. Dr. Wood is associate clin ical professor, de partment of dentistry-orthodontics; Dr. Harri son is clin ical professor, department of dentist ry-oral surgery; Dr. Ackerson is clin ical instruc tor, department of dentistry-general dentistry; and Dr. McCurdy is senior resident, department of oral surgery, University of T ennessee M emo rial Research Center and Hospital, Knoxville, 37916. Address requests for reprints to Dr. Wood.
W ood-others : ANTERIOR MAXILLARY OSTEOTO M Y ■ 655
CLINICAL REPORTS
Coordination of the goals of orthodontic, surgical, and prosthetic dentistry: anterior maxillary osteotomy Claude Wood, Jr., D D S Byron H arrison, D D S David Ackerson, D D S Ted M cCurdy, D D S , K n o x v ille , T e n n
This p a p e r dem o n stra tes the n e c e s s ity o f a team a p p ro a ch in co m p lica ted ca s e s ; in tro d u ces an in e x p e n s iv e y e t sta b le a p p lia n c e f o r p o stsu rgica l in tra -a rch fixa tio n ; a n d w arns o f the d a n g ers o f reha bilitation b e fo r e total tem p o ro m a n d ib u la r joint resolutio n.
T
B o su ccessfu lly treat any patient w ho has com plex dental problem s, a team approach is essential. One den tist or dental sp ecialist is not capable of diagnosing, m uch less treating, som e o f the cond itions that confront today’s practitioners. W henever this is attem pted on an individual basis, the case is usu ally com prom ised to som e degree. W e strongly urge, therefore, the use o f a team effort w hen it is practical. W ith increased know ledge and tech n ica l advance m ents in treating adult patients orth o d ontically w ith the aid o f orthog nathic surgery., patients w ho previ ously had required com plete dental prostheses are now able to receive com plete and com prehensive oral rehabilitation . 650 ■ JADA, Vol. 97, October 1978
M eth od Careful diagnosis and treatm ent planning is essential for the su ccess ful restoration of m ouths that have the m utilated conditions so often seen. T h e team approach, although help ful in m ost instances, m ay easily becom e a detrim ent, leaving the pa tien t confused and w ith a question ing attitude concerning the com pe ten ce of several or all m em bers of the dental team . To m inim ize this em barrassing situation, all m em bers of th e dental team m ust agree on certain basic p rin cip les of dentistry. T h e philosophy we use in these cases is to attem pt to give the patient a m outh free from dental disease. T his in cludes not only a caries-free m outh, but also a healthy periodontium , teeth positioned suitably over the basal supporting bone, harm onious bony relationsh ip in w ell-balanced faces and, m ost of all, a cen trically related occlu sion . It has been our ex perien ce that if the last prin ciple of occlu sio n is overlooked or ignored, failu re w ill result to som e degree in nearly all cases.
R e p o rt of c a s e A 34-year-old white woman had diffi culty with mastication and had protru
sion of the maxillary anteriorteeth (Fig 1). The patient had lost a number of teeth in previous years, which resulted in supraeruption of the remaining teeth and overclosure of the bite. The condition was diagnosed as a severe, Class II, Division I malocclusion with a skeletal basis. The patient recently had had frequent head aches, difficulty in chewing, and gradual worsening of the protrusion of the m axil lary anterior teeth. The orthodontist obtained cephalometric radiographs, photographs, and dental cases mounted on a semiadjustable Whip-M ix articulator with use of the Whip-mix Centric-Ceph1 face-bow and centric registration. Because of the symp toms in the temporomandibular joint, three centric relations were recorded by the orthodontist; two additional centric registrations had been previously ob tained by the general dentist. All five rec ords of centric relation were identical. By use of the Centric-Ceph face-bow tech nique, the cephalometric tracings were made both in centric occlusion and in centric relation. Although the case showed an extreme deflective m alocclu sion clinically and on the mounted casts, little change was seen in the two ceph alometric tracings. This was due to the extreme subluxation of the condyles over the dental interferences. The following plan for treatment was developed: □ Preliminary adjustment of the oc clusion to close the centrically related
C L IN IC A L
REPORTS
Fig 1 ■ Facial photographs: frontal view, lateral view; in traoral photographs in centric occlusion: frontal view, right, left.
vertical dimension to 4 mm of bite open ing rather than the original 6 mm. □ Construction of a maxillary Hawley-type appliance to accom plish the following goals: close the maxillary an terior diastemas; open the bite in centric relation to the 4 mm determined previ ously, but also afford the patient full con tact of the posterior teeth at the vertical dimension and good anterior disclusion; and test the patient’s tolerance of the new vertical dimension, and elim inate the preexisting temporomandibular joint dysfunction syndrome. □ Construction of a maxillary surgical splint. □ Maxillary segmental osteotomy in volving the edentulous maxillary right second premolar and left first premolar areas. (Argument could be made for man dibular advancement rather than for the maxillary procedure, but the presence of the existing space, the elim ination of maxillomandibular fixation during heal ing, and the desire to reduce pain for the patient made the prescribed surgical site advisable in this case.) □ Fabrication of the necessary crown and bridge work.
T re a tm e n t c o u rs e After the preliminary adjustment of the occlusion, the Hawley-type
appliance was inserted (Fig 2 ). The appliance was worn full time by the patient and was checked by the or thodontist at four-week intervals for space closure, reduction of symp toms in the temporomandibular joint, and accuracy of centric rela tion. In the next four months, space clo sure, tolerance of the newly estab lished vertical dimension, and relax ation of the mandibular musculature were seen. A week before surgery, the orthodontist noticed an extreme change in the centric relation (Table 1 , Fig 3,4). After occlusal adjustment to the predetermined 4 mm of bite opening, the maxillary appliance was adjusted to accommodate the
change in centric relation, and surgery was postponed. The change in the position of the centric relation was attributed to res olution of the pain in the tem poromandibular joint or of the mus cle pain dysfunction syndrome. Dur ing resolution of the problem of the temporomandibular joint, more ver tical repositioning occurred than did posterior repositioning of the con dyles in the glenoid fossa. The change in the centric relation was producible on recordings of the cen tric relation during the ensuing four-month period. Furthermore, the patient said she had a reduction of symptoms with “unbelievable com fort and freedom of my lower jaw ,”
T able 1 ■ Cephalometric analysis preoperatively. Angle
N orm
C entric occlusion
C entric relation 1°
C entric rela tio n 2°
N AP F H -N P SNA SN B AN B M P-SN M P -FH U l-S N L l-M P U 1 to L I N to A N S
0 87.8° 82° 80° 2° 32° 25° 104° 93° 130° 7
11 87° 85 79 6 36 29 110 94 116 6.6
12 86° 85 78 7 37 30 110 94 115.5 6.6
13.5 85° 85 77 8 38 31 110 94 115 6.6
A N S to GN
9
7.0
7.0
7.0
W ood-others : ANTERIOR MAXILLARY OSTEOTOM Y ■ 651
C L IN IC A L
REPO RTS
Fig 2 ■ Top: anterior discluder wax-up; bottom (left to right): custom acrylic guide table, completed Hawley-type appliance, intraoral cen trically related occlusion.
i
^ JS im
Fig 4 ■ Intraoral photographs showing change in centric relation: right, left, frontal.
At that time, surgery was resched uled. FABRICATION OF THE SPLINT. A
vacuum-formed
plastic
maxillary
652 ■ JADA, Vol. 97, October 1978
splint was constructed (Fig 5). The vacuum-formed acrylic splint has been used since 1970 on at least 25 similar osteotomy procedures to offer a quick, inexpensive, yet stable
applian ce for fixation of the m obile segm ents. OPERATION. On the first hospital day, the patient was placed under
C L IN IC A L
REPORTS
Fig 5 ■ Top: m odel surgery on articulator: right, left. M iddle: trim m ing excess O m nivac m aterial with stiff Robinson b ristle brush; splint with occlu sal buildup; m aterials used for adjusting splint to centric relation. Bot tom: centric stops in powder spray; finished splint right view; finished splint left view (Om nivac .080 clea r m aterial).
Fig 6 ■ Postoperative intraoral photographs: right, left, frontal.
general anesthesia and was prepared and draped for the operation in the usual manner. An anterior maxillary osteotomy with a midline split was performed. The technique was sim i lar to that described by Wunderer .2 The preformed acrylic splint was in serted and was held in position with periodontal wires (Fig 6 ). The pa
tient’s condition remained stable throughout the surgery. POSTOPERATIVE COURSE. Steroid and antibiotic therapy was given dur ing and after the surgery. The patient responded in the usual manner to the operation without complications, and she was discharged on the third
hospital day. Postoperative cephalometric analysis disclosed a dis tinct improvement in facial and dental balance (Table 2, Fig 7). RESTORATIVE DENTISTRY. After the orthodontic and surgical phases of treatment, new models were ob tained with face-bow transfer centric
W ood-others : ANTERIOR M AXILLARY OSTEOTOM Y ■ 653
C L IN IC A L
REPORTS
T ab le 2 ■ Cephalometric analysis preoperatively and postoperatively. Angle
C entric preoperatively
C entric postoperatively
NAP F H -N P SN A SN B ANB M P-SN M P -FH U l-S N L l-M P U1 to LI N to AN S
13.5 85 85 77 8 38 31 110 94 115 6.6
0 85 79 77 2 38 31 105 94 125 6.5
A N S-G n
7.0
7.5
maxillary canine and lateral incisors were restored with use of Nuva-Fil for esthetic reasons; the anterior teeth were reshaped and were rounded slightly for a more pleasing and feminine effect. On com pletion, we believe that we have been able to provide th e patient w ith an extrem ely b en eficial result, esthetically and fun ctionally (Fig 9).
S u m m a ry a n d c o n clu s io n
and lateral bite registrations for mounting on a Whip-mix articulator. A complete occlusal equilibration that was performed to obtain the best possible anterior guidance gave satisfactory results. Because the re sulting plane of occlusion was still irregular, new models were made. The casts were then modified to give the desired plane of occlusion, with the understanding that the ideal tooth form was not completely ob
tainable because of the position of the teeth. The amount of desired reduc tion on the extruded teeth was noted on the original casts and was marked with hard-base, plate wax cores for transfer to the mouth to allow accu rate reduction during preparation (Fig 8 ). The resultant partial dentures produced a comfortable, satisfactory centric relaxation with well-functioning excursions and with no inter ferences with balance. Finally, the
This case shows what dentistry has to offer if dentists work together. No one area of dentistry could possibly have achieved the results that were seen in this case. Although the intro duction of a splint that is easily con structed and sound in usage for seg mental osteotomies is important, the overwhelming value of this experi ence was in the use of a team effort to resolve the temporomandibular joint dysfunction syndrome before further treatment. Often dentists are hasty in diagnosis and treatment. If a patient had undergone the surgical proce dure before total resolution of the joint, coupling or approximation of the anterior teeth would have been impossible. The available recourses of treatment would have been to give further orthodontic treatment; place restorations and partial dentures dis regarding centric relation and thereby encouraging symptoms in the temporomandibular joint to reappear; or repeat the surgical pro cedure. Alternatives like these lead to poor relationships between pa-
Fig 8 ■ W ax cores, left, right.
654 ■ JADA, Vol. 97, October 1978
C L IN IC A L
REPORTS
F ig 9 ■ T o p : fa c ia l p h otog rap h s, fro n ta l a n d la te ra l; p re o p e ra tiv e c e n tric a lly re la te d ca sts: rig h t, left. M id d le: p o sto p e ra tiv e c e n tr ic a lly re la te d o cclu s io n c a s t, rig h t, left; fin a l in tra o ra l w o rk in g view , rig h t. B o tto m : fin a l in tra o ra l v iew s: left b a la n cin g , rig h t b a la n cin g , le ft w o rk in g .
tients and doctors, hard feelings, and possibly legal complications. The purpose of this report has been to advise dentists to proceed cauti ously, seek consultation, be as cer tain as possible of the diagnosis, and be aware of the possibility of a change in centric relation. Failure, although always a possibility, will be
greatly minimized; your fellow prac titioners w ill thank you, and your pa tients will be grateful for the extra effort to ensure the best possible re sults that dentistry has to offer. 1. Wood, C.R., Jr. Centrically related cephalometrics. Am J Orthod 71:156 Feb 1977. 2. W underer, S . Profile correction in the m id facial area w ith the help o f the pedunculated
m axillary fragment method. Trans Fourth Int Conf Plastic Reconstr Surg Rome, O ct 1976. Dr. Wood is associate clin ical professor, de partment of dentistry-orthodontics; Dr. Harri son is clin ical professor, department of dentist ry-oral surgery; Dr. Ackerson is clin ical instruc tor, department of dentistry-general dentistry; and Dr. McCurdy is senior resident, department of oral surgery, University of T ennessee M emo rial Research Center and Hospital, Knoxville, 37916. Address requests for reprints to Dr. Wood.
W ood-others : ANTERIOR MAXILLARY OSTEOTO M Y ■ 655
