Surgical-Orthodontic Treatment in Class III Skeletal …[email protected] Dr.Camelia Szuhanek was born in Timisoara, Romania, on 25th of November 1975. She is a specialist

Abstract—The correction of dento-facial deformity often

requires combined surgical and orthodontic therapy. Poor

facial appearance and functional difficulties are the motivating

factors for seeking treatment in patients with Class III skeletal

anomalies. This presentation aims to show the surgical and

orthodontic procedure in correcting Class III patients.

Keywords—skeletal anomalies, orthognathic surgery, class

III malocclusion.

I. INTRODUCTION

During the last few decades our profession has witnessed an

intense interest in the treatment of facial deformities.[1,2,3,4]

Orthognathic surgery has become an acceptable treatment plan

for patients with various maxillofacial deformities with

pleasing results. The rehabilitation of severe Class III adult

patients requires a complex interdisciplinary orthodontic and

orthognathic approach. The interdisciplinary team provides the

professional opinion and guidance for diagnosis of the

problem, selection of orthodontic and surgical treatment

plan.[5,6]

This presentation aims to show the surgical and orthodontic

procedure in correcting complexe Class III patients with long

faces.

The goals of combined surgical and orthodontic treatment

are:

• to improve facial and dental aesthetics

• a functional, balanced and stable occlusion

• a satisfied patient.

The management protocol for facial deformity should

comprise the:

• History

• Clinical examination

• Investigations

• Initial diagnosis

• Treatment plan

• Presurgical orthodontics

• Final treatment plan

• Surgery

• Postsurgical orthodontics.

• Retention.

When appropriate, restorative dentistry, psychological

intervention or support and speech therapy will be

required[7].

II. CASE REPORT

A 19 year old male patient presented to the orthodontist

requesting a better dental and facial appearance. The medical

and familial history were not significant in determining the

etiological factor.

Facial features consisted of large lower facial height, lack of

malar proeminence, concave profile, prognathic mandible,

retruded maxilla.

Intraoral findings were also significant: severe class III

malocclusion, large openbite, midline shift, protrusion of

lower incisors, posterior crossbite.

The lateral cephalogram was analysed with the Cephx

software and revealed:

• Extremely large lower face height

• Retruded maxilla

• Retruded upper incisors

• Large intercincisal angle(139.34°)

• Mandible forward to maxilla(concave profile)

• Class III skeletal relationship(ANB – 6.18°)

• Severe high angle associated with openbite

• Upper lip retrusion.

Fig.1 Initial facial situation. Large lower facial height, lack of

malar proeminence, concave profile.

Surgical-Orthodontic Treatment in Class III

Skeletal Anomalies

Eduard Gîdea Paraschivescu, Camelia Szuhanek

Faculty of Dental Medicine,

University of Medicine and Pharmacy “Victor Babes”

Timisoara, ROMANIA [email protected], [email protected]

Proceedings of the World Medical Conference

ISBN: 978-1-61804-036-7 227

Fig.2 Initial occlusion. Severe class III malocclusion, large

openbite.

The cephalometric prediction suggested that surgical

movement would optimize the dental and facial balance.

The treatment plan consisted of:

- Pre-surgical orthodontics

- Bimaxillary surgery

- Post-surgical orthodontics

- Genioplasty, rhinoplasty.

The patient underwent presurgical orthodontics in order to

achieve the alignement and to facilitate surgical intervention.

The surgery consisted of a Le Fort I osteotomy impaction of

the posterior maxilla and bilateral sagittal split ramus

osteotomy setback of the mandible (Obwegeser DalPont).

Rigid internal fixation with plates and screws were used for

stabilisation of the osteotomy sites. Heavy intermaxillary

elastics maintained the occlusion immediately after surgery. In

a second phase, genioplasty and rhinoplasty were performed in

order to obtain a good facial balance.

Postsurgical orthodontic treatment was required in order

to establish normal occlusal relations. The evaluated

parameters significantly improved following

orthodontic/surgical treatment.

Fig.3 Cephalometric objectives of the surgical/orthodontic

treatment.

Fig.4 Pre treatment OPG.

Fig.5 Pre-surgical orthodontic treatment.

Fig. 6 Intermaxillary elastics following surgery.

Proceedings of the World Medical Conference

ISBN: 978-1-61804-036-7 228

Fig.7 The orthodontic treatment was continued after the

surgical intervention and provided good intermaxillary

contacts and alignement.

Fig. 8 Dental study models – before and after treatment,

lateral view.

Fig.9 Dental study models – before and after treatment,

frontal view.

Fig.10 Post-surgical frontal and lateral facial characterics.

Fig.11 Post treatment OPG.

III. DISCUSSION:

Among all dentofacial abnormalities, skeletal class III

anomalies are one of the most complicated problems in both

childhood and adulthood[8,9]. Class III skeletal problems are

treated with a combination of orthodontic and orthopedic

mechanics in growing individuals. In adulthood, correction of

the Class III malocclusion usually requires complex surgical

procedures.

Surgical/orthodontic treatment allows attainment of an

optimal aesthetic and functional result in Class III long face

patients[10]. This approach represents a useful option for the

treatment of these anomalies.

IV.CONCLUSIONS

Surgical-orthodontic treatment is often the only option to

obtain good facial balance in cases with dento-facial

deformity.

The outcome results greatly depends on the experience and

clinical skills of the interdisciplinary team.

Acknowledgement: This work was supported by CNCSIS–

UEFISCSU, project number PNII – IDEI 1738/2008-2011.

V. REFERENCES

[1] Bergamo AZ, Andrucioli MC, Romano FL, Ferreira JT,

Matsumoto MA. Orthodontic-surgical treatment of class III

malocclusion with mandibular asymmetry. Braz Dent J.

2011;22(2):151-6.

[2] Benyahia H, Azaroual MF, Garcia C, Hamou E, Abouqal

R, Zaoui F. Treatment of skeletal class III malocclusions:

orthognathic surgery or orthodontic camouflage? How to

decide. Int Orthod. 2011 Jun;9(2):196-209. Epub 2011 Apr 20.

[3] Tseng YC, Pan CY, Chou ST, Liao CY, Lai ST, Chen CM,

Chang HP, Yang YH. Treatment of adult Class III

malocclusions with orthodontic therapy or orthognathic

surgery: receiver operating characteristic analysis. Am J

Orthod Dentofacial Orthop. 2011 May;139(5):e485-93.

[4] Kang SH, Kim MK, Park SY, Lee JY, Park W, Lee SH.

Early orthognathic surgery with three-dimensional image

simulation during presurgical orthodontics in adults. J

Craniofac Surg. 2011 Mar;22(2):473-81.

[5] MOHAJERANI H., MEHDIZADEH M., SIGAROODI

A.K.: Skeletal Relapse after Correction of Mandibular

Proceedings of the World Medical Conference

ISBN: 978-1-61804-036-7 229

Prognathism by Bilateral Sagittal Split Ramus Osteotomy,

Journal of Dentistry, Tehran University of Medical Sciences,

Tehran, Iran (2009; Vol. 6, No.3), 2008

[6] Nout E, Koudstaal MJ, Wolvius EB, Van der Wal KG.

Additional orthognathic surgery following Le Fort III and

monobloc advancement. Int J Oral Maxillofac Surg. 2011

Jul;40(7):679-84. Epub 2011 Mar 12.

[7] Liao YF, Chiu YT, Huang CS, Ko EW, Chen YR.

Presurgical orthodontics versus no presurgical orthodontics:

treatment outcome of surgical-orthodontic correction for

skeletal class III open bite. Plast Reconstr Surg. 2010

Dec;126(6):2074-83.

[8] Takahashi H., Furuta H., Moriyama S. : Assessment of

three bilateral sagittal split osteotomy techniques with respect

to mandibular biomechanical stability by experimental study

and finite element analysis simulation; Med.Bull. Fukuoka

Univ.: 36(3), 181-192, 200.9

[9] Tompach PC, Wheeler JJ,: Orthodontic considerations in

orthognathic surgery, Int. J Adult Orthoganth. Surg. 1995

[10] Szuhanek C., Paraschivescu E. - Interdisciplinary

surgical-orthodontic treatment of class III long face patients.

87th European Orthodontic Society Congress, 19-23th of June

2011, Istanbul, Turkey.

Consultant Dr. Gidea Paraschivescu

Eduard,PhD - born in

Bucharest,Romania, on 27th of

September 1970. Specialist in Cranio-

Maxillo-Facial Surgery, with 17 years of

experience, currently employed as

Assistant Professor at the "Victor

Babes" University of Medicine and

Pharmacy, Timisoara, Romania and part

time at the Municipal Hospital

Timisoara, as consultant CMF Surgeon.

Author and co-author of several books and articles, published

in Romania and abroad and over 50 papers in oral presentation

at national and international conferences and congresses. Chief

surgeon of the Cleft Children International Humanitarian

Mission in Niger, Africa, where he founded a Center of

Excellence in Cleft Lip and Palate Surgery.

Main fields of interest - orthognathic surgery, cleft surgery,

plastic surgery, oncology.

[email protected]

Dr.Camelia Szuhanek was born in

Timisoara, Romania, on 25th of

November 1975. She is a specialist in

Orthodontics and Dentofacial

Orthopedics and received her DDS,

MSc and PhD degrees at the Faculty

of Dental Medicine, University of

Medicine and Pharmacy “Victor

Babes” Timisoara. She is currently an

Assistant Professor at the Department of Orthodontics and the

director of a research project on orthodontic biomechanics at

the University of Medicine and Pharmacy “Victor Babes”

Timisoara. She published over 140 articles in the field of

orthodontics. Dr.Szuhanek maintains a private practice

limited to orthodontics in Timisoara, Romania. Her main

research interests are biomechanics, numerical analysis,

lingual orthodontics, multidisciplinary treatment and skeletal

anchorage.

e-mail: [email protected]

Proceedings of the World Medical Conference

ISBN: 978-1-61804-036-7 230