Combined Orthodontic Surgical Treatment of a Severe Class III Dentofacial Deformity Case Report

CLINICAL CASE Dent. Med. Probl. 2007, 44, 1, 81 86 ISSN 1644 387X Copyright by Silesian Piasts University of Medicine in Wrocław and Polish Stomatological Association WOJCIECH PAWLAK, BARBARA WARYCH, HENRYK KACZKOWSKI Combined Orthodontic Surgical Treatment of a Severe Class III Dentofacial Deformity Case Report Leczenie ortodontyczno chirurgiczne złożonej wady szkieletowej III klasy opis przypadku Department of Maxillofacial Surgery, Silesian Piasts University of Medicine in Wrocław, Poland Abstract The Class III skeletal deformity may be due to a horizontal excess of the mandible, an antero posterior deficiency of the maxilla, or both. In patients with a severe Class III skeletal discrepancies, growth modification and orthodontic camouflage, not only can compromise the aesthetics but also can jeopardize the stability of the results. In such cases the combined surgical orthodontic correction is considered the best treatment modality. Simultaneous mobilization of the maxilla and mandible is often needed to correct severe Class III dentofacial deformities. In the treatment of these malformations it has been shown that the team approach is very important to achieve high quality functional and aesthetical results. Most cases of Class III dentofacial deformities require orthodontic preparation in order to align dental arches and decompensate anterior teeth. This permits optimal positioning between dental arches after bimaxillary movement. The authors present a case of an 18 year old female patient with a severe Class III dentofa cial deformity interdisciplinary treated using orthodontics and orthognathic surgery. They demonstrate the stages of planning and discuss surgical techniques and results obtained (Dent. Med. Probl. 2007, 44, 1, 81 86). Key words: skeletal Class III malocclusion, orthognathic surgery, multidisciplinary treatment. Streszczenie Wady szkieletowe klasy III mogą być spowodowane nadmiernym doprzednim wzrostem żuchwy, niedorozwojem szczęki lub być kombinacją obu tych zaburzeń. Leczenie pacjentów z nasilonymi wadami szkieletowymi klasy III przez modyfikację niekorzystnego wzorca wzrostu lub kamuflaż ortodontyczny może mieć niekorzystny wpływ na estetykę i być przyczyną nawrotu. W tych przypadkach metodą z wyboru jest zespołowe leczenie ortodontyczno chirurgiczne. Zabiegi chirurgiczne korygujące złożone wady szkieletowe klasy III wymagają często jednoczaso wego uruchomienia szczęki i żuchwy. W leczeniu tych zniekształceń wykazano, że tylko ścisła współpraca chirur ga szczękowego i ortodonty może zapewnić trwałą poprawę funkcji i estetyki. Większość przypadków wad gna tycznych klasy III wymaga uprzedniego przygotowania ortodontycznego polegającego na wyrównaniu łuków zębowych i dekompensacji zębów przednich. Pozwala to na takie przesunięcie odłamów kostnych szczęki i żuch wy, aby uzyskać optymalne warunki zgryzowe. Autorzy przedstawili przypadek 18 letniej pacjentki leczonej ze społowo z powodu złożonej wady szkieletowej klasy III, u której zastosowano skojarzone leczenie ortodontyczno chirurgiczne. W artykule opisano etapy planowania zabiegu oraz omówiono techniki operacyjne i wyniki leczenia (Dent. Med. Probl. 2007, 44, 1, 81 86). Słowa kluczowe: wada szkieletowa klasy III, chirurgia ortognatyczna, leczenie zespołowe. The Class III dentofacial deformities may be the result of mandibular prognathism and/or max illary deficiency. In most cases there is normal maxilla and a large mandible with a low mandibu lar plane (SN GoGn) and a normal SNA with SNB greater than 77 degrees. Less frequently, the mandible is normal and there is maxillary horizon tal deficiency with a low SNA and a high or low mandibular plane angle (SN GoGn). There may be a combination of these two possibilities associated with combined maxillary deficiency and mandibu lar excess [1]. Mandibular prognathism is charac terized by elongation of the mandible producing a negative overjet, often with compensatory retro

82 W. PAWLAK, B. WARYCH, H. KACZKOWSKI clination of the lower incisors, and proclination of the upper incisors Prognathic mandible and retrog nathic maxilla result in a typical concave appear ance with excessive antero posterior length of the lower jaw with Angle Class III malocclusion. In addition to these features, the antero posterior deficiency of the maxilla results in flatness of the paranasal areas and cheeks [2 5]. The Class III dentofacial deformities may cre ate both aesthetic concerns and functional prob lems including masticatory insufficiency, peri odontal disease, difficulties in swallowing and tem poromandibular joints problems [6, 7]. The psychosocial impact of a dentofacial deformity on an individual is often paramount. Such a deformity can profoundly affect the quality of life and often leads to discrimination in social interactions [8, 9]. Etiologies of Class III skeletal deformities include heredity and environmental factors. The relative contribution of genetic factor to Class III malocclusions has been the subject of a number of previous studies [10 13]. Its genetic inheritance pattern can be autosomal dominant or autosomal recessive [11]. Among environmental factors which have been suggested as contributory to the development of Class III deformities are enlarged adenoids, nasal blockage, hormonal disturbances, posture and trauma [12]. Proffit et al. [14] in their study estimated that the prevalence of skeletal Class III malocclusion in the USA population was 0.6%, about 21% of which were severe enough to be disfiguring and required surgery. Severe mandibular prognathism requiring combined orthodontic surgical treatment is estimated to occur in 1% of the Norwegian pop ulation [15]. In patients with a severe Class III skeletal dis crepancies, growth modification and orthodontic camouflage alone would not produce a satisfacto ry functional and aesthetic result. In such cases the combined surgical orthodontic correction is con sidered the best treatment modality. Orthodontics is done first to align the teeth, followed by surgery to align the jaws. A primary goal of presurgical orthodontic treatment is to eliminate all existing dental com pensation. The teeth are aligned in their optimal positions in arch so that an acceptable occlusion can be produced at surgery [4, 6, 7, 16, 17]. After preoperative orthodontic preparation surgery is done to re align the jaw bases. Historically, the ramus osteotomy for mandibular setback used to be the standard proce dure for skeletal Class III correction [8, 15, 18]. However, with improvements in surgical tech niques and with the documentation that better aes thetics and stability can be achieved with com bined maxillary and mandibular surgery, bimaxil lary procedures are now the commonest surgery in skeletal Class III correction [2, 3, 5]. At first the planned surgery is simulated on tracing sheets on the lateral cephalogram. Then the desired situation is transferred to the articulator by making the cuts in the plaster models similar to those planned at the patient [4, 17]. The bilateral sagittal split ramus osteotomy for mandibular setback and maxillary Le Fort I osteotomy for maxillary advancement are the most frequently used methods for surgical correction of skeletal Class III deformities [2, 5]. Following surgical alignment of the jaws, the finishing treatment are applied to the teeth through postoperative orthodontics. This may involve sim ple alignments or more extensive compensation for minor relapse or overcorrections. This paper is to present a patient with a severe mandibular prognathism accompanied by a maxil lary deficiency who underwent simultaneous two jaw surgery combined with orthodontic treatment. Case Report An 18 year old female patient presented to the Maxillofacial Clinic of Wrocław Medical University Hospital with a chief complaint of too prominent lower jaw. The patient was concerned about her appearance and the major reason for seeking treatment was to improve her facial aes thetics.the abnormal forward growth of the mandible was first notice at the age of 10 years and had gradually become more prominent and had remained stable since the age of 17 years. The patient s mother had a similar skeletal Class III malocclusion. The patient had undergone tonsil lectomy approximately 1 year earlier. Her medical history was noncontributory. Clinical Examination Clinical examination revealed the following: 1) extraoral frontal view: slight lower face asym metry with chin deviation toward the left side, increased chin prominence, decreased exposure of upper lip vermilion, flat paranasal areas, decreased squarness of the face. (Fig. 1A); 2) extraoral pro file view: increased chin prominence with obtuse labio mental fold, concave profile, lower lip ever sion, increased neck chin line (Fig. 2A); 3) intrao ral molar and canine Class III malocclusion on both sides, retroclined lower incisors and proclined upper incisors, anterior cross bite, narrow maxil lary dental arch, coincidence of the maxillary den

Severe Dentofacial Deformity 83 tal midline with the facial midline, 2 mm deviation of the mandibular dental midline toward the left side, good oral hygiene and sound periodontal sup port; 4) functional the interincisal distance at maximum mouth opening was 44 mm, there was no limitation in mandibular protrusive and lateral movements, temporomandibular joints functioned without any signs and symptoms; 5) pantomo graphic X ray revealed partially erupted lower wis dom teeth and deeply impacted upper wisdom teeth; 6) lateral cephalometric X ray revealed maxillary deficiency (SNA = 78.0 ) and mandibu lar protrusion (SNB = 86.7 ), suggesting the typi cal Class III skeletal relationship with ANB angle of 8,0. It shows the long mandible with the two rather streached gonial angles. The vertical dimen sion for this patient was within normal limits (Fig. 4A, Tab. 1) A B Fig. 1. A) Presurgical face frontal view photograph after orthodontic decompensation; B) face frontal view photo graph after orthodontic orthognathic treatment Ryc. 1. A) Fotografia twarzy en face przed leczeniem operacyjnym po dekompensacji ortodontycznej; B) fotografia twarzy en face po leczeniu ortodontyczno chirurgicznym A B Fig. 2. A) Presurgical face lateral view photograph after orthodontic decompensation shows typical profile features for Class III skeletal deformities; B) profile view photograph after orthodontic surgical treatment reveals improve ment in facial profile Ryc. 2. A) Fotografia boczna twarzy przed leczeniem operacyjnym po dekompensacji ortodontycznej wykazuje w profilu typowe cechy wady szkieletowej III klasy; B) fotografia boczna twarzy po leczeniu ortodontyczno chirur gicznym wykazuje znaczną poprawę profilu twarzy

84 W. PAWLAK, B. WARYCH, H. KACZKOWSKI Treatment Plan On the basis of clinical examination and cephalometric analysis a skeletal Class III maloc clusion was diagnosed and the following treatment plan was proposed to correct this deformity: 1) Removal of partially erupted lower wisdom teeth. Because of the deep impaction of upper wisdom teeth it was decided to remove them after maxil lary Le Fort I down fracture; 2) presurgical ortho dontics to level and align of the dental arches with elimination of dental compensations; 3) simultane ous bimaxillary osteotomies: Le Fort I osteotomy to advance the maxilla and bilateral sagittal split ramus osteotomy to set back the mandible; 4) post surgical orthodontic treatment to refine the occlu sion and retention after debanding. Treatment Progress Partially impacted lower wisdom teeth were removed and fixed appliances were placed to start preoperative orthodontics. All existing dental compensations were eliminated by proclination of the mandibular incisors and retroclination of the maxillary incisors. Both dental arches were aligned and interarch compatibility was estab lished (Fig. 3A, Fig. 4A). At the age of 19 years 4 months corrective bimaxillary surgery was performed. The maxilla was osteotomized and advanced 5 mm by the con ventional Le Fort I procedure. [19] After down fracture of the maxilla deeply impacted upper wis dom teeth were removed. The occlusal splint con structed during mock surgery on the articulator was applied to determine the planned position of the maxilla. The maxilla was fixed in new position with four titanium miniplates and sixteen mono cortical 2.0 mm screws. 8 mm of mandibular set back was performed using a bilateral sagittal split ramus osteotomy [18] and osteotomized fragments were fixed with three positional bicortical 2.0 mm titanium screws on each side. Maxillomandibular fixation was maintained for 10 days after surgery and then was changed to training elastics to control postoperative occlusion. Postsurgical orthodontic treatment consisted of settling and detailing the occlusion with adjust ing archwires and elastics. After 8 months post surgery, the patient was debonded. Maxillary retainer was applied for retention and lingual retainer was attached in the mandible between the canines. Treatment Results The postreatment extraoral photographs show significant improvement in the frontal and profile facial views (Fig. 1B, Fig. 2B). Facial symmetry was achieved and the soft tissue profile improved with reduced chin and lower lip prominence, increased exposure of upper lip vermilion, short ened chin neck line and increased paranasal full ness. The intraoral postoperative photograph reveals class I canine and molar relationships on both sides and normal overjet and overbite (Fig. 3B). All the functional movements of the mandible were without symptoms. The cephalo metric values were brought into the normal range (Fig. 4B, Tab. 1). Fig. 3. A) Presurgical occlusal view photograph after dental decompensation shows reverse overjet and Class III canine and molar relationships; B) occlusal view photograph after orthodontic surgical treatment reveals class I canine and molar relationships on both sides and normal overjet and overbite Ryc. 3. A) Fotografia zgryzu przed zabiegiem operacyjnym po dekompensacji zębowej wady, z widocznym odwrot nym nagryzem poziomym i zębową III klasą Angle a w zakresie kłów i pierwszych trzonowców; B) fotografia zgryzu po leczeniu ortodontyczno chirurgicznym wykazuje obustronną I klasę Angle a w zakresie kłów i pierwszych trzonowców oraz prawidłowy nagryz poziomy i pionowy

Severe Dentofacial Deformity 85 Fig. 4. A) Presurgical lateral cephalo metric radiograph after dental decom pensation with typical features for Class III skeletal deformity; B) post surgery lateral cephalometric radi ograph with normal range of cephalo metric values Ryc. 4. A) Radiogram profilowy głowy przed zabiegiem operacyjnym po de kompensacji zębowej wady z typowy mi cechami dla wad szkieletowych III klasy; B) radiogram profilowy głowy po zabiegu operacyjnym z prawidłowy mi wartościami pomiarów cefalome trycznych Table 1. Selected cephalometric measurements according to Segner and Hasund analysis [20] before and after surgery Tabela 1. Wybrane przed i pooperacyjne pomiary cefalometryczne wg analizy Segnera i Hasunda [20] Measurements Presurgery Norm Postsurgery (Pomiary) (Przedoperacyjne) (Norma) (Pooperacyjne) SNA 78.0 82.0 ± 3.0 83.8 SNB 86.7 80.0 ± 3.0 82.2 ANB 8.0 2.0 ± 2.0 0.6 GntgoAr 134.5 122.0 ± 7.0 131.7 NL NSL 9.1 8.0 ± 4.0 9.2 ML NSL 31.1 28.0 ± 5.0 31.6 ML NL 22.1 20.0 ± 7.0 22.4 H 0.9 9.0 ± 3.0 8.1 Wits 15 mm 0.0mm ± 2.0 3.4 mm Index 76.7% 80.0% ± 7.0 73.6% With the advances of the orthognathic surgery techniques, patients with skeletal Class III dento facial deformities can be benefited from a bimax illary osteotomies. Simultaneous mobilization of the entire maxilla and mandible is a versatile pro cedure that can be used to correct multiple dento facial deformities including sagittal, vertical and transverse dysplasias of the maxilla and mandible. With proper preoperative assessment and postop erative care, the discomfort and potential compli cations from the surgery can be reduced to a min imum. This case illustrates the importance of prop er diagnosis and treatment planning. A team approach with the orthodontist and maxillofacial surgeon is the best way to achieve good and stable results. This patient who presented with a severe skeletal Class III malocclusion was successfuly treated with combined multidisciplinary approach and satisfactory improvement was achieved regarding aesthetics, function and occlusion. The correction was achieved with a notable improve ments in the patient s self esteem. References [1] JACOBSON A., EVANS W., PRESTON C., SADOWSKY P.: Mandibular prognathism. Am. J. Orthod. 1974, 66, 140 171. [2] BAILEY L., PROFFIT W., WHITE R.: Trends in surgical treatment of Class III skeletal relationship. Int. J. Adult Orthod. Orthognath. Surg. 1995, 10, 108 118. [3] BILL J., WÜRZLER K., REINHART E., BÖHM H., EULERT S., REUTHER J.: Bimaxillary osteotomies with and without condyle positioning long term follow up 1981 2002. Mund Kiefer GesichtsChir. 2003, 7, 345 350. [4] WARYCH B., SEEGER D.: Ortodontyczna kwalifikacja do zabiegów chirurgicznych. Wroc. Stomat. 1998/1999, 99 103.

86 W. PAWLAK, B. WARYCH, H. KACZKOWSKI [5] PROFFIT W., PHILLIPS C., TURVEY T.: Stability after surgical orthodontic correction of skeletal Class III malocclu sion. III. Combined maxillary and mandibular procedures. Int. J. Adult Orthod. Orthogn. Surg. 1991, 6, 211 225. [6] TOMASZEWSKI T., CECHERZ Z., BUCZARSKI B., DOBIEŻYŃSKA B.: Prognacja żuchwy: leczenie ortodontyczno chirur giczne. Ortod. Współ. 2000, 2, 121 124. [7] DONIEC ZAWIDZKA I., BIELAWSKA H., KOWALCZYK R., PISKORSKI D.: Leczenie ortodontyczno chirurgiczne pacjen tów z progenią doświadczenia własne. Czas. Stomat. 2004, 57, 737 745. [8] PAWLAK W.: Odległe wyniki operacyjnego leczenia zniekształceń żuchwy w materiale Katedry i Kliniki Chirurgii Szczękowo Twarzowej AM we Wrocławiu. Praca doktorska, Akademia Medyczna Wrocław 1990. [9] ĆWIORO F.: Odległe wyniki leczenia chirurgicznego progenii wg zmodyfikowanej metody Dal Ponta w ocenie operowanych pacjentów. Czas. Stomat. 1977, 30, 415 419. [10] WOLFF G., WIENKER T., SANDER H.: On the genetics of mandibular prognathism: analysis of large European noble families. J. Med. Gen. 1993, 30, 112 116. [11] HUBERT E., MIDRO A.: Badania genetyczne w wybranych zespołach z prognatyzmem żuchwy. Czas. Stomat. 1997, 50, 823 827. [12] MOSSEY P., ORTH M.: The heritability of malocclusion: part 2. The influence of genetics in malocclusion. Br. J. Orthod. 1999, 26, 195 203. [13] BUI C., KING T., PROFFIT W., FRAZIER BOWERS S.: Phenotypic characterization of class III patients. A necessary background for genetic analysis. Angle Orthod. 2006, 76, 564 569. [14] PROFFIT W., FIELDS H., MORAY L.: Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. Int. J. Adult Orthod. Orthogn. Surg. 1998, 13, 97 106. [15] TORNES K., LYBERG T.: Surgical correction of mandibular prognathism in Norway, 1975 1984. A national survey. Acta Odontol. Scand. 1987, 45, 87 94. [16] DOWNAROWICZ P., ANTOSZEWSKA J., KAWALA B., PAWLAK W., MATTHEWS BRZOZOWSKA T.: Leczenie ortodontycz no chirurgiczne pacjentów z prognacją żuchwy. Przegląd piśmiennictwa i opis przypadku. Magazyn Stomat. 2006, 16, 12, 74 77. [17] PAWLAK W., WARYCH B., KACZKOWSKI H., KOMORSKI A.: Doświadczenia własne w leczeniu wad gnatycznych III klasy metodą jednoczasowej osteotomii szczęki i żuchwy. Streszczenia referatów V Kongres Polskiego Tow. Chir. Jamy Ustnej i Chir. Szczękowo Twarzowej, Lublin 2005, 130 131. [18] ĆWIORO F., KACZKOWSKI H.: Operacyjne leczenie zniekształceń żuchwy według metody Obwegesera Dal Ponta w polskich ośrodkach chirurgicznych. Czas. Stomat. 1984, 37, 985 987. [19] BELL W., MANNAI C., LUHR H.: Art and science of the Le Fort I downfracture. Int. J. Adult Orthod. Orthogn. Surg. 1988, 3, 23 52. [20] SEGNER D., HASUND A.: Indywidualna kefalometria. Med Tour Press International, Warszawa 1996. Address for correspondence: Wojciech Pawlak Department of Maxillofacial Surgery Silesian Piasts University of Medicine Chałubińskiego 5 50 368 Wrocław Poland Tel.: +48 71 748 22 61 E mail: wpawlak@mfs.am.wroc.pl Received: 13.02.2007 Revised: 21.02.2007 Accepted: 21.02.2007 Praca wpłynęła do Redakcji: 13.02.2007 r. Po recenzji: 21.02.2007 r. Zaakceptowano do druku: 21.02.2007 r.