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 , 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

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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 , 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 deviation to left. His dental manifestation presented anterior , 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 , 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 , the lower dental spacing was caused by general size/ 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 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: ; 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 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 allergies. midline was 2 mm left to facial midline. For the maxilla, upper incisors were proclined (U1/SN=128.5°), mild Clinical Findings crowding and right-side up occlusal plane canting. In The clinical examination presented skeletal Class III contrast, the mandible presented spacing between canine relationship, retrognathic maxilla, excessive lower facial and first premolar at both side with slightly retroclined height and prognathic mandible with chin deviation to lower incisors (L1/MP=85°) (Figure 2, Table 1). the left 3 mm. He had non-consonant smile arch without From radiographic examination, all permanent teeth gummy smile. His lateral facial profile was concave with were erupted with 24 endodontically treatment. Average paranasal depression, acute nasolabial angle and shallow retropalatal and retroglossal and airway space, which was mentolabial fold (Figure 1). 9 mm and 12 mm respectively, were observed (Figure 3).

Figure 1. Pre-treatment facial photographs.

Figure 2. Pre-treatment intraoral photographs.

88 Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 2 10.30036/TJO.201906_31(2).0003 Mandibular Prognathism with Atypical Dental Pattern

Figure 3. Pre-treatment radiographs.

Treatment goals and treatment plan From the examination, the treatment goals were set.

Treatment Goals

• Correct facial proportion Soft Tissue • Correct lip posture • Improve smile arch

• Correct midface deficiency and mandibular prognathism Skeletal • Correct maxilla canting • Correct chin deviation

• Correct dental inclination and relationship Dental • Achieve Class I canine and Class II molar relationship

From the diagnosis and treatment goals together with 3. Orthognathic surgery: patient’s expectation, the treatment plan was performed Maxilla: 2-pieces LeFort I osteotomy with a modified surgery-first approach as following steps. Mandible: Köle procedure and BSSO for mandible 1. General dental care: Full mouth scaling and polishing setback and asymmetry correction. 2. Presurgical orthodontic treatment: 14, 24 extraction for Genioplasty: chin contouring reducing incisal proclination, alignment and levelling. 4. Post-surgical orthodontic treatment 5. Retention

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Treatment Progress was clockwise rotated which resulted in upper incisor In the maxilla, the significant maxillary crowding setback 4 mm, downward 1 mm and decreasing their was relieved by 14 and 24 extractions while partially inclination. The posterior portion of maxilla was moved retracting the maxillary incisors to reduce the incisal forward for space closure and posterior impacted for proclination. Then, the upper incisors inclination was further dental occlusion. furtherly corrected more by a 2-pieces LeFort I osteotomy The bilateral sagittal split osteotomies (BSSO) and closure of the 14, 24 residual dental space during were conducted for mandible setback and asymmetry surgery. correction. The mandible was set back 8mm at the In the mandible, the lower dental spacing was right side and 5mm at the left side. Additionally, the caused by general tooth size and jaw bone discrepancy subapical osteotomy with Köle procedure was applied with relative upright incisal inclination. The presurgical with 2mm setback at the right side and 4mm setback at preparation included consolidation the dental space distal the left side. This procedure helped closing the dental to the bilateral mandibular canines. The presurgical space in the mandibular arch while keeping the anterior orthodontics preparation took 7 months before surgery. teeth in relative normal inclination. The excessive chin Then, the pre-operative records were taken included prominence caused by the Köle procedure was reduced by dental radiographs, cone beam computed tomography reduction genioplasty and surface contouring (Figure 4). (CBCT) and surgical models. For surgical plan, a 2-pieces Post-operative orthodontic treatment took about 19 LeFort I osteotomy were performed which was cut at the months included overbite control and detailing of the area between 13-15 and 23-25. Anterior maxilla portion occlusion and interdigitation.

Figure 4. The surgical planning.

90 Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 2 10.30036/TJO.201906_31(2).0003 Mandibular Prognathism with Atypical Dental Pattern

Treatment Results From the superimposition, the mandible was setback After treatment, patient’s profile was improved and the maxilla was clockwise rotated by impaction of to straight facial profile, symmetry and good facial posterior segment upward 3 mm. The pogonion point was proportion. All surgical segments were stable. Class I moved backward by 7 mm along with posterior airway canine relationship and Class II molar relationship were reduction to 8 mm at retropalatal and retroglossal area achieved with 2 mm overjet and 2 mm overbite. The (Figure 6). maxillary incisors proclination were improved, all the This case report was approved by the Institutional dental spaces were closed and well interdigitation (Figure Review Board and Medical Ethics Committee of Chang 5, Table 1). Gung Memorial Hospital (No. 201900284B0).

Figure 5. Post-treatment photographs at the time of debond (19 months after surgery).

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Table 1. The in before and after treatment. Skeletal

Pretreatment Debond Norm

SNA 85.0 84.0 79.4 - 82.5 SNB 92.0 84.0 74.6 - 77.8 ANB 7.0 0.0 4.1 - 5.7 SND-MP 30.5 35.0 34.2 - 38.6 Dental Analysis

Upper-NA (mm) 13.0 8.5 3.8-7.2 U1/SN⁰ 128.5 114.0 103.5-109.1 L1-NB (mm) 28.0 27.0 6.1-9.5 L1/MP⁰ (Me-Go) 85.0 87.5 91.1-98.3 Facial Analysis

Upper 0.5 1.0 0.8-3.2 E-line (mm) Lower 6.0 1.0 1.2-4.4 Retropalatal Airway 12.0 8.0 Retroglossal Airway 9.0 8.0

Figure 6. 2D and 3D Superimposition of before and after treatment. Initial Debond

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DISCUSSION technique alone. They generate a better result with less effect on posterior airway space and provided good 9,17 With the modified surgery-first technique, the skeletal stability. presurgical orthodontic treatment was performed to reduce Although, upper anterior incisors showed severe severe incisal inclination, minor levelling and alignment proclination, an excessive amount of rotation at anterior but didn’t aim for fully dental alignment, space closure segment of maxilla could not be done. The large bony or occlusal interdigitation. Thus, this patient took only 7 step between anterior and posterior segment should be months for presurgical orthodontic treatment preparation. considered. It also could cause the periodontal problem The 2-pieces LeFort I and Köle osteotomy then addressed at distal of canine where the surgical cut and extraction the correction in the dentoalveolar portion for efficiently space closure take place which could lead to periodontal 12 18 control the inclination of the anterior teeth. problem such as gingival recession (1.5%). Therefore, For the surgical design, the clockwise rotation of with the limitation above, the upper incisors still show 5 maxilla could help reducing the incisal inclination. some proclination at the end of the treatment (U1/SN = From the study of Gandedkar et al., the range of 4-8 mm 114⁰), but no periodontal problem was founded. The side setback surgery in bimaxillary surgery showed no change effect of Köle osteotomy set back is bony prominence 15 19 in risk factors scores for obstructive sleep apnea (OSA). and excessive chin contour. The genioplasty could help However, for this patient, a big amount of rotation was contouring the bony prominence and correct remaining needed for fully correction which could affect the amount asymmetry. of bone reduction and could affect the posterior airway Finally, a proper surgical result not only concern 10,11 space. about facial profile and dental occlusion, but also airway On the other hand, the discrepancy between tooth- space should be appropriate considered. Some maxillary size and arch length in this patient resulted in large incisors proclination and minor reduction of airway space amount of spacing in mandibular arch especially at distal were observed, however, patient reports no change in of lower canine at both sides. If the spacing would be sleep quality and feels pleasing with the treatment result. closed by only orthodontic movement before surgery, a large amount of incisors retraction or molar protraction CONCLUSION were needed which could lengthening the presurgical orthodontics treatment. On the contrary, if spacing were The treatment goals of the dentoalveolar portion and kept for prostheses or planned for space closure after facial proportion should be contemplated for the staged surgery, the large amount of mandibular setback more procedures to improve the efficiency and effectiveness of than 8 mm could not be avoided. the treatment outcome. Soft tissue including airway space Therefore, the combination of the clockwise rotation also should be carefully evaluated to avoid the unwanted of maxillary anterior segment from 2-pieces LeFort I side effects and provided the most suitable treatment for osteotomy and Köle osteotomy combined with BSSO was patient. 16 chosen to reduce incisors angulation and space closure. The posterior segment of maxilla was moved forward to REFERENCE close extraction space and Köle osteotomy was helped to close the excessive mandibular spacing which resulted in 1. Hardy D, Cubas Y, Orellana M. Prevalence of angle less amount of total mandibular set back by just BSSO class III malocclusion: A systematic review and meta-

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