Aesthetic Orthognathic Surgery and Rhinoplasty

Derek M. Steinbacher, Derek M. Steinbacher

• Publisher: Wiley-Blackwell
• Year: 2019
• ISBN:
  9781119186984
• Edition: 1
• Topic: Medicine
• Subtopic: Oral Health & Surgery

Comprehensive in scope, Aesthetic Orthognathic Surgery and Rhinoplasty presents orthognathic surgery from an aesthetic perspective, encompassing analysis, diagnosis, treatment, 3D virtual planning, and adjunctive procedures.

• Easily accessible clinical information presented in a concise and approachable format
• Well-illustrated throughout with more than1, 000 clinical photographs
• Includes access to a companion website with videos of surgical procedures

1
Introduction to Aesthetic Orthognathic Surgery and Rhinoplasty

Graham Grabowski and Derek M. Steinbacher

1.1 Introduction

A dentofacial deformity exists when the teeth do not fit together due to incompatibility of jaw size and/or relationship. Functional and appearance issues accompany the dentofacial disharmony, including trouble with incising, chewing, breathing, speaking, smiling, closing the lips, and strong, weak, or asymmetric facial structures. This combination of functional and appearance concerns is bothersome, and motivates patients to seek treatment. The traditional focus of orthognathic surgery is to impart a normal occlusion to improve masticatory function, with possible secondary requisite benefits of other functional and aesthetic related enhancement. However, it is common now that patients are more driven (or at least as much) by the cosmetic opportunity that jaw surgery permits.

The first-level objective in orthognathic surgery is to achieve a stable, functional class I occlusion. However, this basic result, when straightening and aligning the jaws and teeth, can be achieved in any infinite vertical, sagittal, side-to-side, roll, and yaw positions in space. For instance, a class I occlusion can be achieved, yet the jaws still left deficient sagittally (with continued airway obstruction); or a class I with yaw or cant discrepancies can be present, which confers a significant and noticeable unaesthetic appearance. As such, the next-level objective in orthognathic surgery is to place the maxillomandibular unit not only in a class I, but in the most aesthetically optimized position in space. This also tends to incorporate proper functional improvement (e.g. airway), by facial skeletal expansion [1–4]. As in nature, the most balanced and appealing morphology is also frequently the most functional (form and function are intertwined) (Figure 1.1) [5,6].

Figure 1.1 Form and function addressed in an aesthetically minded manner.

Similarly, surgical stability and aesthetics are also complimentary. Rigid fixation, and liberal use of interpositional grafts, allow for practically any three-dimensional movement in space with enhanced stability [7]. The aesthetic-minded orthognathic surgeon has to be comfortable with large magnitude and complex movements, in order to achieve both a Class I occlusion, and also optimal facial balance, function, and harmony. The last level of intervention is attention to the shape and morphology of the maxillomandibular skeleton and the surrounding regions and tissues. Augmentation and/or reduction or other modification of the zygoma, orbits, nose, lips, mandibular angles, chin, and submental region need to be considered and incorporated into the treatment plan.

Levels of objectives in aesthetic orthognathic surgery

1. Class I occlusion^a
2. Facial skeleton in aesthetically (and functionally) optimized position in space
3. Adjunctive facial hard and soft-tissue control, or modification, to optimize aesthetics

^aPrecise Class I occlusion may not be the immediate post-surgical goal in cases of “surgery-first” orthodontic/orthognathic surgery; but the orthodontist will create this by end-treatment.

Given the various objectives with orthognathic surgery, patients may present with different perspectives or chief complaints. When referred by an orthodontist, the goals are typically occlusion-centric (to “fix their teeth”). Some elements of facial balance may have been discussed, but chewing and occlusion are central. It then is incumbent on the surgeon to educate the patient regarding facial imbalance and the aesthetic benefits of surgery. The evaluation should focus on soft-tissue and facial harmony, in addition to occlusion. To formulate the treatment plan, aesthetic goals and objectives from the evaluation are critical. In the same vein, anticipated unaesthetic changes from the jaw surgery, and/or other facial regions requiring manipulation, should be discussed. 3D photos and simulations of the preoperative issues and surgical objectives are essential tools to planning and education (Figure 1.2) [8].

Figure 1.2 3D soft-tissue prediction used as part of patient education.

Increasingly, to the aesthetic-minded practice, patients may present first requesting cosmetic facial modification, not realizing that they have a dentofacial deformity. These patients have not recognized that their accommodated difficulty with biting and chewing (i.e. malocclusion) is in fact linked to jaw imbalance underpinning poor facial aesthetics. A complete occlusal examination is therefore part of the overall facial aesthetic evaluation, and, if indicated, orthognathic surgery is offered as part of the overall plan. Patients hoping for a single “makeover” surgery may then be surprised to learn of a need for orthodontics, and a dental component to their treatment plan. This highlights education as being of utmost importance, and clearly a comprehensive approach will result in the best function and appearance.

The compensated occlusion must be decompensated, which may worsen the occlusal discrepancy, but will facilitate a greater movement of the jaws to impart the most aesthetic result [9]. In patients who are older and/or impatient (wanting near-immediate results, with little time in braces), the “surgery-first” approach can be explored. This will be discussed later in this book, but seeks to limit the overall treatment time and eliminate the need for a prolonged pre-surgical orthodontic phase [10]. However, the orthodontic component is still required post-operatively and is a critical component of the overall treatment (Figure 1.3).

Figure 1.3 Example, pre and post- of orthognathic, rhinoplasty patient; addressing bone, soft tissue, and nasal regions.

Concepts of aesthetic orthognathic surgery

Aesthetic	Orthognathic^a
Balanced Pleasing Younger Well-proportioned Soft-tissue volume and support	Jaws aligned Stable functional occlusion Symmetric jaw outline Optimized airway

^aOrthognathic surgery enables the aesthetic surgeon, to address skeletal, dental, soft-tissue relationships, improving balance, function and aesthetics.

1.2 Patient Education

Given the requirement for combined dental, orthodontic, and surgical intervention, the patient and their family must understand and embrace the sequence, time, and compliance needed pre- and postoperatively [11]. Preparation for orthognathic surgery is a process – it is not simply a surgical procedure and then a recovery period. The period of presurgical braces is necessary to enable the surgery, as the teeth must fit together when moving the jaws. The aesthetic goals are factored into the orthodontic phase, and decompensation should be...