Case Report

Computer assisted orthognathic surgical treatment planning:

a case report

John Eastman Grubb, DDS, MSD

Because there are a number of patients who have significant skeletal disharmonies that cannot be treated with conventional orthodontic therapy, forecasting surgical and orthodontic treatment objectives is becoming more important. Forecasts must be based on known soft tissue changes that occur subsequent to dental and skeletal repositioning.

The use of manual template reconstructions developed from headfilm radiographs and soft tissue estimates made from such recommendations is time-consuming and limited by human error. Computer assisted reconstructions allow the orthodontist to more efficiently and effectively perform these tasks. Computerized treatment planning facilitates the storage, retrieval, modification and duplication of cephalometric records for inter- and intraspecialty communication. It has also increased patient understanding and acceptance of the recommended treatment procedures.

In the first half of the 20th century, orthodontic diagnosis was an exercise in classification. Patients with similar patterns of malocclusion were grouped together based on the premise that dental and skeletal relationships were comparable. The development of the radiographic craniometer by Broadbent' allowed for the precise standardization of anatomic landmarks and the study of growth and development of the skull. Subsequent introduction of cephalometric radiography created a method for the description of facial disharmonies. A number of different cephalometric analyses have been devised since Boadbent's original work in 1934. Those that

have gained wide acceptance include Bjork.' Burstone,> Downs," Steiner,6,7,8 Tweed.?" Riedel," and Ricketts.l-" In addition, most orthodontic and oral and maxillofacial surgical postdoctoral programs have borrowed portions of various analyses to develop cephalometric analyses of their own.

Cephalometries has been used to assist in treatment planning for orthodontic and surgical care, and to quantify changes resulting from such treatment. The importance of accurately estimating facial growth based upon facial pattern was the result of the work of Ricketts who, in 1973,12,13 stressed the importance of predicting facial profile changes.

Additional development of the concept by Bench, Hilgers and Cugino!' established a reasonable method of predicting facial change as a result of growth, Incorporation of the ideal placement of dental units in this growth-altered prediction tracing allowed for the construction of an orthodontic visual treatment objective (VTO). The superimposition of tracings enabled the orthodontist to design mechanics to achieve the treatment objective and its resulting facial profile,

By the late 1960s and early 1970s it became apparent that all skeletal disharmonies could not be corrected by orthodontic treatment alone. During this time articles on orthognathic surgery increased significantly, In 1972, McNeilPs was the first to describe the use of surgical cephalometric prediction tracings, Others had previously described their use in diagnosis and treatment planning, but McNeill demonstrated the practical value of the technique, Robinson" attempted to quantify soft

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figure lA

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Figure 1A-8 Pretreatment photos at 25 yr 5 mo. Note inadequate paranasal and infraorbital contours as well as lip incompetence.

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tissue change relative to skeletal movements in correcting mandibular prognathism. By advocating the use of acetate templates to move skeletal parts superimposed over the original cephalometric tracing, Fish and Epker" continued to refine the technique of soft tissue predictability.

Bell, Profitt, and White" proposed the use of cephalometric prediction using templates to complement model surgery changes, to predict changes in bony relationships not seen on the dental casts, and to predict soft tissue changes.

Wolford, Hilliard, and Dugan" expanded on this topic to develop a systematic approach to prediction tracings. Their method combined the manipulation of hard tissue elements and the generation of consistent soft tissue predictions in a very simple, manageable format. This method is taught in many orthodontic and oral and maxillofacial surgical programs today.

Ricketts 13 and Walker" were among the first to publish their experiences using computers for cephalometric analysis. Their efforts were directed

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Figure 2 Pretreatment cephalometric tracing shows mandibular prognathism in relation to SN.

at clarifying facial changes in the growing individual. Schendal, et. aJ.21 looked at soft tissue changes of the orthognathic surgery patients and reported mean values based on data from digitized pre and postoperative lateral headfilms. Bhatia and Lowery" described an interactive on-line computer analysis program that collected, stored, and analyzed data from cephalometric radiographs. Their program diagnosed dental and skeletal deformities and predicted posttreatment soft tissue profile changes.

Harradine and Birnie", and Walters and Walters" reviewed free-hand and photographic cutting techniques and compared them to computer-based methods of predicting the results of orthognathic treatment. They described a program that collected and stored cephalometric data and used a graphics plotter that would draw both existing and predicted hard and soft tissue tracings.

Hing" investigated the accuracy of a commercially available software program that included prediction tracings. Although the program overestimated anteroposterior changes and under-estimated vertical changes, the mean differences and standard deviations tended to be less than those associated with manually derived predictions.

Video imaging represents a major addition to the role of computers in orthognathic surgery. Sarver, et. a126 described his experiences with a video imaging system that permitted the manipulation of photographic images to coincide with proposed hard tissue movement of orthodontic treatment and surgery. He noted favorable patient acceptance. Thomas, et. al." also noted the favorable response by patients to video imaging. They reported that most patients felt that video imaging improved communication between patient and surgeon, increased patient confidence in surgery, and enhanced the patient-doctor relationship.

A number of software programs are presently available that integrate cephalometric analysis and prediction with video imaging. The programs permit the cephalometric tracing and video image to be altered in response to proposed orthodontic and surgical changes.

The following case report incorporates the use of computerized cephalometric analysis and interactive prediction using video imaging in the treatment planning and actual treatment of one patient..

Treatment report

This 25 year 5 month old woman presented with a chief complaint of dissatisfaction with her appearance. Soft tissue assessment revealed a prominent chin point, inadequate paranasal and infraorbital contours, upturned nasal tip with sharp supra tip break, and lip incompetence. Intraoral tissues were

Computer assisted planning

Figure 3.A

Figure 38

Figure 3D

healthy with normal color and contour. She had a Class III dental and skeletal relationship. General physical health was excellent and no unusual disabilities were reported or observed. Study cast analysis revealed a Class III dental relationship with the tendency for an anterior crossbite. The mandibular incisors were retroinclined. Initial intraoral radiographs were within normal limits and revealed four partially impacted third molars. Tomograms were unremarkable with both condyles centered, no unusual osseous borders evident, and adequate joint space.

A computerized cephalometric analysis indicated a prognathic mandible with Class III dental occlusion. Procumbent maxiliary incisors, the tendency for anterior crossbite, and mild vertical maxillary hyperplasia were noted. Lower lip eversion and increased lower an terior face heigh t were also noted.

Treatment planning

A computerized visual treatment objective was derived and the following changes were made: 1) maxillary incisor torque was improved and procumbency reduced; 2) mandibular incisor retroclination was eliminated; 3) the maxilla was impacted and advanced, moving superiorly more in the posterior then the anterior; and 4) the mandible was set back and anterior vertical height reduced.

The process of computerized cephalometries is quite direct. Demographic data is entered into the system by completing the general information data screen. Next, the lateral cephalometric headfilm is placed on an electronic, back lit grid called a digi-

Figure3C

Figure 3A-E Pretreatment study casts

Figure 4 Cephalometric prediction tracing based on predetermined treatment goals.

Figure 3E

Figure 4

tizer. The digi tizer is equi pped with a stylus tha tthe operator uses to trace the profile and skeletal anatomy and digitize preselected anatomic landmarks.

The entry process can use verbal or graphic prompts. Certain anatomic landmarks are also located and digitized using the stylus.

The points to digitize are circled in red on the screen. The point's name, landmark location and X'y values are displayed on the bottom of the screen.

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Figure SA

Figure 58

Figure 6

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Anatomic areas are then traced or "streamed" using the stylus like a tracing pencil. These anatomic areas are prompted and outlined on the computer screen to assist the operator. By simply

following the outline of the anatomic profile (on the actual x-ray) with the digitizing pen, the entry will be completed. Study casts may also be digitized by first photocopying the occlusal view of each arch. Then, placing the photcopy on the digitizer, the mesio-distal points of each tooth are digitized. Missing or unerupted teeth are designated, and each tooth appears on the screen. The individual tooth

mass is calculated or displayed. The entire arch is portrayed with the corresponding crowding and spacing. This interactive study feature essentially creates an occlusogram.

After cephalometric and study cast data are entered into the system, a wide range of analyses and selected treatment options can be used and simulated. Electronic templates are created that simulate anatomic structures. These templates include maxillary and mandibular incisors and molars, the

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Figure 5A-B Pretreatment diagnostic set-up with removal of maxillary first premolars.

Figure 6 Superimposed pretreatment (black) and prediction (blue) tracings. Note the impaction and rotation of the maxilla combined with a mandibular set-back.

maxilla and mandible, and the soft tissue profile.

From the diagnostic set -u p, pre-surgical orthodontic movement can be accomplished.

Most skeletal problems have some form of dental compensation. It is usually necessary to decompensate dental arches in anticipation of skeletal correction. This results in the development of a significant dental malocclusion that more closely resembles the skeletal discrepancies present, in preparation for their surgical correction. Interactive use of the diagnostic set-up and surgical cephalometric prediction tracings is critical to effective orthognathic surgical treatment planning.

In this case, the diagnostic set-up was constructed after considering the following criteria: 1) decompensate maxillary incisor procumbency and alleviate anterior crowding; 2) eliminate retroclination of the lower anterior segment; and 3) achieve proper arch coordination.

To accomplish these set-up goals, maxillary first premolars were removed. The maxillary incisors were decompensated and crowding eliminated. The incisors were then retracted to an ideal intra arch relationship. The mandibular teeth were aligned and advanced with appropriate torque added to the anterior segment. Both arches were coordinated. These changes resulted in a significant anterior crossbite that more closely resembled the underlying skeletal discrepancy.

A patient conference was held and the proposed treatment plan and predictive records were presented, including a computerized video image that showed the anticipated changes in facial appearance. The patient was advised that the information provided was no guarantee of actual outcome, but was considered a reasonable expectation of treatment.

Active treatment

Following patient acceptance, treatment was initiated. The maxillary first premolars and all third molars were extracted. Necessary operative dentistry was completed. The arches were banded and bonded and the teeth leveled and aligned. Based on the diagnostic set-up and predictive visual treatment objective tracing, the maxillary anterior segment was retracted aproximately 2 to 3 mm and de-torqued.

Residual maxillary space was eliminated by slipping molar anchorage mesially, leaving a small area for the intended surgical cuts. The mandibular incisors were uprighted, aligned, and each arch was coordinated relative to its respective skeletal base.

The surgical phase of treatment occurred approximately 23 months following the initiation of active orthodontic treatment. A Le Fort I osteotomy was performed to impact and move the maxilla anteri-

orly. Bilateral sagittal split mandibular osteotomies permitted the mandible to be moved posteriorly and superiorly. Both jaws were stabilized using internal rigid fixation. Infraorbital rim implants were placed to augment facial contours.

Following surgery, the arches were coordinated with flexible nickel titanium edgewise wires to prevent any interferences that would hinder settling. Final stainless steel edgewise arch wires were used to refine the occlusion, improve torque control and arch coordination. Settling was accomplished with light round wires and vertical elastic mechanics. Minor occlusal equilibration was accomplished during these finishing stages.

After 33 months of active orthodontic care, appliances were removed. Retention consisted of a maxillary .036 wraparound retainer worn full-time and a direct bonded .0195 CAC braided 3-3 wire attached to each tooth. A light-activated direct bonded method was used for ease of placement and strength of bonding.

Posttreatment evaluation

Results achieved include a Class I anterior occlusion and Class II molar relationship. Vertical and horizontal overlap were within normal limits with excellent anterior coupling. Midlines were coincident and the anterior crossbite was eliminated.

Radiographs revealed some root blunting of the maxillary left second premolar. Titanium plating and screw fixation were present in both jaws. Tomography revealed satisfactory condylar position and adquate joint space.

Cephalometric assessment paralleled the presurgical VTO with the maxilla impacted posteriorly more than anteriorly (although not as much as predicted) and brought forward. The mandible was moved posteriorly to articulate correctly with the repositioned maxilla.

Lip incompetence was decreased and the soft tissue drape is within normal limits. Intraoral photographs demonstrate a balanced occlusion and a normal overbite/overjet relationship.

Crowding was eliminated as was the anterior crossbite. The midlines were coincident with each other and the facial midline. A satisfactory soft tissue profile with the elimination of lower lip eversion and incompetence was evident on the facial photographs. A satisfactory "smile line" was achieved as was an increased fullness of the paranasal and infraorbital areas.

Superimposition of headfilms one year posttreatment shows excellent dental and skeletal stability.

Discussion

Pretreatment and presurgical prediction results can be achieved using manual tracings and acetate

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Computer assisted planning Figure 7 Posttreatment panoramic radiograph shows pteryqomaxulary fissure area with vascular clips used for hemostasis and multiple bone plates at the right mandibular angle region to stabilize an unfavorable sagittal split.

Figure 8

Figure 98

Figure 8

Posttreatment cephalometric traclnq shows improved skeletal and soft tissue balance.

Figure 9A-B

Posttreatment photos at 28 yr 4 mo. Note increased fullness in the paranasal area and improved lip competence.

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Figure 10A-E Posttreatment study casts.

Figure 11

Superimposed, computer-generated pretreatment (blue) and posttreatment (black) cephalometric tracings.

Figure 12

Superimposed prediction (blue) and actual posttreatment (black) tracings.

Figure 10B

Figure 10D

Fi'gure 10C

Figulre 10E

Figure 11

Figure 12 template reconstructions. Computers offer an important enhancement by providing information relevant to anticipated facial esthetic changes for a variety of surgical procedures quickly and accurately.

Manual techniques, although reasonably accurate28,29 are understandably arduous, and time consuming. Computerized cephalometric pretreatment and preoperative prediction techniques are quickly and easily prepared. With the widespread avail-

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ability of computers and graphic spreadsheets, cephalometric data entry and access have been greatly simplified. A number of orthodontic surgical software programs currently on the market make it possible to: 1) accurately enter cephalometric data; 2) simulate treatment; 3) prepare color VTOs of good quality in a fraction of the time it takes to do these tasks manually; and 4) produce photographic images for patient review. (e.g. Prescription Planner, Orthognathic Treatment

Computer assisted planning

Figure 13A Planner.)

Presurgical orthodontic treatment of this case included decompensation of maxillary incisor procumbency, elimination of crowding, an increase in the dental Class III discrepancy, selective space closure and anchorage drain, and proper arch coordination. Because the diagnostic set -up occlusogram and the predictive head film are interactive, changes made in tooth position, as in the diagnositc set-up, can be transferred to the predictive tracing on the lateral headfilm.

Surgical movements included Le Fort I maxillary impaction and advancement. This was indicated on the computer with selective electronic template re-orientation. Mandibular auto-rotation and setback osteotomy were shown by repositioning the corresponding anatomic electronic template. The soft tissue changes that accompanied the dental and skeletal movements were automatically reflected in the re-drawing of the profile based on known norms of soft tissue changes.

Because of the computer's excellent storage capacity, record retrieval is easily accomplished for any number of daily practice requirements.

Rapid superimposition techniques before and during treatment allow for improved planning and implementation of mechanotherapy. Patient education is markedly enhanced with the system. Today, more than ever before, it is important to provide patients with as much graphic data as possible so that they can make intelligent, informed choices before consenting to care.

There are some important caveats to keep in mind when using an electronic system.

It is unwise to assume that soft tissue forecasts achieved by any computer based system at the present time will be completely accurate. Therefore, it is prudent to advise the patient that the final result may not be exactly as forecast because of the variables inherent in soft tissue reorganization following surgery.

Fortunately, orthodontic and maxillofacial surgical researchers are making great strides in developing a more exact science. Although

Figure 138

Figure 13C

Equipment list for computerized cephalometries and video imaging

80486 computer:

5-112 floppy disk drive 3-114 floppy disk drive 205 Mb hard disk

12 Mb RAM

33 MHz clock speed

17" multiscan color monitor (non-interlaced) Color plotter printer (optional)

Digitizer with stylus

Cables

Laser jet printer Video capture board Video cabling

Bus mouse

Camera - broadcast quality Thermal color printer

Additional software and supplies: floppy disks

power director

virus protection

software

cabling

transparency and computer paper printer and plotter supplies

Optical disk storage, compression boards, and software will be needed as patient files expand

computerization is an improvement on the manual template techniques previously discussed, beauty and soft tissue interpretation is still subjective. There will always be variations among clinicians. Although general anatomic parameters and esthetic guidelines should be followed, the individual orthodontist's appreciation of art form will still ultimately determine the type of change that leads to improved facial esthetics.

The Angle Orthodontist

Figure 13A-C

A. Surgical treatment objective shows hard and soft tissue change overlay, with surgical cuts and magnitude of hard tissue correction necessary.

B. Hard tissue tracing over initial photo, surgical treatment objective, and end of treatment photo.

C. Comparisons of: initial soft tissue with hard tissue outline and overlay; surgical treatment objective tracing; and final soft tissue result with hard tissue outline and analysis overlay.

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Author Address

John Eastman Grubb, DDS 345 F Street

Suite 250

Chula Vista, CA 91910

J.E. Grubb is in private practice in Chula Vista, Calif.

He IS Director of the orthognathic surgical section of the Department of Developmental Dentistry, University of Southern California School of Dentistry and a clinical instructor, Graduate Orthodontic Department, University of Southern California School of Dentistry.

References

Acknowledgments

Thanks to the orthognathic surgical team members at the University of Southern California School of Dentistry, Department of Graduate Orthodontics: Dr. Markell Kahn, Dr. Tim Smith and Dr. Mel Wishan. Special thanks to Dr. Kelly Cruser for constant inspiration to publish this material.

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