Class II surgical-orthodontic treatment of a patient with severe … · 2017-12-22 · Class II surgical-orthodontic treatment of a patient with severe coronary disease: 5 years of

CASE REPORT

Class II surgical-orthodontic treatmentof a patient with severe coronary disease:5 years of follow-up

Alexandre A. Francoa and Jos�e Augusto M. Miguelb

Rio de Janeiro, Brazil

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This case study describes the retreatment and long-term follow-up care of a patient with a medical history of2 heart surgeries and a Class II malocclusion that included a severe anteroposterior skeletal discrepancycharacterized by mandibular deficiency. The patient's initial orthodontic camouflage treatment was poorlyperformed and failed to correct the maxillofacial disorders. In this article, we report the successful retreatmentwith a surgical-orthodontic protocol and include the 5-year follow-up records showing stable results. Guidelinesfor the stratification of cardiac risk are included. (Am J Orthod Dentofacial Orthop 2013;143:855-66)

Elective dental treatment, except for conservativeemergency procedures, has traditionally beencontraindicated in patients who have experienced

unstable angina and acute myocardial infarction duringthe previous 6 months.1 The American College ofCardiology and the American Heart Associationpublished risk stratification guidelines for professionalswho are performing several types of noncardiac surgicalprocedures in patients with various cardiopathologies.2

This topic is important for orthodontists because moreorthodontic patients have a history of heart disease orsurgery; these guidelines emphasize how a dentaltreatment plan should be established to ensure thatreasonable and safe decisions are made and specificallyto determine with confidence whether a patient will beable to tolerate a planned procedure. For example,surgical orthodontic treatment for maxillomandibulardisharmony could be indicated for a patient witha history of acute myocardial infarction as long as thepatient is stratified as having a low cardiac risk.3

Over the past few years, great progress has beenmadein surgical orthodontic protocols4,5 for the treatment of

the School of Dentistry, State University of Rio de Janeiro, Rio de Janeiro,.raduate student, Department of Orthodontics.ciate professor, Orthodontic Clinic.uthors report no commercial, proprietary, or financial interest in thects or companies described in this article.t request to: Alexandre A. Franco, Rua Duque de Caxias, 167 Apto 602,-320, Aracaju, SE, Brazil; e-mail, [email protected], revised and accepted, April 2012.5406/$36.00ight � 2013 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2012.04.028

malocclusions with skeletal involvement that hadpreviously been arbitrarily addressed by orthodonticcamouflage.6 Camouflaging sometimes achieves limitedresults, unacceptable facial esthetics, or unstableocclusal contacts that do not meet the patient's expec-tations.7

In this article, we present guidelines for the stratifica-tion of cardiac risks. We also present 5 years of follow-upcare for a patient with a Class II malocclusion, mandib-ular deficiency, and a medical history of 2 heart surger-ies, who was treated with a surgical-orthodonticprotocol after a poorly performed orthodontic camou-flage treatment.

DIAGNOSIS AND ETIOLOGY

A 30-year-old woman came for an initial examina-tion in a generally good state of health. Her medicalhistory indicated that she was a cardiac patient with2 previous heart surgeries (internal thoracic artery andmyocardial revascularization). Her cardiac risk stratifica-tion for extensive maxillofacial surgical procedures, suchas orthognathic surgery, was intermediate according toEagle et al,2 with an overall reported cardiac risk below5%. Parafunctional habits were not considered, exceptlingual interposition during swallowing. Unsatisfactoryfacial esthetics and masticatory function were thepatient's chief complaints, especially in the tearing offoods with the anterior teeth. The patient's dentalhistory showed the loss of the mandibular right firstand second molars because of caries and the extractionof the maxillary right and left first premolars during theprevious orthodontic treatment, with the unattained

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http://dx.doi.org/10.1016/j.ajodo.2012.04.028

Fig 1. Initial facial and intraoral photographs.

856 Franco and Miguel

goal of correcting an overjet caused by mandibulardeficiency.

The facial evaluation of the patient showed anabsence of labial seal at rest and an inverted contourof the upper lip, indicating an esthetic deficiency. Thesoft-tissue profile was convex, and the nasolabial anglewas harmonious. There was also a general appearance ofpremature aging (Fig 1).

The intraoral clinical examination and an evaluationof the orthodontic documentation supported the diagno-sis of a Class II malocclusion (Figs 1 and 2) with anaccentuated anteroposterior maxillomandibulardiscrepancy (ANB, 8.5�; SNA, 74.5�; SNB, 66�), withgreater mandibular retrusion than maxillary retrusion(Fig3). The convexbone profilewas accentuated (convex-ity, 11.5�), the direction of growth was severely vertical(y-axis, 64.5�; SN-GoGn, 47�), and there was transversalskeletal atresia of the maxilla, with an intercanine dis-tance of 30.7mm and an intermolar distance of 44.9mm.

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Dental evaluation showed an excessive overjet(11.5 mm) and an overbite of 5.5 mm. There was a slightdeviation to the right of the mandibular midline and anaccentuated mandibular curve of Spee (Fig 1). The maxil-lary incisors appeared to be slightly vestibularized andprotruded (1-NA, 24�, and 1-NA, 5.5 mm, respectively),and the mandibular incisors were lingualized (1-NB,20.5�) (Fig 3). The patient had a poorly planned fixedbridge with abutments on the mandibular right first andsecond premolars and third molar, which interfered withthe protrusive function of themandible by the thirdmolar.

Evaluation of the panoramic radiograph showed theabsence of the maxillary right third molar, the mandib-ular left third molar, and the mandibular right first andsecondmolars (Fig 3); distal positioning of the abutmentof the fixed bridge on the mandibular right third molar;the mesioangular and extrusive position of the mandib-ular right third molar; and root dilaceration of themandibular right second premolar (Fig 3).

Journal of Orthodontics and Dentofacial Orthopedics

Fig 2. Dental casts before the treatment.

Fig 3. Initial radiographs.

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TREATMENT OBJECTIVES

The patient had a medical history of 2 surgeries andprevious orthodontic camouflage treatment, includingthe extraction of the maxillary first premolars, and wasmotivated to follow the proposed treatment plan, whichincluded a combined surgical-orthodontic protocol.

American Journal of Orthodontics and Dentofacial Orthoped

Surgical disjunction to correct the maxillary atresiawas conducted at a separate time, because of the largediscrepancy, so that the patient would not be subjectedto a long surgery (in a combined surgery) and to preventthe risk of maxillary segmentation, which would causea more complex scarring process. A slight vestibular

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Fig 4. Presurgical photographs.


torque was measured for the incisors, and increases inthe intercanine and intermolar distances were observed.

Mandibular retrusion was corrected by orthognathicsurgery (bilateral sagittal split osteotomy maintainingthe vertical component). Intrusion of the anteriormandibular teeth was planned using segmentedmechanics to correct the curve of Spee. The removal ofthe fixed mandibular bridge and the placement of animplant in the space for the mandibular right first molarwas also planned.

TREATMENT ALTERNATIVES

A dental plan for the correction of the mandibulardeficiency using dental compensation (orthodonticcamouflage) had been attempted previously with littlesuccess. A surgical-orthodontic protocol for the correc-tion of the Class II defects was considered to have thegreatest likelihood of restoring the patient's estheticsand correcting the dental malocclusion.


The cardiologist, an anesthesiologist, and an oralmaxillofacial surgeon discussed the direction of theorthognathic surgery and preventive measures, andtreatment decisions were made according to the cardiacrisk stratification to ensure the safety of the procedure(\5% risk). These measures included control of arterialpressure and anxiety and the temporary discontinuationof the patient's anticoagulant medications.

TREATMENT PROGRESS

A hyrax palatal expander was placed, and the patientunderwent osteotomy surgery through the lateralmaxillary wall and the median palatine suture, accordingto previous protocols.8 The protocol called for 1complete turn of the expanding screw on the first dayand subsequent quarter turns in the morning and atnight after the second day (twice a day) for 10 days.Once expanded, the apparatus was left in place forpassive retention for 4 months. The dental implant was


Fig 5. Dental casts before the surgery.

Fig 6. Presurgical panoramic and teleradiographic profile radiographs. Occlusal radiographs weretaken during the maxillary surgical disjunction phase.


placed in the space for the mandibular right first molarduring the maxillary surgery to create a skeletal anchor,and the patient's accentuated mandibular curve of Speewas corrected through the intrusion of the anterior man-dibular teeth using the segmented-arch technique.


During the restraint phase of the disjunction, themandibular dental arch was leveled with minimumproclination of the incisors; this is fundamentalfor mandibular advancement. The apparatus usedhad an MBT prescription and a 0.022 3 0.028-in slot


Fig 7. Final facial and intraoral photographs.


(Abzil Ind. e Com. Ltda, S~ao Paulo, Brazil). The ortho-dontic leveling of the maxillary and mandibular archeswas performed with nickel-titanium 0.014- and 0.016-in arches and stainless steel 0.016-, 0.018-, 0.020-,and 0.019 3 0.025-in archwires to prepare the dentalarches.

Figures 4, 5, and 6 show the dental and facialmodifications before surgery, the predictive tracingover the cephalometric radiograph, the surgical modelsmounted on a semiadjustable articulator, and thefabrication of the surgical splint.

A 12-mm surgical mandibular advancement wasperformed through a sagittal ramus osteotomy in whichthe mandible was placed anteriorly using a surgicalsplint and fixed screws.9-11 In the postsurgical phase,short intermaxillary 1/8-in double bilateral elasticswere used for a total treatment time of 44 months,with several interruptions caused by changes in thepatient's general health.


The orthodontic apparatus was removed, anda removable circumferential retainer with a canine-to-canine fixed arch was placed (0.028 in, or 0.70 mm).

TREATMENT RESULTS

Analysis of the posttreatment records (Figs 7-9)shows that the treatment objectives were reached. Astraight facial profile, labial seal at rest, anda harmonious smile with adequate exposure of themaxillary incisors were obtained. The final intraoralphotos showed harmonious maxillary and mandibulararches, with correction of the maxillary atresia andhygienic fixed mandibular retention. The occlusalphotos show the correct anteroposterior relationshipbetween the dental arches and the canines at thepoints of occlusion. The slight mandibular midlinedeviation that remained was due to the loss of themandibular right first and second molars; thisproduced a shift of the mandibular midline. In the


Fig 8. Dental casts after the treatment.

Fig 9. Final radiographs.


skeletal context, the data in Table I show that theanteroposterior and vertical positions were maintainedand the transverse position was improved, withcorrection of the atresia, as shown by the 3-mmincreases in the intercanine and intermolar distances.


The mandible exhibited significant anterior modifica-tion, as shown by the 5� increase in the SNBangle (from 66� to 71�) and complete correction of theANB angle (from 8.5� to 2�). The convexity angle of1.5� shows that the osseous profile was harmonious after


Table I. Cephalometric measurements

Variable Normal T1 T2 T3 T4SNA (�) 82 74.5 72.5 73 73.5SNB (�) 80 66 66.5 71 71.5ANB (�) 2 8.5 6 2 2Angle of convexity (�) 0 11.5 7.5 1.5 1.5Y-axis (�) 59 66 65 63.5 63Facial angle (�) 87 80 80.5 84 84SN-GoGn (�) 32 49.5 47.5 48.5 47.5FMA (�) 25 37 35.5 37.5 38IMPA (�) 90 85 90 84.5 841-NA (�) 22 24 28 21.5 211-NA (mm) 4 5.5 8.5 6.5 61-NB (�) 25 22.5 25 25.5 24.51-NB (mm) 4 5.5 5.5 6.5 61/1-interincisal angle (�) 130 128 121.5 131 1321-APo (mm) 1 �1.5 0 3.5 3.5Upper lip-S line (mm) 0 0 0 �3 �2.5Lower lip-S line (mm) 0 �5 1.5 �1 �0.5

T1, Pretreatment; T2, presurgery; T3, posttreatment; T4, 5 yearsposttreatment.


the mandibular advancement (Table I; Fig 9). Themaxillary and mandibular incisors showed correctvestibular inclination after treatment (1-NA, 21.5�, and1-NB, 25.5�, respectively), indicating that the overbitehad been corrected, although the incisors wereprotruded slightly (1-NA, 6.5 mm; 1-NB, 6.5 mm). Thefinal IMPA angle of 84.5� also confirms good inclinationof the mandibular incisors, enabling the mandibularadvancement to be maintained.4 The posttreatmentpanoramic radiograph demonstrates the distalangulation of the maxillary canines from the use ofthe Roth technique, which promotes these artisticpositionings. The root resorption observed near themaxillary incisors was compatible with the mechanicsused and caused no risks to the teeth.

Five years later, the same facial equilibrium wasobserved as at the end of treatment: the facialprofile was straight, and the labial musculature waswell-adapted to the mandibular advancement (Fig 10).The occlusion was maintained without reincidence ofoverjet, and the canine contacts were stabilized in ClassI, similar to the final treatment period (Figs 10 and 11). Acomparison of the cephalometric values measured in theposttreatment phase and at the 5-year follow-up (TableI; Fig 12) indicated no skeletal changes in the maxillaand the mandible, reflecting the balance of the facialsoft tissues and the maintenance of the straight profile.A comparison of the dental measurements showedpositional stability across treatment phases, consistentwith the correct sagittal relationship between the dentalarches and the correct overjet, as well as alignment ofthe maxillary and mandibular teeth. The slight midline


deviation persisted, but it was restricted to themandibular arch and was attributed to the loss of themandibular right first and second molars. Therefore, itwas not related to the orthodontic treatment, andit did not compromise the smile esthetics.

Figure 13 shows the cephalometric superimpositionsbetween the initial and final phases of treatment,and between the end of the treatment and 5 yearsposttreatment.

DISCUSSION

The risk evaluation for dental treatment in patientswith ischemic cardiopathology involves 3 factors: theseriousness of the illness, the type and extent of thedental procedure, and the patient's stability and bloodsupply.3 The American College of Cardiology and theAmerican Heart Association have published risk stratifi-cation guidelines for patients with various types ofcardiopathologies undergoing different noncardiacsurgical procedures (Table II).2

Recent myocardial infarction (within the last 7-30days) and unstable angina are clinical predictors ofa higher risk for perioperative complications. Stableangina (light) and a previous history of myocardialinfarction are intermediate risk factors for perioperativecomplications.3 The type and extent of the plannedprocedure should be considered, along with theperioperative risk associated with the illness itself.Using these guidelines, most dental procedures, includ-ing minor oral surgery and periodontal surgery, areconsidered low risk, in the category of “superficialprocedures,” with a risk of less than 1%.2 Nonsurgicaldental procedures might have an even lower risk thansurgical procedures. More extensive maxillofacial andoral surgical procedures, and perhaps more extensiveperiodontal surgical procedures, could fall under thecategory of intermediate cardiac risk under “head andneck procedures” (\5% risk). The procedures withthe greatest risks include major emergency surgery inelderly patients, aortic or vascular surgery, and periph-eral vascular surgery. These procedures are performedwith the patient under general anesthesia and areassociated with the possibility of significant bloodand plasma loss, resulting in adverse hemodynamiceffects.1

In orthodontic camouflaging, it is expected that themaxillary incisors will be retracted and the mandibularincisors will be proclined toward the labial aspect; thiswould correct the overjet and compensate for the ClassII malocclusion. One study stated that the main risksof orthodontic camouflaging are the possibilities ofsevere resorption of the roots of the maxillary incisorsand the clinical failure to control the torque of the


Fig 10. Facial and intraoral photographs at 5 years posttreatment.


maxillary incisors; these would result in considerablelingual inclination.7

The important clinical questions are whether camou-flage has been successful (ie, esthetically acceptable) andwhether further improvements would be worth the highcosts and risks of orthognathic surgery.6 For thisassessment, the esthetic classification of patients beforetreatment is of the utmost importance to preventesthetically damaging effects. Our patient had a ClassII malocclusion with a significant mandibular deficiency.Her overjet was not corrected by the camouflageprocedure, and her facial esthetics remained poor aftertreatment; therefore, a further surgical orthodonticprotocol was chosen. We suggest that camouflagetreatment might be more effective for patients whoalready have reasonably good facial esthetics beforetreatment.

The development of the bilateral sagittal split osteot-omy enabled mandibular advancement,9-11 providing an


integrated surgical orthodontic protocol for thetreatment of maxillomandibular disharmonies.12,13 Astability and predictability hierarchy based on theextensive database of orthognathic surgical resultsobtained at the University of North Carolina14,15

showed that mandibular advancement was the secondmost stable orthognathic procedure, surpassed only bysuperior repositioning of the maxilla.16,17 In this casereport, from the presurgical phase to the posttreatmentphase, the SNB angle increased by 4.5�, and the ANBangle was positively modified from 6� to 2�, thusbringing the sagittal maxillomandibular relationshipinto harmony. The patient's mandible was stable overthe long term; the mandibular relationship with thebase of the skull (SNB) and the maxillomandibular(ANB) values did not change between the end oftreatment and 5 years later.18 The maxillary andmandibular incisors also maintained their positions,and overjet and overbite were normal.19


Fig 11. Dental casts at 5 years posttreatment.

Fig 12. Radiographs at 5 years posttreatment.


The major goals of the second phase of treatmentwere to achieve adequate occlusal function and facialesthetics, as desired by the patient, despite her 2 heartsurgeries. The desire to move beyond an unfavorableprior orthodontic experience (camouflaging) andacceptance of the proposed surgical orthodontic


protocol demonstrated great motivation on the patient'spart, as well as a good understanding of the correcttreatment plan. Patients should always be properlyinformed of their treatment options throughout thediagnostic process and in their follow-up visits so thatthey can consider the limitations of the protocols


Fig 13. Cephalometric superimpositions: A, initial vs final (immediately posttreatment); B, final vs 5years posttreatment.

Table II. Cardiac risk* stratification for noncardiacsurgical procedures

High (reported cardiac risk often greater than 5%)Emergent major operations, particularly in the elderlyAortic and other major vascular surgeryPeripheral vascular surgeryAnticipated prolonged surgical procedures associated with largefluid shifts and/or blood loss

Intermediate (reported cardiac risk generally less than 5%)Carotid endarterectomyHead and neck surgeryIntraperitoneal and intrathoracic surgeryOrthopedic surgeryProstate surgery

Lowy (reported cardiac risk generally less than 1%)Endoscopic proceduresSuperficial proceduresCataract surgeryBreast surgery

Reprinted from Journal of the American College of Cardiology,2002;39(3). Kim A. Eagle, Peter B. Berger, Hugh Calkins, BernardR. Chaitman, Gordon A. Ewy, Kirsten E. Fleischmann, Lee A. Fleisher,James B. Froehlich, Richard J. Gusberg, Jeffrey A. Leppo, ThomasRyan, Robert C. Schlant, William L.Winters, et al, ACC/AHA guidelineupdate for perioperative cardiovascular evaluation for noncardiacsurgery—executive summary: A report of the American College ofCardiology/American Heart Association Task Force on PracticeGuidelines (Committee to Update the 1996 Guidelines on Perioper-ative Cardiovascular Evaluation for Noncardiac Surgery), Copyright2002; with permission from Elsevier.*Combined incidence of cardiac death and nonfatal myocardialinfarction; ydo not generally require further preoperativecardiac testing.



recommended by professionals. Therefore, all relevantinformation must be given to patients so that theyhave confidence in their treatment decisions.

CONCLUSIONS

With the increased likelihood that orthodontistswill encounter patients with cardiopathologies, thisarticle provides tools for the safe stratification of car-diac risks. Our therapeutic protocol combinedorthognathic surgery and orthodontics to producesatisfactory long-term results, and this treatment forClass II malocclusion allowed for the harmonizationof the patient's bone bases and facial profile. Thetreatment also improved her self-esteem and psychoso-cial behavior.

We thank the oral maxillofacial surgeon, Luiz CarlosFerreira da Silva, for his important contributions to thecardiac risk section of this article and Edvaldo D�oriaAnjos for performing the surgery.

REFERENCES

1. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management ofthe medically compromised patient. St Louis: Mosby; 2008.

2. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA,Fleischmann KE, et al. ACC/AHA guideline update for perioperativecardiovascular evaluation for non-cardiac surgery—executive sum-mary. A report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines (committeeto update the 1996 guidelines on perioperative cardiovascular



evaluation for noncardiac surgery). Anesth Analg 2002;94:1052-64.

3. Niwa H, Sato Y, Matsuura H. Safety of dental treatment in patientswith previously diagnosed acute myocardial infarction or unstableangina pectoris. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2000;89:35-41.

4. Potts B, Shanker S, Fields HW, Vig KW, Beck FM. Dental andskeletal changes associated with Class II surgical-orthodontictreatment. Am J Orthod Dentofacial Orthop 2009;135:566.e1-7;discussion 566-7.

5. Potts B, Fields HW, Shanker S, Vig KW, Beck FM. Dental andskeletal outcomes for Class II surgical-orthodontic treatment:a comparison between novice and experienced clinicians. Am JOrthod Dentofacial Orthop 2011;139:305-15.

6. Kinzinger G, Frye L, Diedrich P. Class II treatment in adults:comparing camouflage orthodontics, dentofacial orthopedicsand orthognathic surgery—a cephalometric study to evaluatevarious therapeutic effects. J Orofac Orthop 2009;70:63-91.

7. Proffit WR, Phillips C, Douvartzidis N. A comparison of outcomesof orthodontic and surgical-orthodontic treatment of Class IImalocclusion in adults. Am J Orthod Dentofacial Orthop 1992;101:556-65.

8. Pogrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assistedrapid maxillary expansion in adults. Int J Adult Orthod OrthognathSurg 1992;7:37-41.

9. TraunerR,ObwegeserH.The surgical correctionofmandibular prog-nathism and retrognathia with consideration of genioplasty. I. Sur-gical procedures to correct mandibular prognathism and reshapingof the chin. Oral Surg Oral Med Oral Pathol 1957;10:677-89.


10. Dal Pont G. Retromolar osteotomy for the correction of progna-thism. J Oral Surg Anesth Hosp Dent Serv 1961;19:42-7.

11. Epker BN. Modifications in the sagittal osteotomy of the mandible.J Oral Surg 1977;35:157-9.

12. Bell WH, Jacobs JD. Combined orthodontic-surgical correctionof moderate mandibular deficiency. Am J Orthod 1979;75:481-506.

13. Ow A, Cheung LK. Bilateral sagittal split osteotomies and mandib-ular distraction osteogenesis: a randomized controlled trialcomparing skeletal stability. Oral Surg Oral Med Oral Pathol OralRadiol Endod 2010;109:17-23.

14. Proffit WR, Turvey TA, Phillips C. The hierarchy of stability andpredictability in orthognathic surgery with rigid fixation: anupdate and extension. Head Face Med 2007;3:21.

15. Proffit WR, Turvey TA, Phillips C. Orthognathic surgery: a hierarchyof stability. Int J Adult Orthod Orthognath Surg 1996;11:191-204.

16. Bailey LJ, Proffit WR, White R Jr. Assessment of patients fororthognathic surgery. Semin Orthod 1999;5:209-22.

17. Bailey LJ, Cevidanes LH, Proffit WR. Stability and predictability oforthognathic surgery. Am J Orthod Dentofacial Orthop 2004;126:273-7.

18. Simmons KE, Turvey TA, Phillips C, Proffit WR. Surgical-orthodon-tic correction of mandibular deficiency: five-year follow-up. Int JAdult Orthod Orthognath Surg 1992;7:67-79.

19. Watzke IM, Turvey TA, Phillips C, Proffit WR. Stability of mandib-ular advancement after sagittal osteotomy with screw or wirefixation: a comparative study. J Oral Maxillofac Surg 1990;48:108-21.


Class II surgical-orthodontic treatment of a patient with severe … · 2017-12-22 · Class II surgical-orthodontic treatment of a patient with severe coronary disease: 5 years of

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