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Maxillary–mandibular aesthetic orthognathic surgery

Key points • As the aesthetic impact of orthognathic surgery is increasingly appreciated, occlusal plane rotation may be used by the surgeon to optimize facial balance. This approach requires bimaxillary surgery. • Over impaction can cause a significantly “aged” appearance. Moreover, it is important to recall that the upper lip lengthens with age. • It is generally felt that there is increased reliability when the maxillary…

Mandibular skeletal orthognathic surgery

Key points • To simplify diagnosis and corrective surgical planning the mandible may be considered in: a genial component, a ramus-and-corpus component, and a dentoalveolar component. • The chin has no clearly defined function however it forms a key element in total facial harmony. • The shape and and size of the chin is equally important to its anteroposterior projection. • Comprehensive planning for the pre-surgical…

Maxillary skeletal orthognathic surgery

• The overall facial arc should have a slight convexity, with the projection greatest at the subnasale (anterior nasal spine [ANS]). • Women typically prefer a more convex face, which is more feminine, rather than a flatter face, which is typical of increasing masculinity and preferred by men. • Maxillary central incisor show at rest is 2 to 3 mm in males and 3 to 4…

Advances in orthodontic treatment

Key points • The advantage of using CBCT is the accurate visualization of the root angulations. • Initial records using CBCT technology and intraoral scans of the dentitions can be used to simulate treatment outcomes, and this can be extremely helpful in choosing among multiple treatment options. • One of the major benefits of CAD/CAM orthodontics is the straight-line approach of tooth movement from its initial…

3D virtual surgical planning: From blueprint to construction

Key points • Cephalometric analysis is performed in three-dimensions to allow the surgeon and the orthodontist to address asymmetry in all three planes. • The time-consuming laboratory process of facebow transfer, plaster mounting of dental casts, sectioning, repositioning, and remounting of the dental casts are all eliminated. • In addition to the physical examination, three additional components are needed for virtual planning (VP): CBCT data, 3D…

Optimizing aesthetics in facial skeletal surgery

• Orthognathic surgery should achieve a functional occlusion while optimizing facial form. • Aesthetic facial analysis takes priority over cephalometric norms when developing the treatment plan. • Treatment plans should be designed that will optimally support the soft tissue as the patient matures. • Expansion of the facial skeleton optimizes soft tissue support. • Skeletal contraction will prematurely age a person’s face. • Skeletal disproportion can…

Embryology and development of the facial skeleton

Key points • The embryological components of the facial skeleton are derived from the three divisions of the skull: the desmocranium, the chondrocranium and the viscerocranium. • The ectomeninx has chondrogenic and osteogenic properties which translate into intramembranous bone that forms the skull vault or calvaria. • The facial bones develop intramembranously from the ossification centers in the neural crest mesenchyme of the embryonic facial prominences.…

Biology of fat grafting

• Centrifuged fat has three layers: (1) the upper supernatant, containing lipid; (2) the middle stromal vascular fraction, containing adipose-derived stem cells, stromal cells, vascular cells, and mural cells; and (3) the lower layer, containing blood, local anesthetic, and tissue fluid. • The donor site has not been shown to influence fat graft survival. • Centrifuge and rolling techniques are the preferred processing techniques for fat…

Aging of the facial skeleton

• Visible changes in the aging face (such as jowls, sagging, crow’s feet) are, in part, due to thinning skin that has lost its intrinsic elasticity and nonuniform loss of subcutaneous fat. • The bony skeletal provides the framework on which the skin, subcutaneous fat, and muscle layers create the overall three-dimensional facial contour. • The aging facial skeleton undergoes predictable resorption of bone, most notably…

Alloplastic and natural materials used as implants

Key points • The success of any implant depends not only on minimizing the inflammatory reaction of the material but also on the prosthetic porosity and stress at the tissue–implant interface. • The porosity of an implant will dictate whether the implant becomes encapsulated (low porosity) or allows tissue in-growth (high porosity) leading to quiescence and toleration. • Effective tissue repair with the use of allografts…

Biology of bone and cartilage grafting

• Autologous bone and cartilage grafts remain important tissue sources for surgery of the facial skeleton due to their biocompatibility and long-term success rates. • The revascularization of autologous grafts reduces long-term complications because the graft ultimately establishes a blood supply in its recipient site. • The selection of different types of grafts is dictated by the functional needs of the defect. • Mesenchymal stem cells…

Surgical anatomy and approaches to the facial skeleton

Key points • Select an access incision that will provide the most direct route to the underlying bone. • A coronal incision can be used to access the cranial vault, forehead, zygoma, orbit, nasal dorsum, temporomandibular joint (TMJ), and condylar/subcondylar regions. • The Gillies approach is an incision that allows a blunt instrument to be placed deep to the zygomatic arch. • The upper blepharoplasty approach…

Relationship between the soft tissue and the skeletal framework

Key points • The visible surgical result is related to the soft tissue envelope and not the underlying skeletal structures that support the facial surfaces and volumes. • Predicting how a procedure will change the skeletal framework is simple; forecasting how it will affect the soft tissues is hard. • Biological soft tissues are anisotropic—that is, the mechanical properties are not the same in all directions.…

Photographic advances in facial imaging

• Photography is an essential tool to objectively document patient conditions, evaluate physical deformities, plan treatment approaches, and assess surgical outcomes. • In plastic surgery, clinical photography accomplishes two goals primarily: first, documentation of preoperative conditions and postoperative surgical results, and second, recording of surgical procedures and techniques. • It is always beneficial to understand the basic mechanics of a camera, in order to obtain high…

Radiologic advances in facial imaging

Key points • The deleterious effects of ionizing radiation are cumulative, necessitating the judicious use of ionizing radiation. • Cone beam CT (CBCT) allows for image capture that displays excellent spatial resolution (image detail) of hard tissue at a relatively low dose of ionizing radiation. • CBCT data sets can be integrated with task specific diagnostic software programs such as virtual surgical planning. • A radiation…

The importance of patient-reported outcomes in aesthetic skeletal facial surgery

Key points • Patient-reported outcome instruments (PROIs) are questionnaires that measure concepts by asking patients directly, without clinician interpretation, and should be used to measure procedural outcomes. • The FACE-Q is a new validated, reliable, and responsive PROI. • There are four FACE-Q domains: appearance appraisal, quality of life, process of care, and adverse effects. • The Face Q link is www.qportfolio.org . • PROIs can…

Motivations of patients seeking aesthetic surgery of the face

Key points • Celebrities’ values and beauty standards are a major influence on patients seeking aesthetic surgery. • The explosion of social media and reality television has become an ever-increasing motivator for patients to consider aesthetic surgery. • The K-Pop export of the ideal V-shaped face, achieved often by quite invasive bony surgery and reduction of the angles of the mandible and the zygoma, has led…

Psychology of facial aesthetics

• Darwin’s description of the theory of natural selection is one of the earliest scientific acknowledgments of the importance of physical appearance. • Evolutionary theorists believe that the ability to develop symmetrical features in a world full of environmental pathogens is conferred on only the healthiest of a population. • Individuals who are judged to be more physically attractive receive preferential treatment in a wide range…

Anthropometrics

Key points • Complete reliance on cephalometric analysis for treatment may lead to suboptimal aesthetic results. • Beautiful faces of different ethnicities have quite different shapes, but individuals of all ethnicities recognize them as beautiful. • Faces that conform to the neoclassical canons are moderately attractive, but most attractive faces do not conform to these rules. • In female faces, femininity is considered attractive, whereas masculinity…