Volume 30 Issue 3 Article 5
2018
Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite
Wei-Chih Hung Department of Dentistry, Songshan Branch, Tri-Service General Hospital, Taipei, Taiwan; Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan
Wei-Cheng Lee Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan
Yi-Chieh Chen Chicing Plastic Clinic, Taipei, Taiwan
Lih-Juh Chou Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan
Chung-Hsing Li Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General FHospital,ollow this Taipei, and additional Taiwan" works at: https://www.tjo.org.tw/tjo
Part of the Orthodontics and Orthodontology Commons See next page for additional authors
Recommended Citation Hung, Wei-Chih; Lee, Wei-Cheng; Chen, Yi-Chieh; Chou, Lih-Juh; Li, Chung-Hsing; and Chen, Gunng-Shinng (2018) "Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite," Taiwanese Journal of Orthodontics: Vol. 30 : Iss. 3 , Article 5. DOI: 10.30036/TJO.201810_31(3).0005 Available at: https://www.tjo.org.tw/tjo/vol30/iss3/5
This Case Report is brought to you for free and open access by Taiwanese Journal of Orthodontics. It has been accepted for inclusion in Taiwanese Journal of Orthodontics by an authorized editor of Taiwanese Journal of Orthodontics. Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite
Authors Wei-Chih Hung, Wei-Cheng Lee, Yi-Chieh Chen, Lih-Juh Chou, Chung-Hsing Li, and Gunng-Shinng Chen
This case report is available in Taiwanese Journal of Orthodontics: https://www.tjo.org.tw/tjo/vol30/iss3/5 Case Report
Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite
1,3 3 2 3 3 3 Wei-Chih Hung, Wei-Cheng Lee, Yi-Chieh Chen, Lih-Juh Chou, Chung-Hsing Li, Gunng-Shinng Chen 1 Department of Dentistry, Songshan Branch, Tri-Service General Hospital, Taipei, Taiwan 2 Chicing Plastic Clinic, Taipei, Taiwan 3 Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan
Anterior open bite is a complicated problem due to its multiple etiologies, including anatomical, environmental, and genetic factors. The complexity of skeletal class III deformity depends on the severity of bony discrepancy, especially with anterior open bite. Surgical-orthodontic treatment is often required for complete correction. We present the case of an 18-year-old female patient who had been diagnosed with skeletal Class III deformity and an anterior open bite. The patient underwent a well-planned sequential treatment with surgery- first approach. Two-jaw surgery with maxillo−mandibular complex clockwise rotation had improved her skeletal deformities, smile arc, dental inclination and facial harmony. The total orthodontic treatment time was 13 months and had a successful outcome, with harmonious facial profile and stable occlusion. This case demonstrated that communication between the patient, orthodontist, and surgeon, in addition to an accurate diagnosis and treatment plan, is essential for successful outcomes in such cases. (Taiwanese Journal of Orthodontics. 30(3): 171-180, 2018)
Keywords: Class III malocclusion; anterior open bite, two-jaw orthognathic surgery.
Furthermore, the severity of skeletal Class III INTRODUCTION malocclusion is more marked in Asian populations, 3,4 Skeletal Class III discrepancy includes maxillary often requiring two-jaw surgical correction. In modern retrognathism, mandibular prognathism, or a combination orthodontics, cone-beam computed tomography is a useful 1 of both. The prevalence of Class III malocclusion imaging tool to survey the bony deformity in order to plan 2 is higher in Asian than in Caucasian populations. appropriate surgical procedures.
Received: May 11, 2018 Revised: August 30, 2018 Accepted: September 3, 2018 Reprints and correspondence to: Dr. Gunng-Shinng Chen, School of Dentistry, National Defense Medical Center, No.161, Section 6, Min-Chuan East Road, Neihu 114, Taipei 114, Taiwan, Republic of China Tel: +886-2-87923311 ext 88144 Fax: +886-2-87927147 E-mail: [email protected]
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Treatment options for adult skeletal Class III CASE PRESENTATION malocclusions include orthodontic camouflage or orthodontic treatment combined with orthognathic An 18-year-old female patient reported experiencing surgery. The choice between surgery and non-surgical difficulty biting off food with her front teeth and a long orthodontic treatment for adult Class III patients should lower jaw. She denied history of major systemic diseases base on complete evaluation and diagnosis. In additional and facial trauma. to sagittal discrepancy, the vertical problem of anterior or The frontal view demonstrated a longer lower facial 4 lateral open bite often complicates the treatment decision. third, lip incompetence with mentalis strain, and a flat We present a sequential surgical and orthodontic smile arc with no major facial asymmetry. The upper and treatment of an adult patient with severe skeletal Class III lower dental midlines coincided with the facial midline. A deformity and an anterior open bite. The surgery included lateral view showed midface deficiency with mandibular LeFort I maxillary osteotomy and bilateral sagittal split prognathism and an acute nasolabial angle (Figure 1). osteotomy (BSSO) in the mandible with clockwise Intraoral examination revealed a Class III canine and rotation of maxillomandibular complex (MMC), as well as molar relationship on both sides, as well as an anterior osseous genioplasty for chin advancement. Post-treatment cross bite and open bite. Moreover, the lower arch was results showed a harmonious facial profile, curved smile ovoid and narrow, with lingual tipping of the molars. The arc, as well as stable dental and skeletal relationship. upper arch form was square in shape.
Figure 1. Pre-treatment facial and intraoral photographs.
172 Taiwanese Journal of Orthodontics. 2018, Vol. 30. No. 3 DOI: 10.30036/TJO.201810_31(3).0005 Class III Anterior Open Bite
Panoramic radiographs revealed four impacted The patient was diagnosed with a skeletal Class III wisdom teeth. Lateral cephalogram examination relationship, with midface deficiency and mandibular demonstrated that the patient had a skeletal Class prognathism, as well as Angle’s Class III malocclusion III deformity, with proclined maxillary incisors and with an anterior open bite. retroclined lower incisors (Figure 2 and Table 1).
Figure 2. (A) Lateral cephalometric film. (B) Panoramic film before treatment.
Table 1. Comparisons of pre-treatment and post-treatment cephalometric analysis.
Skeletal Pre-treatment Post-treatment Norm
SNA° 81.5 85 79.8 - 83.2
SNB° 87 82 75.7 - 78.1
ANB° -5.5 3 3.2 - 5.0
SN-MP ° 31 33.8 33.8 - 38.4
Dental
U1 to NA (mm) 8.5 5 4.3 - 8.1
U1 to SN (°) 122 105 103.85 -108.75
L1 to NB (mm) 6 6 5.4 -10.2
L1 to MP (°) 90 91.5 93.4 -99.2
Soft Tissue
E-line Upper -6 -2 0.7 -3.1
(mm) Lower +2 -1 0.2 -3.4
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TREATMENT GOALS AND PLAN TREATMENT PROGRESS
The treatment objectives included: A week prior to surgery, we performed presurgical 1. Correct midface deficiency and mandibular prognathism. orthodontic preparation, which included full-mouth 2. Correct dental compensation and inclination. bonding and wire consolidation to prevent the bracket falling into the patient’s airway during surgery. In this 3. Achieve a bilateral Class I canine and molar relationship. surgery-first case, dental model was used to simulate 4. Improve her facial profile, lip posture and smile arc. treatable post-surgical occlusion. The surgical occlusion Based of the diagnosis, treatment goals, and the setup open contact in the posterior teeth to avoid patient’s primary concerns, the following treatment plan unpredictable surgical interferences. was presented: The LeFort I osteotomy was performed on the maxilla, with 2-mm advancement and 5-mm posterior 1. Orthognathic surgery to improve her facial profile. impaction. BSSO was performed bilaterally on the 2. LeFort I advancement with posterior maxillary mandible, with an 8-mm setback. Additionally, osseous impaction with clockwise rotation of the maxilla and genioplasty was performed to improve the chin contour. BSSO for mandibular setback. Postoperative orthodontic treatment was initiated 3. Post-surgical orthodontic treatment for leveling and 1 week after surgery. The treatment involved leveling alignment and to achieve satisfactory interdigitation. and alignment with sequential wire changes. Inter-arch elastics were used for correction of the posterior open bite and cross bite. At 13 months after surgery, the orthodontic treatment was completed (Figure 3,4).
Figure 3. Facial and intraoral photographs after treatment.
174 Taiwanese Journal of Orthodontics. 2018, Vol. 30. No. 3 DOI: 10.30036/TJO.201810_31(3).0005 Class III Anterior Open Bite
(A) (B)
(C)
Figure 4. (A) Lateral cephalometric film after operation. (B) Lateral cephalometric film after treatment. (C) Panoramic film after treatment.
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as well as normal overjet and overbite. Dental midlines TREATMENT RESULTS coincided with the facial midline. Cephalometric analysis The lateral facial profile, chin prognathism, and revealed ANB angle improvement from -5.5° to +3°. The anterior open bite of the patient were corrected. The angle between U1 to SN had decreased by 17°; moreover, nasolabial angle was markedly increased. The patient also the angle between L1 to MP had increased by 1.5° (Figure displayed a consonant smile arc. Intraoral examination 5 and Table 1). The patient expressed satisfaction with the revealed a bilateral Class I canine and molar relationship, outcome.
Figure 5. Overall and regional superimpositions of pre-treatment and post-treatment lateral cephalometric tracings. Blue line, pre-treatment; green line, post-operation; red line, post-treatment.
176 Taiwanese Journal of Orthodontics. 2018, Vol. 30. No. 3 DOI: 10.30036/TJO.201810_31(3).0005 Class III Anterior Open Bite
In a vertical view, open bite can be categorized into DISCUSSION skeletal open bite and dental open bite. However, it is Severe skeletal Class III deformity with an anterior difficult to make a differential diagnosis between these open bite poses a treatment challenge, and involves categories, because the clinical features often entail a 18 anterior-posterior, transverse, and vertical control combination of both factors. Hence, evaluating soft of the teeth and skeleton. In the evaluation of the tissue, skeletal features, as well as dental features can 19 anterior-posterior aspect, two-jaw surgery with maxilla clarify the identification of an open bite tendency. The advancement can resolve midfacial deficiency. Two- etiologies of an anterior open bite are mainly classified jaw surgery is also recommended over one-jaw surgery into three groups: anatomical, environmental, and genetic 18 for greater ANB angular correction, particularly in cases factors. In the present case, the anatomic features of 6 with severe skeletal Class III discrepancy. Clockwise the skeletal open bite were an abnormal lower gonial rotation of the MMC and occlusal plane can correct the angle value and overbite depth indicator (ODI) as shown 18,20-24 proclination of the upper incisors and can improve the flat in Figure 6 and Table 2. A greater lower gonial 7,8 smile arc. In addition, clockwise rotation of the MMC angle indicates more vertical growth of the mandible and 25 can lead to a greater amount of mandibular setback and an increased lower anterior facial height. In terms of 7,9 improved facial esthetics. Due to the invasive nature of environmental factors, tongue thrusting was observed, two-jaw surgery, several studies have suggested the use along with step-up in the upper anterior incisor region, of maxillary molar intrusion with temporary anchorage the open bite was mainly limited at the anterior teeth. devices as an alternative to LeFort I osteotomy for maxilla To resolve the habit of tongue thrusting, we bonded a 10,11,12 impaction. However, maxillary molar intrusion lingual button over the palatal side of the upper incisor cannot resolve midfacial deficiency and poses the risk of as a reminder of tongue position. During orthodontic 13 apical root resorption. In this case, we performed two- treatment, we guided and checked the patient’s tongue jaw surgery with maxilla advancement and clockwise position at every appointment. The use of positioners rotation of the MMC to achieve better esthetic results. for finishing or retention offers advantages in preventing 26 From the transverse view, in patients with open bite. No genetic factors were involved, based on mandibular prognathism, some studies have noted the the family history of this case. Hence, we corrected the development of buccal tipping of the upper posterior anterior open bite with clockwise rotation of the maxilla teeth and lingual tipping of the lower posterior teeth, by LeFort I osteotomy. Another factor influencing post- 14,15 to maintain masticatory function. In skeletal Class surgical instability was posterior facial height (PFH) 27 III patients, transverse dental compensation is closely enhancement. In our case, we retained PFH to achieve a 16 related to sagittal and transverse skeletal discrepancy. stable result. In surgery-first orthognathic cases, dental compensation When deciding between surgery and orthodontic of the upper and lower posterior teeth in the transverse camouflage treatment for skeletal Class III patients, the 17 section may cause occlusal interference during surgery. patient’s chief complaints, facial profile, limitation of After surgery, the inter-arch cross-elastics were applied teeth movement, and severity of bony discrepancy should to correct the transverse dental compensation of posterior be taken into consideration. A recent study reported six teeth. The posterior open bite was setup for surgical cephalometric measurements (overjet ≤ -4.73 mm; Wits occlusion to avoid unpredictable occlusal interference and appraisal ≤ -11.18 mm; L1-MP angle ≤ 80.8°; Mx/Mn unexpected post-surgical anterior open bite. ratio ≤ 65.9%; overbite ≤ -0.18 mm; and gonial angle ≥
Taiwanese Journal of Orthodontics. 2018, Vol. 30. No. 3 177 DOI: 10.30036 / TJO.201810_31(3).0005 Hung WC, Lee WC, Chen YC, Chou LJ, Li CH, Chen GS
Figure 6. Cephalometric evaluation of skeletal open bite.
Table 2. Cephalometric Measurements related to skeletal open bite.
Measurement Pre-treatment Norm
UAFH / LAFH 87% 70% - 90%
PFH / AFH 70% 64.19 ± 6.94%
Y-AXIS 64.5 53 - 66 °
Lower Go angle 78.5 70 - 75°
Overbite depth indicator 60.3 74.5 ± 6.07 (MP ^ AB plane angle ± FH ^ Palatal plane angle)
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