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Jueves, 20 Febrero 2020 19:33

234 - Virtual Planning for Bimaxillary Orthognathic Surgery in a Patient with Facial Asymmetry

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A 26 yearS old male patient is referred to Maxillofacial Diagnostic Institute (IDM) by Dr. Samuel Allen, for virtual planning of orthognathic surgery.

Figure 1 shows the pre-surgical panoramic radiography with the fixed apparatus for bimaxillary orthodontics and the interdental fixation surgical pins.

The evaluation of the pre-surgical volumetric tomography (CBCT) (Figure 2) of the craniofacial massif shows sagittal deficiency of the upper jaw, occlusal edging, discrepancy of the height of both branches characterized by an increase in the length of the left mandibular branch, mandibular deviation to the right side, mandibular prognathism, cross bite of the right side and anterior open bite.


An intraoral digital scan of the dental arches was performed (Figure 6) using the Emerald scanner (Planmeca); superimposing the digital models to the tomographic volume and using the surgery module of the Romexis 5.3 software (Planmeca), surgical planning was carried out together with the Maxillofacial Surgeon. A Lefort I osteotomy was performed with a maxillary advance of 5mm, anterior descent of 2mm; likewise a bilateral sagittal branch osteotomy was performed, the most posterior mandibular and to the left (10 mm) were positioned; a left condylectomy was also planned. The virtual surgical movements obtained three bony positions (initial, intermediate and final) (Figure 3, 4, 5, 6) of which the intermediate and final were used to make the surgical splints which were materialized by a 3D printer ( Figure 7).


The immediate post-surgical volumetric tomography (CBCT) (Figure 8) of the massive facial skull and the superposition with the pre-surgical tomography (Figure 9) show the corrections of the maxillofacial deformities specified in the areas of non-overlap (gray color for the initial position and orange color for the final position.


The pre and post-surgical Proface (Planmeca) 3D photography records were also obtained (Figure 10), which allow an assessment of facial changes; the superposition of both (Figure 11) shows the greatest facial changes at the level of the middle and lower third, as well as the correction of the asymmetry (blue color shows the greatest facial change of 10 mm at the level of the lower third).


Paraphrase
For the management of dentofacial deformities an accurate diagnosis is essential, during the preoperative development it is essential to make a reproduction of bone movements until adequate occlusal stability is achieved that is the key to the success of the surgery. The latter can be done in the conventional manner through surgical occlusal splints with virtually guided planning protocols.

Thanks to the design and manufacture of these guides by means of injection techniques, it has been possible to eliminate the alterations and errors that can be made during their manual manufacturing.
The intermediate surgical occlusal splints constitute the universal transfer system that takes as reference the occlusal component to reposition the osteotomized bone segments of the maxilla and the jaw, this system includes errors that must be corrected during surgery and leave control to the surgical team and the positioning of the mandibular condyles that can condition the correct positioning of the maxillary fragment.

The usefulness of three-dimensional (3D) planning has been widely proven, since it provides great advantages over traditional methods of planning orthognathic surgery cases, being the origin of one of the major changes that represents the evolution in the field of maxillofacial surgery. 3D planning allows us to preview with a precise control the movements of the jaw and jaw without overlooking the condyle position.

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