Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite

Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open BiteJanuary 2018
Deformity and Anterior Open Bite 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 Hospital, Taipei, Taiwan"
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Recommended Citation 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.
Abstract Abstract 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 surgeryfirst 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.
Keywords Keywords Class III malocclusion; anterior open bite, two-jaw orthognathic surgery
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Authors 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
INTRODUCTION
of both. 1 The prevalence of Class III malocclusion
is higher in Asian than in Caucasian populations. 2
Fur thermore, the sever i ty of skele ta l Class I I I
malocclusion is more marked in Asian populations,
often requiring two-jaw surgical correction. 3,4
In modern
orthodontics, cone-beam computed tomography is a useful
imaging tool to survey the bony deformity in order to plan
appropriate surgical procedures.
Case Report
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.
surgical-orThodonTic TreaTmenT for a PaTienT wiTh skeleTal class iii deformiTy and anTerior oPen BiTe
Wei-Chih Hung, 1,3
2 Lih-Juh Chou,
3 Chung-Hsing Li,
3 Gunng-Shinng Chen
2 Chicing Plastic Clinic, Taipei, Taiwan
3 Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital,
Taipei, Taiwan
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]
172 Taiwanese Journal of Orthodontics. 2018, Vol. 30. No. 3 DOI: 10.30036/TJO.201810_31(3).0005
CASE PRESENTATION
An 18-year-old female patient reported experiencing
difficulty biting off food with her front teeth and a long
lower jaw. She denied history of major systemic diseases
and facial trauma.
third, lip incompetence with mentalis strain, and a flat
smile arc with no major facial asymmetry. The upper and
lower dental midlines coincided with the facial midline. A
lateral view showed midface deficiency with mandibular
prognathism and an acute nasolabial angle (Figure 1).
Intraoral examination revealed a Class III canine and
molar relationship on both sides, as well as an anterior
cross bite and open bite. Moreover, the lower arch was
ovoid and narrow, with lingual tipping of the molars. The
upper arch form was square in shape.
Treatment options for adult skeletal Class III
malocclusions include orthodontic camouflage or
orthodontic treatment combined with orthognathic
surgery. The choice between surgery and non-surgical
orthodontic treatment for adult Class III patients should
base on complete evaluation and diagnosis. In additional
to sagittal discrepancy, the vertical problem of anterior or
lateral open bite often complicates the treatment decision. 4
We present a sequential surgical and orthodontic
treatment of an adult patient with severe skeletal Class III
deformity and an anterior open bite. The surgery included
LeFort I maxillary osteotomy and bilateral sagittal split
osteotomy (BSSO) in the mandible with clockwise
rotation of maxillomandibular complex (MMC), as well as
osseous genioplasty for chin advancement. Post-treatment
results showed a harmonious facial profile, curved smile
arc, as well as stable dental and skeletal relationship.
Figure 1. Pre-treatment facial and intraoral photographs.
Hung WC, Lee WC, Chen YC, Chou LJ, Li CH, Chen GS
173Taiwanese 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
wisdom teeth. Lateral cephalogram examination
demonstrated that the patient had a skeletal Class
III deformity, with proclined maxillary incisors and
retroclined lower incisors (Figure 2 and Table 1).
The patient was diagnosed with a skeletal Class III
relationship, with midface deficiency and mandibular
prognathism, as well as Angle’s Class III malocclusion
with an anterior open bite.
Table 1. Comparisons of pre-treatment and post-treatment cephalometric analysis.
Skeletal Pre-treatment Post-treatment Norm
Dental
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
Figure 2. (A) Lateral cephalometric film. (B) Panoramic film before treatment.
TREATMENT GOALS AND PLAN
The treatment objectives included:
2. Correct dental compensation and inclination.
3. Achieve a bilateral Class I canine and molar relationship.
4. Improve her facial profile, lip posture and smile arc.
Based of the diagnosis, treatment goals, and the
patient’s primary concerns, the following treatment plan
was presented:
2. LeFort I advancement with posterior maxillary
impaction with clockwise rotation of the maxilla and
BSSO for mandibular setback.
alignment and to achieve satisfactory interdigitation.
Figure 3. Facial and intraoral photographs after treatment.
TREATMENT PROGRESS
A week prior to surgery, we performed presurgical orthodontic preparation, which included full-mouth bonding and wire consolidation to prevent the bracket falling into the patient’s airway during surgery. In this surgery-first case, dental model was used to simulate treatable post-surgical occlusion. The surgical occlusion setup open contact in the posterior teeth to avoid unpredictable surgical interferences.
The LeFort I osteotomy was performed on the maxilla, with 2-mm advancement and 5-mm posterior impaction. BSSO was performed bilaterally on the mandible, with an 8-mm setback. Additionally, osseous genioplasty was performed to improve the chin contour.
Postoperative orthodontic treatment was initiated 1 week after surgery. The treatment involved leveling 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 4. (A) Lateral cephalometric film after operation. (B) Lateral cephalometric film after treatment. (C) Panoramic film after treatment.
(A) (B)
(C)
TREATMENT RESULTS
anterior open bite of the patient were corrected. The
nasolabial angle was markedly increased. The patient also
displayed a consonant smile arc. Intraoral examination
revealed a bilateral Class I canine and molar relationship,
as well as normal overjet and overbite. Dental midlines
coincided with the facial midline. Cephalometric analysis
revealed ANB angle improvement from -5.5° to +3°. The
angle between U1 to SN had decreased by 17°; moreover,
the angle between L1 to MP had increased by 1.5° (Figure
5 and Table 1). The patient expressed satisfaction with the
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.
DISCUSSION
anterior-posterior, transverse, and vertical control
of the teeth and skeleton. In the evaluation of the
anterior-posterior aspect, two-jaw surgery with maxilla
advancement can resolve midfacial deficiency. Two-
jaw surgery is also recommended over one-jaw surgery
for greater ANB angular correction, particularly in cases
with severe skeletal Class III discrepancy. 6 Clockwise
rotation of the MMC and occlusal plane can correct the
proclination of the upper incisors and can improve the flat
smile arc. 7,8
can lead to a greater amount of mandibular setback and
improved facial esthetics. 7,9
two-jaw surgery, several studies have suggested the use
of maxillary molar intrusion with temporary anchorage
devices as an alternative to LeFort I osteotomy for maxilla
impaction. 10,11,12
apical root resorption. 13
jaw surgery with maxilla advancement and clockwise
rotation of the MMC to achieve better esthetic results.
From the t ransverse view, in pat ients with
mandibular prognathism, some studies have noted the
development of buccal tipping of the upper posterior
teeth and lingual tipping of the lower posterior teeth,
to maintain masticatory function. 14,15
In skeletal Class
related to sagittal and transverse skeletal discrepancy. 16
In surgery-first orthognathic cases, dental compensation
of the upper and lower posterior teeth in the transverse
section may cause occlusal interference during surgery. 17
After surgery, the inter-arch cross-elastics were applied
to correct the transverse dental compensation of posterior
teeth. The posterior open bite was setup for surgical
occlusion to avoid unpredictable occlusal interference and
unexpected post-surgical anterior open bite.
In a vertical view, open bite can be categorized into
skeletal open bite and dental open bite. However, it is
difficult to make a differential diagnosis between these
categories, because the clinical features often entail a
combination of both factors. 18
Hence, evaluating soft
The
into three groups: anatomical, environmental, and genetic
factors. 18
the skeletal open bite were an abnormal lower gonial
angle value and overbite depth indicator (ODI) as shown
in Figure 6 and Table 2. 18,20-24
A greater lower gonial
an increased lower anterior facial height. 25
In terms of
along with step-up in the upper anterior incisor region,
the open bite was mainly limited at the anterior teeth.
To resolve the habit of tongue thrusting, we bonded a
lingual button over the palatal side of the upper incisor
as a reminder of tongue position. During orthodontic
treatment, we guided and checked the patient’s tongue
position at every appointment. The use of positioners
for finishing or retention offers advantages in preventing
open bite. 26
the family history of this case. Hence, we corrected the
anterior open bite with clockwise rotation of the maxilla
by LeFort I osteotomy. Another factor influencing post-
surgical instability was posterior facial height (PFH)
enhancement. 27
stable result.
camouflage treatment for skeletal Class III patients, the
patient’s chief complaints, facial profile, limitation of
teeth movement, and severity of bony discrepancy should
be taken into consideration. A recent study reported six
cephalometric measurements (overjet ≤ -4.73 mm; Wits
appraisal ≤ -11.18 mm; L1-MP angle ≤ 80.8°; Mx/Mn
ratio ≤ 65.9%; overbite ≤ -0.18 mm; and gonial angle ≥
Table 2. Cephalometric Measurements related to skeletal open bite.
Measurement Pre-treatment Norm
Y-AXIS 64.5 53 - 66 °
Lower Go angle 78.5 70 - 75°
Overbite depth indicator (MP ^ AB plane angle ± FH ^ Palatal plane angle) 60.3 74.5 ± 6.07
Figure 6. Cephalometric evaluation of skeletal open bite.
120.8°) that can be used to determine whether surgical
intervention is appropriate in borderline cases. 28
Surgical
treatment is recommended if the patient meets at least
four of the six criteria. In this case, the patient met four of
the criteria (overbite: -1 mm, Mx/Mn ratio: 61.6%, Wits
appraisal: -15 mm, gonial angle: 122°) and she agreed
with surgical orthodontic treatment.
open bite, orthodontists must know the etiology,
treatment sequence, and surgical pattern before starting
surgical orthodontic treatment. An accurate diagnosis
and treatment plan alongside effective communication
between the patient, orthodontist, and surgeon are
essential for successful outcomes in such cases.
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Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite
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Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite
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Surgical-orthodontic Treatment for a Patient with Skeletal Class III Deformity and Anterior Open Bite

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