Planning Treatment to Optimize Facial Esthetics DR. DON JOONDEPH It is very important to base treatment decisions to achieve a good functional correction and also to optimize facial esthetics for, believe it or not, contrary to what patients initially report the most important consideration for both male and female patients is an improvement in their appearance. With this in mind Dr. Joondeph examined the literature with regard in particular to transverse discrepancies in adults. It is known that the mid palatal section remains patent into the 3rd and 4th decade of life. This section does become quite interlocked after growth ceases. However it has been shown that 3-4mm of maxillary expansion can be achieved in the non-growing patient. This is mostly alveolar change and not skeletal widening. Larger expansions will require surgical assistance. Surgically assisted rapid palatal expansion is a very stable correction that can be classified as distraction osteogenesis. Maxillary expansion with a Le Fort I procedure is the least stable of surgeries and with it the upper lip is flattened over time, nasal tip goes up, nose widens and nares exposure increases. We know the soft tissue changes prior to surgery and this concept must be a part of treatment planning. Dr. Joondeph is particularly interested in mandibular constriction in the correction of transverse discrepancies. This is accomplished surgically with a mandibular midline osteotomy. He has found the procedure lends itself to moderate width changes. We often find a manxillary surgical procedure necessary just for the transverse dimension change and then often see unwanted soft tissue changes and of course the high expense associated with it. Mandibular Midline Osteotomy 1. Stable correction - (Alexander, C. et al AJO Dentofac Orthop. 1993.) 2. Periodontal adjustment to the surgery is good 3. Normal function returns to TMS Comparing mandibular advancement with BSSO to mandibular advancement with BSSO plus mandibular midline osteotomy: his paper, now in press , finds less condyle rotation in the mandibular midline osteotomy group than with the BSSO alone. Also a BSSO causes a condylar expansion where as a BSSO combined with a MMO does not. He found no significant difference between the two groups in stability or TMJ concerns. This has been borne out with other studies. Expense also is significantly lower with a BSSO using a MMO for transverse correction than it would be with the addition of a Le Fort procedure for tranverse correction. Vertical changes with surgical counter clockwise rotation of the mandible also have been shown to be stable. (Knaup ,C. et al Int .J Adult Orthod. Orthognath Surg. 1993.) It has been shown that leveling the maxillary arch in open bite is as stable as leaving a step between incisors and buccal segments for a three piece maxillary osteotomy. (Lo, F. et al Int. J. Orthod. Orthognath Surgery 1998) We can level an upper arch before surgery and expect it to stay. An open bite, up to 5mm., can be closed in the lower arch alone with counter clockwise surgical rotation and with good stability expected. To Summarize: Esthetics are often the primary motivation for patients to seek treatment Surgical procedures now exist that can reduce the need for Le Fort procedures; with their expense and often unwanted soft tissue changes. Another tool to allow for more precise esthetic soft tissue planning.