Fourth Gen. Meeting 2008-09

By Dr. Glenn M. Gonzales

The Association of Philippine Orthodontists (APO) held it’s 4th general meeting at the Palm Grove room of the Rockwell Club, Makati.  Highlights of the meeting include: 1. A case report of a Class III Surgical Orthodontic  patient was jointly presented by Dr. Bernie Tansipek (Plastic Surgeon) and Dr. Alex Urriquia (APO student member), and  2.  a table clinic presentation of Phase III examination cases  by Dr. Maria Janet Pandan.

At around 8:30 am, the meeting started with a prayer led by Dr. Lotus Llavore. This was followed by the singing of the national anthem. Dr. Jose Rivera, APO’s current president, gave a welcome address. Mrs. Patricia de Vera, unit manager of AXA Philippines (APO meeting sponsor, affiliated with the Metrobank and the Global AXA group), then gave a short talk on financial planning.

By 9:00 am, committee reports were given by Dr. Laarni Serraon ( pitching in for Dr. Bernie Go, Membership), and Dr. Marilyn Leung (Philippine Board of Orthodontics / PBO). Dr. Marilyn gave important PBO related updates (PBO exams), while Dr. Laarni spoke on behalf of Dr. Bernie Go, for the membership committee (membership dues, credit points).

Around 9:30 am, the joint presentation of an Orthognathic surgery case ( supplemented by lectures on Orthognathic surgery)  by Dr. Bernie Tansipek and Dr. Alex Urriquia began.  Dr. Urriquia spoke first, presenting the Pre-Surgical Orthodontic work-up. He reminded us that the term “Orthognatic Surgery” came from “orthos” (straighten) and “gnathos” (jaw). He also reminded us that the mechanics involved for Camouflage therapy, and Decompensation are entirely different.

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The surgical orthodontic patient was an adult male, who had Class III Open Bite Skeletal Malocclusion, with slight canting of the occlusal plane. For this specific case, some of the treatment objectives post-surgical orthodontics include achieving favorable overjet and overbite, a Class I Canine relationship,  good interdigitation, and reduction of the anterior facial height. Extraction of the lower third molars was also recommended, to achieve maximum mandibular setback. It was also noted that excess  extraction space would still be present (due to previously missing teeth) even after orthognathic surgery. These spaces will be managed with a dental prosthesis.

Pre-Surgical orthodontic treatment sequence was as follows: 1. Leveling and Alignment (with Niti wires), 2. Decompensation, 3. Stabilization with rigid wires (which should  to be done 1 month prior to mock paper surgery, and mock model surgery).

Mock paper surgery and mock model surgery  were then done in order to make a surgical splint (necessary as an aid for stabilizing the teeth and the jaws after orthognathic surgery).  Simulated surgical repositioning were first done with mock paper surgery, using measurements from the patient’s Cephalometric tracing. The resultant measurements were then transferred to a model cast mounted on a Hanau articulator, for the mock model surgery. The surgical splint/s were then fabricated.

Dr. Tansipek spoke next. He discussed the surgery proper. He mentioned that when it comes to orthognathic surgery, the orthodontist is the “architect” while the surgeon is the “engineer”. Nasotracheal intubation of the patient , during general anesthesia, is recommended, as this allows easier manipulation of both the upper and the lower jaws. For this particular case, Lefort Osteotomy of the upper arch, and Mandibular setback of the lower arch, were done.

For the mandible, using a surgical handpiece, an initial notch was made just before the lingula. This serves as a guide, and helps keep the Inferior Alveolar Nerve intact. After an initial cut was made, a chisel was used to separate the mandibular bony segments. For the maxilla, a cut was made from the sulcus  to all the way back, to the pterygoids. A gentle downfracture of the upper jaw was then done. Fitting and placement of the surgical splint came next. For proper placement of the mandibular segments ( in order to avoid post-op TMJ problems), gentle placement of the condyles into the Glenoid fossa had to be achieved. Direct fixation of the Maxilla was done, using Titanium plates. Transcutaneous fixation of the Mandible was achieved, using Lag Screws.

Dr. Urriquia spoke again, and reported that post-op Cephalometric measurements revealed a marked improvement of SNA and SNB values. The heavy archwire was kept in use post-op , with the patient instructed to perform opening and closing movements with box elastics. After finishing and detailing, retainers are to be made for the patient, with the residual spaces filled up with a dental prosthesis.  A marked improvement in the profile of the patient was noted post-op.

Dr. Tansipek spoke last, and volunteered to add more to scope of the joint presentation, touching on the possible application of orthognathic surgery for sleep apnea. Most of the obstruction in sleep apnea was noted to be retropalatal or retroglossal. Maxilla-mandibular advancement (through  Muti Segmental Supraapical Osteotomies ) may prove beneficial in reducing a patients RDI ( Respiratory Distress Index – indicates the number of times a patient stops breathing during sleep ).  A conscious effort to try and maintain the patient’s profile , even with the advancement, is encouraged for sleep apnea cases (particularly when changing the patient’s profile is unnecessary).