Case Report Combined Orthodontic and Surgical Approach in...

Hindawi Publishing CorporationCase Reports in DentistryVolume 2013 Article ID 797846 12 pageshttpdxdoiorg1011552013797846

Case ReportCombined Orthodontic and Surgical Approach inthe Correction of a Class III Skeletal Malocclusion withMandibular Prognathism and Vertical Maxillary ExcessUsing Bimaxillary Osteotomy

George Jose Cherackal1 Eapen Thomas2 and Akhilesh Prathap2

1 Department of Orthodontics Pushpagiri College of Dental Sciences Medicity Tiruvalla Kerala 689 107 India2Department of Oral and Maxillofacial Surgery Pushpagiri College of Dental Sciences Medicity Tiruvalla Kerala 689 107 India

Correspondence should be addressed to George Jose Cherackal drgeorgejosegmailcom

Received 19 October 2013 Accepted 19 November 2013

Academic Editors J H Campbell C Evans M B D Gaviao and C Landes

Copyright copy 2013 George Jose Cherackal et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

For patients whose orthodontic problems are so severe that neither growth modification nor camouflage offers a solution surgeryto realign the jaws or reposition dentoalveolar segments is the only possible treatment Surgery is not a substitute for orthodonticsin these patients Instead it must be properly coordinated with orthodontics and other dental treatments to achieve good overallresults Dramatic progress in recent years has made it possible for combined surgical orthodontic treatment to be carried outsuccessfully for patientswith a severe dentofacial problemof any typeThis case report provides an overviewof the current treatmentmethodology in managing a combination of asymmetrical mandibular prognathism and vertical maxillary excess

1 Introduction

The correction of dentoskeletal malocclusions has always hada threefold goal of achieving functional efficiency structuralbalance and aesthetics [1 2] The physical health of patientswith severe malocclusion may be altered or compromisedin various ways such as inducing masticatory dysfunctionspeech disorders upper airway resistance compromised oralhygiene and temporomandibular joint dysfunction Never-theless above all in a modern society the aesthetic aspectof severe malocclusion with its related psychosocial impactis more important than the associated physical problems[3] The positive effects of having an attractive face on anindividualrsquos mindset are clear in terms of self-confidence andself-respect

In cases of severe malocclusion with dentoskeletal dis-crepancy there are generally only three possible therapeuticoptions early modification of growth orthodontic camou-flage through dental compensation or combined orthodontic

and surgical (orthognathic) repositioning of the jaw bases[1] In recent years an increasing number of patients elect toundergo orthognathic treatment to correct severe malocclu-sion that is not susceptible to a comprehensive orthodonticsolution This case report presents the treatment of an adultgirl with skeletal discrepancies in all three planes of spacesagittal (Class III malocclusion) vertical (vertical maxillaryexcess) and transverse (facial asymmetry)

2 Case Report

An adult female patient with a chronological age of 19years and 4 months and an ectomorphic body type reportedto the Department of Orthodontics Pushpagiri College ofDental Sciences with the chief concern of unattractive facialappearance due to forwardly placed lower jaw and teeth(Figures 1ndash4) Her parents pointed out that she was greatlydissatisfied by her looks There was no relevant familial

2 Case Reports in Dentistry

(a) (b) (c)

Figure 1 Pretreatment face (a) frontal (b) profile and (c) smile

(a) (b)

Figure 2 Pretreatment face (a) oblique and (b) vertical proportions and symmetry

history pertaining to skeletal Class III malocclusion nor anypertinent medical history

21 Clinical Characteristics Extraoral clinical examination infrontal view exhibits the patientrsquos face to be leptoprosopic(oval) paranasal areas were deficient lips were potentiallyincompetent with excessive lower lip vermilion exposureand facial asymmetry was evident with the lower borderof mandible moderately shifted to the right Her growthpattern was predominantly vertical and there was increasedincisor and gingival visibility at smile Examination of verticalfacial proportions (Figure 2) revealed that both her midfacialand lower anterior facial heights were increased whichcorroborates an increased display of teeth and gingiva Lateral

view and oblique view showed pronouncedmandibular prog-nathism with a concave profile an acute nasolabial angle aneverted and hypotonic lower lip reduced labiomental fold along chin-throat length with a well-defined inferior border ofthe mandible and an acute lip-chin-throat angle

Intraorally the molar relationship was Class III with acomplete anterior crossbite along with a reverse overjet of2mm (Figure 3) There was generalized interdental spacingamongst her anterior teeth and the incisors were flared com-bined with an anterior open bite These characteristics maypoint to a large tongue A lower dental midline discrepancywas present due to mandibular shift to the right She hadrecently undergone endodontic treatment for her lower leftfirst molar

Case Reports in Dentistry 3

(a) (b)

(c)

Figure 3 Pretreatment occlusion (a) right (b) left and (c) front

(a) (b)

Figure 4 Pretreatment (a) upper and (b) lower arch

Pretreatment radiographic records included lateral andposteroanterior (PA) cephalograms and orthopantomogram(OPG) (Figures 5-6) Cephalometric analysis (Table 1)revealed a Class III skeletal base with mandibular prog-nathism increased maxillary skeletal and dental heightincreased vertical chin height and upper anterior proclina-tion with compensatory lower anterior retroclination

22 Treatment Plan After a joint clinic discussion with theDepartment of Oral and Maxillofacial Surgery PushpagiriCollege of Dental Sciences Le Fort I maxillary impactionin combination with mandibular setback by bilateral sagittalsplit osteotomy (BSSO) with presurgical and postsurgicalorthodontics was planned in order to achieve facial aestheticsand a functionally optimum occlusion During BSSO anasymmetrical setback with more orientation to the left was

planned in order to correct the shift of the lower jaw andmidline Vertical reduction genioplasty for correction of thechin was considered subjected to the changes at the time ofsurgery or as a secondary procedure Lower lip augmentationto reduce the thickness and vermillion display along withrhinoplasty later was planned if needed after thoroughposttreatment evaluationTherapeutic extractions of all thirdmolars were to be done prior to surgery

23 Presurgical Orthodontics After initial restorative andprophylactic measures presurgical orthodontics was begunwith 002210158401015840 times002810158401015840 Roth preadjusted edgewise prescriptionappliance Intra-arch levelling and aligning were achievedand spaces were consolidated in both the arches To achievesufficient decompensation and ideal maxillary incisor incli-nation therapeutic extractions of upper first premolars were


(a) (b)

Figure 5 Pretreatment (a) lateral and (b) PA cephalograms

Table 1 Cephalometrics for orthognathic surgery

Variable Clinical norm Pretreatment Posttreatment DescriptionHorizontal (skeletal)

N-A-Pg 26 plusmn 51mm minus2∘ 7∘ Convexity

N-A minus20 plusmn 37mm 5mm 9mm Maxillary position

N-B minus69 plusmn 43mm 13mm 5mm Mandibular position

N-Pg minus65 plusmn 51mm 15mm 10mm Position of chin

Vertical (skeletal and dental)

N-ANS 500 plusmn 24mm 56mm 51mm Anterior upper facial height

ANS-Gn 613 plusmn 33mm 76mm 72mm Anterior lower facial height

PNS-N 506 plusmn 22mm 56mm 51mm Posterior upper facial height

MP-HP 242 plusmn 5∘ 31∘ 28∘ Angle of mandibular to horizontal plane

1U-NF 275 plusmn 17mm 29mm 27mm Distance of incisal edge of 1U to palatal plane

1L-MP 408 plusmn 18 mm 46mm 46mm Distance of incisal edge of 1L to mandibular plane

6U-NF 230 plusmn 13mm 29mm 25mm Distance of mesial cusp of 6u to palatal plane

6L-MP 321 plusmn 19mm 29mm 30mm Distance of mesial cusp of 6l to mandibular planeMaxilla and mandible

ANS-PNS 526 plusmn 35mm 53mm 54mm Maxillary length

Ar-Go 468 plusmn 25mm 58mm 57mm Ramus length

Go-Pg 743 plusmn 58mm 86mm 79mm Mandibular length

B-Pg 72 plusmn 19mm 6mm 9mm Chin prominence

Ar-Go-Gn 1220 plusmn 69∘ 144∘ 138∘ Gonial angle

Dentition

A-B minus04 plusmn 25∘

minus105∘ 0∘ Distance of A to B on occlusal plane

Max1-NF 1125 plusmn 53∘ 136∘ 121∘ Angle of axis of 1U to palatal plane

Mand1-MP 959 plusmn 57∘ 86∘ 84∘ Angle of axis of 1L to mandibular plane


Figure 6 Pretreatment orthopantomogram (OPG)

(a) (b) (c)

Figure 7 Presurgical face (a) frontal (b) profile and (c) smile

(a) (b)

Figure 8 Presurgical face (a) oblique and (b) vertical proportions and symmetry

done which was followed by controlled retraction of max-illary anterior segment with loop mechanics Maxillary andmandibular arches were aligned up to 002110158401015840 times 002510158401015840stainless steel wire and arch compatibility was establishedbetween upper and lower arches (Figures 7 8 9 and 10)In due course upper and lower third molars were extracted

to facilitate the orthognathic surgery At the end of thepresurgical phase radiographic records were repeated andcompared (Figures 11 and 12)

In order to assess the practical considerations and furtherpredict the results of the planned surgical approach cephalo-metric prediction tracing was done both manually using the


(a) (b)

(c)

Figure 9 Presurgical occlusion (a) right (b) left and (c) front

(a) (b)

Figure 10 Presurgical (a) upper and (b) lower arch

template method and with computer image prediction Intemplate method skeletal profiles of maxilla and mandiblewere traced on an acetate paper Profile tracing was thenduplicated and transferred to a thin cardboard This outlinewas then cut to produce a cardboard template From thesetemplates trial sections were made until desirable locationand amount for osteotomy were found The cut sectionsof both maxilla and mandible were then fitted back tothe tracing in desired occlusal relation Finally soft tissueoutline can be traced in regard to the reference ratios andthe probable postsurgical changes were checked [4] Latercomputer-based analysis was done wherein cephalometriclandmarks were digitized and the surgical repositioning wasmonitorized Measurements calculations and analyses wereperformed using Facad (Ilexis AB Sweden) The obtained

data was incorporated into prediction algorithms to providesingle-line profile drawings predicting the final treatmentgoal (Figure 13) In the Maxilla a 5mm of superior repo-sitioning along with an advancement of about 3mm wassufficient enough to reduce the gingival showand improve thepara-nasal hollowing In Mandible 8mm of setback broughtabout good posterior intercuspation with an aestheticallypleasing profile

Cast prediction or model surgery and fabrication ofocclusal splints for use at surgery were the next steps in theplanning sequence Since both jaws were to be repositionedthe maxillary and mandibular dental casts were mounted ona semiadjustable articulator with the aid of facebow transfer(Figure 14(a)) and bite registration taken with the patientrsquosjaws in the retruded contact position or centric relation


(a) (b)

Figure 11 Presurgical (a) lateral and (b) PA cephalograms

Figure 12 Presurgical orthopantomogram (OPG)

(a) (b)

Figure 13 (a) Digital simulation of intended jaw movements (blue) and (b) predicted photo


(a) (b) (c)

Figure 14 (a) facebow transfer and model surgery with (b) intermediate and (c) final occlusal splints

(a) (b) (c)

Figure 15 (a) Le Fort Imaxillary osteotomy (b) rigid fixationwith bone plates and intermediate occlusal splint and (c) BSSOwithmandibularsetback and final occlusal splint

Model simulation of the anticipated surgical movement wasperformed next The individual dental casts were reposi-tioned simulating the movements of the jaws as depicted bythe manual and digital prediction An intermediate acrylicocclusal splint was fabricated after the maxillary cast wasrepositioned on the articulator (Figure 14(b)) The mandibu-lar cast was then repositioned to oppose the maxillary castsimulating the final position of the jaws at surgery Basedon this position the final occlusal splint was then fabricated(Figure 14(c))

24 Surgical Procedure Le Forte I maxillary impaction wascarried out initially as decided with utilization of modifiedhypotension to decrease blood loss in anaesthesia [5] Themaxilla was repositioned 5mm superiorly and 3mm ante-riorly (Figure 15(a)) Bilateral sagittal split osteotomy withshort lingual split was carried out using surgical saws and themandible was set back by 8mm (Figure 15(c)) after compen-sating for the mild autorotation due to maxillary impaction[6 7]The BSSO setback was performed asymmetrically withmore orientation to the left so as to aid in the correctionof mandibular shift thereby improving facial and dental

symmetry Rigid type fixations were used in both jaws usingfour-hole miniplates and screw on both sides (Figure 15(b))Genioplasty was to be performed as a secondary procedureif needed after thorough evaluation of postsurgical healingIntermaxillary guiding elastics were engaged on the archwirehooks for 14 days during the immediate postoperative phaseThe patient was followed up closely after the procedure andwas guided to perform opening and lateral jaw movements

25 Postsurgical Orthodontics Active orthodontic treatmentwas resumed 4 weeks after surgery when a satisfactoryrange of jaw movement was achieved and there was goodbone healing and tolerance The goal was to achieve idealocclusal relationships in terms of canine class molar classoverjet overbite and coincidence of the dental midlinesDuring postsurgical orthodontics arch wires were sequen-tially changed from 001710158401015840 times 002510158401015840 NiTi to 001910158401015840 times 002510158401015840SS wires Closure of any residual diastema was achievedand intercuspation was perfected by segmental settling withshort inter-maxillary elastics In the course of the postsurgicalphase the only eventful occurrence was with her mandibularright bone plate loosening and the upper left bone plate


(a) (b) (c)

Figure 16 Posttreatment face (a) frontal (b) profile and (c) smile

(a) (b)

Figure 17 Posttreatment face (a) oblique and (b) vertical proportions and symmetry

screw getting exposed into the vestibule both of which wereremoved in the due course After seven months of interven-tion fixed appliances were debonded (Figures 16 17 18 and19) and posttreatment retention phase was initiated with bothfixed retainers and removable retention plates Posttreatmentradiographs were taken (Figures 20-21) and evaluated fortreatment changes by superimposition (Figure 22) Pre- andposttreatment cephalometric values have been compared inTable 1 The overall treatment duration was 34 months

3 Discussion

Establishing common objectives and expectations concern-ing the outcome of proposed surgical orthodontic therapy is

a crucial part of the treatment planning process Therefore amultidisciplinary team approach in recommending two-jawsurgery to the patient such as in this case requires clinicaljudgment and experience After thorough evaluation thepresurgical phase of orthodontic treatment was initiated withthe aim to achieve ideal inter- and intra-arch coordinationwith each tooth in the correct position always bearing inmind the goals of the subsequent surgical repositioning Inthis case both manual and digital cephalometric predictionswere employed at the end of presurgical phase Predictionsof changes in the frontal view still are artwork rather thanscience but current computer prediction programs do agood job in predicting profile changes [8] Though computersimulations are only as good as the algorithms on which theyare based these have considerably improved in recent years


(a) (b)

(c)

Figure 18 Posttreatment occlusion (a) right (b) left and (c) front

(a) (b)

Figure 19 Posttreatment (a) Upper and (b) lower arch

allowing reliable adjustment of the hard-to-soft tissue ratiosHowever one drawback could be that these ratios often donot take into account potential long-term skeletal relapse

Bimaxillary osteotomy has a greater potential to decreaseor increase anterior face height compared to one-jawosteotomies and the soft tissuesmay be affected by relaxationor stretching In most patients such as in this case thisis performed because of an excessive vertical dimension ofthe lower face [9] These surgical movements have beenshown to have excellent postsurgical stability when upwardand forward movements of the maxilla are combined withlower border ramus osteotomies thus preventing excessiveforward rotation of the mandible [10 11]The relative amountof maxillary advancement and mandibular setback shouldalso be planned according to the desired profile changesand should take into account the extent to which the soft

tissues follow the hard tissue relapse in the long term Inthis case since there was an evident paranasal hollowingit was decided to advance the maxilla marginally to obtainfacial fullness and as well limit the degree of mandibularsetback within stable limits During mandibular osteotomya differential setback was performed which significantlyimproved the facial symmetry Previous studies have shownthat asymmetric setback of the mandible with intraoperativemanual positioning of the condyle was favourable and doesnot significantly change the articular disc position in thecondylar fossa [12 13] During the post surgical phase therewas notable change in the soft tissue contour of the noseand lip If necessary both reduction cheiloplasty to addressincreased anterior projection vertical lip height and wet-vermilion show and rhinoplasty for refinement of the tip andlateral nasal walls were to be done along with genioplasty


(a) (b)

Figure 20 Posttreatment (a) lateral and (b) PA cephalograms

Figure 21 Posttreatment orthopantomogram (OPG)

Figure 22 Cephalometric superimposition before (black) and after(red)

as a secondary procedure Cheiloplasty will address anincreased anterior projection vertical lip height and wet-vermilion show Rhinoplasty can be done for refinement of

the nose tip and lateral nasal walls and genioplasty withlateral shift can address the chin asymmetry [14]

Postsurgical orthodontics was done in this case for 7months and it primarily involves finalization of the occlusionand retention The duration of the final orthodontic phasedepends on the degree of preparation achieved during presur-gical treatment [15] It is however important to stress thatgood dental retention contributes to maintaining the finalocclusion that was achieved surgically guaranteeing occlusalstability which will surely have positive repercussions on thefinal hard tissue stability

Acknowledgment

The authors would like to thank Dr Suja Mathew ReaderDepartment of Prosthodontics for her valuable assistance

References

[1] J P Reyneke Essentials of Orthognathic Surgery QuintessenceCarol Stream Ill USA 2003

[2] H L Legan ldquoOrthodontic considerations of orthognathic sur-geryrdquo in Principles of Oral and Maxillofacial Surgery L JPeterson Ed vol 3 pp 1237ndash1278 Lippincott Philadelphia PaUSA 1992

[3] Z Liu C McGrath and U Hagg ldquoThe impact of malocclusionorthodontic treatment need on the quality of life a systematicreviewrdquo Angle Orthodontist vol 79 no 3 pp 585ndash591 2009

[4] W R Proffit andDM Sarver ldquoTreatment planning optimizingbenefit to the patientrdquo in Contemporary Treatment of Dentofa-cial Deformity W R Proffit R P White Jr and D M SarverEds pp 172ndash244 Mosby-Year Book St Louis Mo USA 2003

[5] J Shepherd ldquoHypotensive anaesthesia and blood loss in orthog-nathic surgeryrdquo Evidence-Based Dentistry vol 5 no 1 article16 2004 Comment on British Journal of Oral andMaxillofacialSurgery vol 39 no 2 pp 138ndash140 2001


[6] B N Epker ldquoModifications in the sagittal osteotomy of themandiblerdquo Journal of Oral Surgery vol 35 no 2 pp 157ndash1591977

[7] M S Leonard P Ziman R Bevis G Cavanaugh M T Speideland F Worms ldquoThe sagittal split osteotomy of the mandiblerdquoOral Surgery Oral Medicine and Oral Pathology vol 60 no 5pp 459ndash466 1985

[8] J D Smith P M Thomas and W R Proffit ldquoA comparisonof current prediction imaging programsrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 125 no 5 pp527ndash536 2004

[9] G Jakobsone A Stenvik and L Espeland ldquoSoft tissue responseafter Class III bimaxillary surgeryrdquoThe Angle Orthodontist vol83 no 3 pp 533ndash539 2013

[10] W R Proffit C Phillips and T A Turvey ldquoStability after sur-gical-orthodontic corrective of skeletal Class IIImalocclusionmdash3 Combined maxillary and mandibular proceduresrdquo TheInternational Journal of Adult Orthodontics and OrthognathicSurgery vol 6 no 4 pp 211ndash225 1991

[11] F Costa M Robiony S Sembronio F Polini and M PolitildquoStability of skeletal Class IIImalocclusion after combinedmax-illary and mandibular proceduresrdquoThe International Journal ofAdult Orthodontics and Orthognathic Surgery vol 16 no 3 pp179ndash192 2001

[12] S-H Baek T-K Kim and M-J Kim ldquoIs there any differencein the condylar position and angulation after asymmetricmandibular setbackrdquoOral Surgery Oral Medicine Oral Pathol-ogy Oral Radiology and Endodontology vol 101 no 2 pp 155ndash163 2006

[13] M Kawakami K Yamamoto T Inoue A Kajihara M Fuji-moto and T Kirita ldquoDisk position and temporomandibularjoint structure associated withmandibular setback inmandibu-lar asymmetry patientsrdquo Angle Orthodontist vol 79 no 3 pp521ndash527 2009

[14] B P Maloney M E Tardy Jr D M Toriumi and D A HechtldquoAesthetic surgery of the liprdquo in Facial Plastic and ReconstructiveSurgery Ed D Ira Papel Ed pp 459ndash468 Thieme MedicalPublishers New York NY USA 3rd edition 2009

[15] F Luther D OMorris and K Karnezi ldquoOrthodontic treatmentfollowing orthognathic surgery how long does it take and whyA retrospective studyrdquo Journal of Oral andMaxillofacial Surgeryvol 65 no 10 pp 1969ndash1976 2007

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(a) (b) (c)

Figure 1 Pretreatment face (a) frontal (b) profile and (c) smile

(a) (b)

Figure 2 Pretreatment face (a) oblique and (b) vertical proportions and symmetry

history pertaining to skeletal Class III malocclusion nor anypertinent medical history

21 Clinical Characteristics Extraoral clinical examination infrontal view exhibits the patientrsquos face to be leptoprosopic(oval) paranasal areas were deficient lips were potentiallyincompetent with excessive lower lip vermilion exposureand facial asymmetry was evident with the lower borderof mandible moderately shifted to the right Her growthpattern was predominantly vertical and there was increasedincisor and gingival visibility at smile Examination of verticalfacial proportions (Figure 2) revealed that both her midfacialand lower anterior facial heights were increased whichcorroborates an increased display of teeth and gingiva Lateral

view and oblique view showed pronouncedmandibular prog-nathism with a concave profile an acute nasolabial angle aneverted and hypotonic lower lip reduced labiomental fold along chin-throat length with a well-defined inferior border ofthe mandible and an acute lip-chin-throat angle

Intraorally the molar relationship was Class III with acomplete anterior crossbite along with a reverse overjet of2mm (Figure 3) There was generalized interdental spacingamongst her anterior teeth and the incisors were flared com-bined with an anterior open bite These characteristics maypoint to a large tongue A lower dental midline discrepancywas present due to mandibular shift to the right She hadrecently undergone endodontic treatment for her lower leftfirst molar


(a) (b)

(c)


(a) (b)







(a) (b)






















Dentition







(a) (b) (c)


(a) (b)






(a) (b)

(c)


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(a) (b)



3 Discussion




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(c)


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(a) (b)







Acknowledgment


References
























Biomaterials












Journal of




















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(c)


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Dentition







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3 Discussion




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(c)


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(a) (b)







Acknowledgment


References
























Biomaterials












Journal of




















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3 Discussion




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Acknowledgment


References
























Biomaterials












Journal of





















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3 Discussion




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Acknowledgment


References
























Biomaterials












Journal of




















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3 Discussion




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Acknowledgment


References
























Biomaterials












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Acknowledgment


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Acknowledgment


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Case Report Combined Orthodontic and Surgical Approach in...

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