A Modified Surgery-First Approach for Mandibular Prognathism with Proclined Maxillary Incisor and Mandibular Spacing
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Volume 31 Issue 2 Article 3 2020 A Modified Surgery-First Approach for Mandibular Prognathism with Proclined Maxillary Incisor and Mandibular Spacing Jutharath Chanruangvanich Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan; Graduate Institute of Dental and Craniofacial science, Chang Gung University, Taoyuan, Taiwan Ellen Wen-Ching Ko Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan; Graduate Institute of Dental and Craniofacial science, Chang Gung University, Taoyuan, Taiwan; Craniofacial Research Center, Chang Gung University, Taoyuan, Taiwan Ying-An Chen Craniofacial Research Center, Chang Gung University, Taoyuan, Taiwan; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan Follow this and additional works at: https://www.tjo.org.tw/tjo Part of the Orthodontics and Orthodontology Commons Recommended Citation Chanruangvanich, Jutharath; Ko, Ellen Wen-Ching; and Chen, Ying-An (2020) "A Modified Surgery-First Approach for Mandibular Prognathism with Proclined Maxillary Incisor and Mandibular Spacing," Taiwanese Journal of Orthodontics: Vol. 31 : Iss. 2 , Article 3. DOI: 10.30036/TJO.201906_31(2).0003 Available at: https://www.tjo.org.tw/tjo/vol31/iss2/3 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. Case Report A MODIFIED SURGERY-FIRST APPROACH FOR MANDIBULAR PROGNATHISM WITH PROCLINED MAXILLARY INCISOR AND MANDIBULAR SPACING 1,2 1,2,3 3,4 Jutharath Chanruangvanich, Ellen Wen-Ching Ko, Ying-An Chen 1 Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan 2 Graduate Institute of Dental and Craniofacial science, Chang Gung University, Taoyuan, Taiwan 3 Craniofacial Research Center, Chang Gung University, Taoyuan, Taiwan 4 Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan This case report describes the management of an adult patient presenting with a skeletal Class III malocclusion, mandibular protrusion, upper incisor proclination and mandibular arch spacing by a modified surgery-first approach. A 26-year-old man had skeletal Class III and dental Class III malocclusion with concave facial profile, midface deficiency and mandibular prognathism with chin deviation to left. His dental manifestation presented anterior crossbite, upper incisors proclination and spacing in his mandibular arch. Treatment was performed with a modified surgery-first approach, which included a short presurgical alignment phase. In the maxilla, the significant maxillary crowding was relieved by 14 and 24 extractions while partially retracting the maxillary incisors to reduce the incisal proclination. Then, the upper incisors inclination was furtherly corrected more by a 2-pieces LeFort I osteotomy and closure of the 14, 24 residual dental space during surgery. In the mandible, the lower dental spacing was caused by general tooth size/ jaw bone discrepancy with relative upright incisal inclination. The presurgical preparation included consolidation the dental space distal to the bilateral mandibular canines. The bilateral sagittal split osteotomies were conducted for mandible setback and asymmetry correction. Additionally, the subapical osteotomy with Köle procedure was applied to close the dental space in the mandibular arch while keeping the anterior teeth in relative normal inclination. The excessive chin prominence caused by the Köle procedure was reduced by reduction genioplasty and surface contouring. Post-operative orthodontic treatment included overbite control and detailing of the occlusion. After treatment, the maxillary incisors proclination was corrected and all the dental spaces were closed. Patient’s profile was dramatically improved with well teeth alignment, angulation and interdigitation. The 2-pieces LeFort I and Köle osteotomy are the surgical procedures to address the correction in the dentoalveolar portion for efficiently control the inclination of the anterior teeth. Moreover, it also provides benefits for patients who require large amount of jaw setback with minimal effect at the posterior airway space. The treatment goals of the dentoalveolar portion and facial proportion should be contemplated for the staged procedures to improve the efficiency and effectiveness of the treatment outcome. (Taiwanese Journal of Orthodontics. 31(2): 86-94, 2019) Keywords: orthognathic surgery; modified surgery-first approach; skeletal Class III malocclusion; mandibular prognathism; segmental osteotomy. Received: February 26, 2019 Accepted: March 5, 2019 Reprints and correspondence to: Dr. Ellen Wen-Ching Ko, Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taipei, Taiwan. 6F, 199, Tung Hwa North Road, Taipei 105, Taiwan Tel: +886-2-27135211 ext.3533 Fax: +886-2-25148246 E-mail: [email protected] 86 Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 2 10.30036/TJO.201906_31(2).0003 Mandibular Prognathism with Atypical Dental Pattern amount of severe dental discrepancy such as excessive or INTRODUCTION recessive inclination and major dental interference which A Class III skeletal pattern could lead to could impact the setting of surgical occlusion, still there malocclusion and disharmony facial profile. From the are some correction needed for postsurgical orthodontic systematic review and meta-analysis of Hardy et al. in treatment to be done. 2012, the Angle Class III malocclusion had been found Furthermore, surgical techniques to enhance in Southeast Asian population with the highest rate of dental correction can be benefit for patients who have 1 15.80% compare to other population. As well as the atypical skeletal and dental pattern. Segmental osteotomy study from Soha et al. in 2005, the relationships of Class can be used to improve surgical outcome and help III incisor in Asian male army were 22.4% and Class III occlusal set up instead of strictly relying on orthodontic molar relationship were 24.2 % at right side and 21.2% tooth movement. In the maxilla, the maxillary segmental 2 8 at left side. Tang also reported the prevalence of Class osteotomy provided stable outcomes in sagittal plane. III malocclusion which was 14.8% in male dental student With the rigid fixation and interpositional bone grafting, 3 in Hong Kong. Most of the Class III malocclusion also the stability in horizontal plane of maxilla advancement 4 presented a skeletal discrepancy (75.4%). in segmental group is the same as one-piece group and 9 Although mild skeletal discrepancy can be treated shows less relapse rate in vertical plane. by camouflage orthodontic treatment. To improve facial For mandible, main reason of skeletal Class III profile and dental occlusion in severe skeletal relationship, comes from mandibular prognathism (47.4%) or excessive the treatment usually leads to orthognathic surgery. growth, meanwhile the maxilla found to be retrognathism 4 For conventional orthognathic surgery, the presurgical (10.5%) or micrognathia (8.8%). To deal with the orthodontic treatment is needed to decompensate teeth excessive mandible, mandibular setback by bilateral alignment before surgery which provides benefits of sagittal split osteotomies (BSSO) is usually performed in changing the amount of surgical reposition procedure and our centre. Still the large amount of setback could affect 5 10,11 gives the best surgical results. However, patients who the posterior airway space or could not fully correct received presurgical orthodontic treatment were found to patient’s problem. The mandibular anterior segmental 6 have negative impact on their quality of life. subapical osteotomy was first introduced by Hullihen in 8 The surgery- first approach was introduced in 1988 1849. After that many modification procedures by Köle 12 by Behrman and Behrman with the advantages of short was introduced in 1959. The subapical osteotomy at treatment period due to no presurgical orthodontics the anterior part of mandible provide more modification 7 treatment stage. Patients also reported the improvement on lower jaw such as adjusting incisal position, incisal 13,14 of quality of life immediately after surgery in surgery- inclination and arch length. 6 first approach group. Yet in some cases, the degree Therefore, this case report describes the management of complexity exceeds the limitation for surgery-first of an adult patient presenting with a skeletal Class approach. III malocclusion with mandibular protrusion, upper A modified surgery-first approach has an advantage incisor proclination and mandibular arch spacing by a of using short period of presurgical orthodontic modified surgery-first approach. The surgical technique preparation simply for minor teeth adjustment. The aim included segmental LeFort I osteotomy in maxilla and of dental correction prior the surgery is to decrease the BSSO combined with subapical osteotomy in mandible. Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 2 87 10.30036/TJO.20190631(2).0003 Chanruangvanich J, Ko EWC, Chen YA His dental manifestation presented Angle’s CASE REPORT Classification III malocclusion with a negative overjet of A 26-year-old man had chief complaint of a long -2 mm and overbite of 2.5 mm. The upper dental midline lower jaw. He denied any major systemic diseases or drug was 2 mm right to facial midline while the lower dental