module 6 tx plan

[Chad Carter (Course Director)]

Good question!

LeForts come in all shapes and sizes. A posterior impaction is indicated when their is a steep palatal plane. This shows excess vertical bone in the posterior of the maxilla – the surgeons have to have something to cut down in order to do the impaction. I look at this case and think of a multipiece LeFort with anterior downgraft splitting with the posterior impaction. The multipiece will help treat the asymmetry.

KEY THING: Don’t forget that there is no such thing surgically as a straight up or down LeFort. Once the surgeons do the downfracture they will have about a 2mm advance just to be able to clear the pterygoid plates. Also even though technically a LeFort “setback” is possible (cutting out a ridge of the palate) it’s not realistic. I’ve worked with over a dozen orthognathic surgeons and I’ve met only one that did the surgery one time (in a very long career) and he said he’d never do it again.

[Pegah Kamrani]

very helpful thank you! Are Lefort impactions necessary when we are doing a BSSO advancement and want to rotate the mandible CCW to decrease LAFH? thank you!

[Chad Carter (Course Director)]

Pegah,

Great question! When planning a CCW rotation of the mandible, I do normally default to planning a maxillary surgery as well. This might be a posterior impaction. It might be a three piece. Or it could be maxillary incisor extrusion. Definitely think of the target occlusal plane. The surgeons in our VSP sessions tend to be more dialed in on the occlusal plane angle relative to FMA than most orthodontists think about. Sometimes as orthodontists we are timid about planning surgery…. just remember if the patient is undergoing surgery to give them the BEST outcome. I ask every patient after their surgery “What was worse – separators for fitting bands or the surgery?” Almost 100% say separators for placing bands are worse – they didn’t know what to expect and it is uncomfortable. People expect surgery to be uncomfortable and prepare for it – now great thing about orthognathics is that they are generally numb afterwards which helps recovery though they do have significant swelling and eating challenges. I tell people it will be an uncomfortable couple weeks.