|Year : 2014 | Volume
| Issue : 2 | Page : 94-96
Ortho-surgical treatment of Class III dentofacial deformity
Valdinei Anisio Santos1, Luiz Evaristo Ricci Volpato1, Mike Reis Bueno1, Tereza Aparecida Delle Vedove Semenoff1, Alessandra Nogueira Porto1, Reidson Stanley Soares Dos Santos2, Mateus Rodrigues Tonetto1, Matheus Coelho Bandeca3, Alvaro Henrique Borges1
1 Department of Dentistry, University of CuiabŠ, CuiabŠ, Brazil
2 Department of Post-Graduate in Dentistry, CEUMA University, S„o Luis, Brazil
3 Department of Dentistry, University of CuiabŠ, CuiabŠ; Department of Post-Graduate in Dentistry, CEUMA University, S„o Luis, Brazil
|Date of Web Publication||5-Jun-2014|
Matheus Coelho Bandeca
Department of Dentistry, University of CuiabŠ, CuiabŠ; Department of Post-Graduate in Dentistry, CEUMA University, S„o Luis
Source of Support: None, Conflict of Interest: None
Class III facial pattern is characterized by a negative sagittal lineament and has been one of the greatest challenges in orthodontics. This is due to the poor prognosis of this type of malocclusion. The treatment of this malocclusion, in adulthood, involves orthodontic mechanics combined with orthognathic surgery. In general, the facial aspect is greatly compromised, and this is precisely what encourages the patient to seek treatment in most cases. This study is based on a clinical case whose treatment consisted of two surgical steps: Palatal disjunction followed by procedures in the mandible (osteotomy for bilateral sagittal split and mentoplasty) and maxilla (Le Fort I). In the cases of major maxillomandibular discrepancies, surgical-orthodontic treatment )is indicated, considering that none of specialties alone show functional and aesthetically satisfactory results.
Keywords: Malocclusion, orthodontic appliances, orthognathic surgery
|How to cite this article:|
Santos VA, Ricci Volpato LE, Bueno MR, Vedove Semenoff TD, Porto AN, Dos Santos RS, Tonetto MR, Bandeca MC, Borges AH. Ortho-surgical treatment of Class III dentofacial deformity. J Dent Res Rev 2014;1:94-6
|How to cite this URL:|
Santos VA, Ricci Volpato LE, Bueno MR, Vedove Semenoff TD, Porto AN, Dos Santos RS, Tonetto MR, Bandeca MC, Borges AH. Ortho-surgical treatment of Class III dentofacial deformity. J Dent Res Rev [serial online] 2014 [cited 2022 Dec 2];1:94-6. Available from: https://www.jdrr.org/text.asp?2014/1/2/94/133957
| Introduction|| |
The treatment of malocclusion in adult patients with Type III growth pattern is an interesting challenge in orthodontics. The potentially unfavorable nature of this growth pattern makes the prognosis unpredictable at medium- and long-term. These patients are found to show transverse deficiency or maxillary retrusion combined with normal or slightly prognathic mandible. Regarding mouth breathers, the transverse maxillary deficiency is more pronounced.  According to Epker and Wolford,  maxillary expansion is indicated when the transverse bone discrepancy is larger than 6 mm.
It is considered that until 18 years of age, in general, orthodontic expansion of the maxilla can be done without surgery due to the nonunion of the palatal suture. After this age, even though some professionals in rare cases succeed with maxillary expansion achieved only by means of orthodontic treatment, surgically-assisted maxillary expansion is indicated as an adjunct to the treatment of the dentofacial deformity. 
The combination of orthognathic surgery with orthodontic treatment provides correction of dentoskeletal deformity with better and more stable results.  The present study reports a case of a young patient undergoing orthodontic-surgical treatment.
| Diagnosis and Treatment|| |
Male patient, leucoderma, sought orthodontic treatment at 21 years of age with a chief complaint of esthetical nature (reports of unpleasant facial aesthetics) and anterior cross-bite. On clinical examination, it was observed angle Class III malocclusion and vertical growth pattern with SN-GoGn angle of 42° [Figure 1]a-c]. It was verified a mandibular deviation to the right side at maximum habitual intercuspation, in addition to bilateral anterior and posterior cross-bite, and negative overjet of 3 mm [Figure 2]a]. Furthermore, the patient was presented with bilateral maxillary atresia causing severe crowding in the upper teeth, tooth 46 missing and good periodontal health. During the interview, the patient reported having no systemic disease.
|Figure 1: (a-c) Intra-oral photographs at baseline. Severe upper crowding, anterior open-bite and poor anteroposterior skeletal relationship. (d-f) Installation of Hyrax expansor. (g-i) Photographs showing correction of the upper crowding without the need to perform dental extractions. (j-l) Intra-oral photographs after the end of treatment and removal of orthodontic appliances|
Click here to view
|Figure 2: (a) Cephalometric analysis at the beginning of the treatment. (b) Cephalometric analysis after the end of treatment|
Click here to view
At the 1 st month of orthodontic treatment, two surgical steps were set out. The first step aimed to perform the surgically-assisted palatal expansion after installing a Hyrax appliance; the patient returned in 7 days to be re-evaluated and presented good healing of the mucosal incisions, with no pain in the postoperative period. Immediately after removal of the sutures, the appliance was activated. The patient was instructed to activate it (Ό turn) twice daily at each 12 h until complete expansion, totalizing an activation of 0.5 mm/day [Figure 1]d-f]. After 22 days of activation, the desired expansion was accomplished. The expander appliance was kept for 3 months and then replaced by a transpalatal bar for a 6-month period.
The orthopedic treatment (disjunction) corrected the transverse discrepancy, but there was no anteroposterior correction, so leading to a rotation of the palatal plane in the counterclockwise direction with marked anterior open-bite. The Ricketts orthodontic technique was used. Dental arches were leveled to the 17 × 25 steel wire, with consequent closure of the anterior diastema. All teeth were included in the appliance. The lower molars and first upper molars were banded, while the other teeth had brackets bonded on their surfaces [Figure 1]g-i]. A dental relationship allowing the orthognathic surgery to be performed was achieved 18 months after beginning treatment, with the purpose of correcting anterior open-bite and making possible the dental arches advancement.
The surgery was performed under general anesthesia with nasal intubation and combined procedures in the mandible (osteotomy for bilateral sagittal split and mentoplasty) and maxilla (Le Fort I). The advancements achieved were of 6 mm and 8 mm for the mandible and ment, respectively. The maxilla was repositioned forward (10 mm), and 3 weeks after the surgery the patient started using Class III elastics 5/16 "medium for 90 days". After that period, intercuspation arches were installed. Then, after removal of the fixed appliance, it was installed the Hawley upper retainer and a 3 × 3 lower lingual arch. Finally, orthodontic mechanics positioned the teeth spatially within their bony bases [Figure 1]j-l]. Patient returned for 3-years follow-up [Figure 1]j-l] and cephalometric exam revealing occlusal harmony [Figure 2]b].
| Discussion|| |
Orthognathic surgery has a positive psychosocial influence on quality-of-life. Overall, the esthetic factor is more relevant in relation to the functional one for most individuals, which contraindicates orthodontic treatment alone for the correction of dentoskeletal deformities with major facial involvement in adults.  Hence, orthognathic surgery becomes a reality in dentistry, ensuring complete esthetic and functional recovery of patients.
A persistent issue to be addressed is whether or not there would be, hypothetically, treatment options for this patient, if done earlier. Could a treatment with functional orthopedics prevent the need for orthognathic surgery, providing esthetically satisfactory results? There are professionals who opt for the execution of two operations in one-step (palatal disjunction and orthognathic advancement); however, severe upper crowding requires palatal disjunction to prevent extraction of premolars in this phase. ,
Delayed search for treatment on the part of the patient restricts considerably the treatment options. Mouth breathers require careful attention from healthcare professionals, particularly in childhood. Prolonged mouth breathing interferes in craniofacial growth and development, leading to the establishment of malocclusions, asymmetries and alterations of the stomatognathic system. , In the case reported herein, it can be affirmed that if the patient had recovered his normal respiratory function in childhood, with multidisciplinary therapies, he would have had great chances of not undergoing surgical procedures in adulthood or at worst, one of these operations could be avoided. , The treatment provided the patient with gains in his facial esthetics. There were major advancements in the mandible and ment, which overcame the anteroposterior deficiency of soft tissues in the ment and resulted in a better definition of the cervical mandibular angle. The advancement and superior repositioning of the maxilla resulted in a more pleasant nose, with the apex displaced upward, and a nice display of incisors during smile. In addition, the postoperative profile was found to show a better filling of the paranasal region, better relationship between the upper/lower lips and the soft pogonion. Finally, it was observed an improvement in the length of the neck-ment line.
| Conclusion|| |
According to the case reported herein, it is correct to affirm that in cases of major maxillomandibular discrepancies the orthodontic-surgical treatment is indicated, considering that none of the specialties alone show functional and aesthetically satisfactory results.
| References|| |
|1.||de Lir Ade L, de Moura WL, Oliveira Ruellas AC, Gomes Souza MM, Nojima LI. Long-term skeletal and profile stability after surgical-orthodontic treatment of Class II and Class III malocclusion. J Craniomaxillofac Surg 2013;41:296-302. |
|2.||Epker BN, Wolford LM. Dentofacial Deformities: Surgical-Orthodontic Correction. St. Louis: Mosby; 1980. |
|3.||Waring D, Henley E. Growth modification treatment in class III malocclusions - An orthodontic case report. Dent Update 2006;33:546-8, 551-2, 554. |
|4.||Jose Cherackal G, Thomas E, Prathap A. Combined orthodontic and surgical approach in the correction of a class III skeletal malocclusion with mandibular prognathism and vertical maxillary excess using bimaxillary osteotomy. Case Rep Dent 2013;2013:797846. |
|5.||Gelgör IE, Karaman AI. Non-surgical treatment of Class III malocclusion in adults: Two case reports. J Orthod 2005;32:89-97. |
|6.||Brunharo IH. Surgical treatment of dental and skeletal Class III malocclusion. Dental Press J Orthod 2013;18:143-9. |
|7.||Bergamo AZ1, Andrucioli MC, Romano FL, Ferreira JT, Matsumoto MA. Orthodontic-surgical treatment of Class III malocclusion with mandibular asymmetry. Braz Dent J 2011;22:151-6. |
|8.||Pangrazio-Kulbersh V1, Berger JL, Janisse FN, Bayirli B. Long-term stability of Class III treatment: Rapid palatal expansion and protraction facemask vs LeFort I maxillary advancement osteotomy. Am J Orthod Dentofacial Orthop 2007;131:7.e9-19. |
|9.||Minami K, Mori Y, Tae-Geon K, Shimizu H, Ohtani M, Yura Y. Maxillary distraction osteogenesis in cleft lip and palate patients with skeletal anchorage. Cleft Palate Craniofac J 2007;44:137-41. |
|10.||Wolf GR. Case report RW: Correction of a mandibular transverse discrepancy resulting from anteroposterior skeletal disharmony. Angle Orthod 1994;64:167-73. |
[Figure 1], [Figure 2]