Surgical-orthodontic Treatment of a Patient with Severe ...

Volume 29 Issue 1 Article 5

2017

Surgical-orthodontic Treatment of a Patient with Severe Skeletal Surgical-orthodontic Treatment of a Patient with Severe Skeletal

Class III Anterior Open Bite and High Mandibular Plane by Class III Anterior Open Bite and High Mandibular Plane by

Preserving the Posterior Facial Height Preserving the Posterior Facial Height

Tz-Ya Hung Resident, Department of Dentistry, Songshan Branch, Tri-Service General Hospital, Taipei, Taiwan

Wei-Cheng Lee Resident, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan

Benjamin Lo Attending doctor, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan

Philip Kuo-Ting Chen Director, Craniofacial Center, Chang Gung Memorial, Hospital, Taoyuan, Taiwan.

Lih-Juh Chou Attending doctor, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan

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Recommended Citation Recommended Citation Hung, Tz-Ya; Lee, Wei-Cheng; Lo, Benjamin; Chen, Philip Kuo-Ting; Chou, Lih-Juh; and Li, Chung-Hsing (2017) "Surgical-orthodontic Treatment of a Patient with Severe Skeletal Class III Anterior Open Bite and High Mandibular Plane by Preserving the Posterior Facial Height," Taiwanese Journal of Orthodontics: Vol. 29 : Iss. 1 , Article 5. DOI: 10.30036/TJO.201703_29(1).0005 Available at: https://www.tjo.org.tw/tjo/vol29/iss1/5

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Surgical-orthodontic Treatment of a Patient with Severe Skeletal Class III Anterior Surgical-orthodontic Treatment of a Patient with Severe Skeletal Class III Anterior Open Bite and High Mandibular Plane by Preserving the Posterior Facial Height Open Bite and High Mandibular Plane by Preserving the Posterior Facial Height

Authors Authors Tz-Ya Hung, Wei-Cheng Lee, Benjamin Lo, Philip Kuo-Ting Chen, Lih-Juh Chou, and Chung-Hsing Li

This case report is available in Taiwanese Journal of Orthodontics: https://www.tjo.org.tw/tjo/vol29/iss1/5

https://www.tjo.org.tw/tjo/vol29/iss1/5

39Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

Case Report

Class III malocclusions with a hyperdivergent vertical facial pattern are often difficult to treat without

combining the surgical-orthodontic approach. The aim of this article is to present a collaborative management of

a case with severe skeletal class III and anterior open bite. The 19-year-old man was characterized with midface

deficiency, mandibular prognathism, high mandibular plane angle, long lower facial height, and excessive

anterior open bite. The achievement of a stable surgical setup in interdigitation prior to orthognathic surgery

(OGS) is critical for a successful treatment via dental decompensation. Two-jaw surgery with clockwise rotation

of the maxilla and bilateral sagittal split osteotomies was performed to correct the skeletal Class III malocclusion

and anterior open bite. An acceptable smile arc and facial profile were achieved. The total treatment duration

was 28 months. The treatment outcome presented a good facial profile and solid occlusion. Moreover, the

skeletal and dental relationships were stable 2 years after finish. Accurate diagnosis and treatment design, good

patient’s compliance, and effective communication are essential to correct the severe dentoskeletal deformaties.

(Taiwanese Journal of Orthodontics. 29(1): 39-51, 2017)

Keywords: Class III malocclusion; anterior open bite; vertical facial pattern

surgical-orThodonTic TreaTmenT of a paTienT wiTh severe skeleTal class iii anTerior open biTe

and high mandibular plane by preserving The posTerior facial heighT

Tz-Ya Hung,1 Wei-Cheng Lee,

2 Benjamin Lo,

3 Philip Kuo-Ting Chen,

4 Lih-Juh Chou,

3 Chung-Hsing Li,

5

Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan1Resident, Department of Dentistry, Songshan Branch, Tri-Service General Hospital, Taipei, Taiwan

2Resident, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry,

Tri-Service General Hospital, Taipei, Taiwan 3Attending doctor, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry,

Tri-Service General Hospital, Taipei, Taiwan4Director, Craniofacial Center, Chang Gung Memorial, Hospital, Taoyuan, Taiwan.

5

Director, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan.

Received: Stepmber 8, 2016 Revised: March 10, 2017 Accepted: March 13, 2017Reprints and correspondence to: Dr. Chung-Hsing Li, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry,

Tri-Service General Hospital, Taipei, TaiwanNo. 325, Sec. 2, Chenggong Rd, Neihu District, Taipei City 114, Taiwan, ROCTel: 886-2-87927285 Fax: 886-2-87927147 E-mail: [email protected]

40 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

INTRODUCTION

Class III malocclusions represent a small fraction

of the malocclusions in orthodontic patients,1 with an

incidence of 1–4% in Caucasians.2,3,4

However, in the Asian

population the incidence ranges from 9%–19% owing

to the large percentage of Asian patients with maxillary

deficiency.5,6,7,8

The incidence of Class III malocclusion is

reported to be 4–13% in Japanese9 and 4–14% in Chinese

patients.10

In Lin’s study, in Chinese children with age in

9 to 15 years, the prevalence of pseudo- and true Class III

malocclusion was 2.3% and 1.7%, respectively.11

Patients with skeletal Class III malocclusion can

be treated using orthopedics, orthodontic camouflage,

or orthodontic treatment combined with orthognathic

surgery (OGS). The optimal method depends on the age

of the patient, the stage of craniofacial development, the

degree of skeletal discrepancy, the skeletal pattern, and

the facial profile.12,13

Anterior open bite combined with

any malocclusion makes both features difficult to correct,

particularly in concurrent with a Class III malocclusion.14

Camouflage orthodontic treatment can result in

proper occlusion and esthetics in nonsurgical cases

of Class III malocclusion. However, in surgical cases

of Class III malocclusion, dental decompensation is

necessary before surgery to facilitate skeletal corrections.

Several studies have reported that the most effective

treatment option in adult patients with skeletal open bite

is surgical repositioning of either the maxilla or both

jaws.15,16

In addition, Sugawara et al. found that in patients

with skeletal Class III open bite, moving the anterior

maxillary structures down with clockwise rotation of the

palatal plane effectively produces a reasonably stable

correction of the anterior open bite.17

Herein, we present the treatment of an adult patient

with severe skeletal Class III maxillary deficiency

Hung TY, Lee WC, Lo Benjamin, Chen KT, Chou LJ, Li CH

combined with mandibular prognathism, an extremely

high mandibular plane angle, and anterior open bite.

With the aid of the reduction genioplasty, LeFort I

osteotomy, and bilateral sagittal split osteotomy (BSSO),

the clockwise rotation of the maxillomandibular complex

(MMC) altered the existing occlusal plane, the outcome

demonstrated a consonant smile curve, harmonized facial

aesthetics, a stable skeletal relationship and god dental

occlusion.

CASE REPORT

A 19-year-old male patient who had no history of

illness or trauma, presented the following complaints

including inability to bite off food with his incisors,

difficulty chewing, tooth crowding over both arches,

a long face, and occasional involuntary opening of the

mouth.

The extraoral examination revealed that the patient

had skeletal Class III malocclusion with midface

deficiency, mandibular prognathism, a high mandibular

plane, an excessively long lower third of the face, facial

asymmetry, an acute nasolabial angle, a flat labiomental

fold due to straining to compensate for the vertical

discrepancy, lip incompetence with mentalis strain, a flat

smile arc, and uncoordinated dental and facial midlines

(Figures 1).

The intraoral examination revealed that the patient

had Angle’s Class III malocclusion with anterior open

bite and negative overjet, bilateral posterior and anterior

crossbite, non-coincident upper and lower dental midlines,

and large interincisal angle which due to flaring maxillary

incisors and retroclined lower incisors, a reverse curve of

Spee in the lower arch, crowding of both arches, mesial

tipping of the lower arch, and impaction of tooth #18

(Figures 1-3 and Table 1).


Surgical-orthodontic Treatment in Class III

Figure 1. Facial and intraoral photographs, before treatment.

Figure 2. Study models in before treatment.



Figure 3. A Lateral cephalometric film, B panoramic radiographs before treatment.

Table 1. Cephalometric summary.

Measurement Pre-treatment Post-treatmentSkeletal

SNA° 79.8 84.3SNB° 84.9 80.5ANB° -5.1 3.8AO-BO (mm) -2.2 -0.6SN-MP° 44.3 42.1FMA° 37.6 35.2Y-axis° 63 68.6Lower Go angle° 94.4 90Articular angle° 164.7 169.4PFH (mm) 9.6 9.6AFH (mm) 15.3 14.8PFH/AFH (%) 61.5 63.6

Dental1 TO NA (mm) 1.1 1.21 TO SN° 109 102.91 TO NB (mm) 1.6 0.91 TO MP° 74.7 89.2FMIA° 67.7 55.6OCC. PLANE angle° 21.8 23.8

Facial

E-LINE (mm)Upper -7 -1Lower 0 -2

NLA° 90 100Z-Angle° 77 75UPPER LIP (mm) 14 15TOTAL CHIN (mm) 8 16



TREATMENT OBJECTIVES

● �To correct the midface deficiency, the vertical

maxillary excess and anterior open bite; to correct the

mandibular prognathism and the excessive lower third

of the face; and to correct the canting occlusal plane in

facial skeleton.

● �To improve the acute nasolabial angle and paranasal

depression, to improve the flat labiomental fold and

chin contour, and to shape the bilateral gonial angle in

facial soft tissue.

● �To correct the dental compensation and anterior open bite.

● �To achieve a stable, functional occlusion by establish

Class I canine relationships as well as a consonant

smile arc and competent lip posture.

TREATMENT ALTERNATIVES

The first treatment option included advanced LeFort I

osteotomy, BSSO mandibular setback, clockwise rotation

of the MMC, and vertical reduction genioplasty with

advancement. This option could improve the paranasal

depression and mandibular prognathism and result in a

balanced facial profile.

The second treatment option was one-jaw surgery

mandibular surgery. The intrusion of posterior teeth and

correction of occlusal plane cant would be corrected with

the application of temporary anchorage devices (TADs)

over the posterior maxilla. This method could only correct

the anterior open bite, but compromised facial esthetics

was expected.

The patient chose the two-jaw surgery to achieve a

better facial aesthetics.

TREATMENT PLAN

A comprehensive diagnosis, treatment objectives, and

treatment alternative were presented to the patient. With

patient’s consent, the following treatment plan was chosen:

● �Placement of pre-adjusted edgewise appliances to

level, align and coordinate the dental arches and to

correct dental compensation.

● �OGS: 1) LeFort I osteotomy with advancement,

posterior maxillary impaction and clockwise rotation

of occlusal plane to correct canting occlusal plane

and improve the paranasal depression; 2) BSSO to

correct skeletal discrepancy, anterior open bite, and

mandibular prognathism.

● �Vertical reduction genioplasty with advancement to

improve the flat labiomental fold and chin contour.

● �Surgical-orthodontic combined treatment to get

balanced facial profile and good interdigitation.

TREATMENT PROGRESS

Preoperative orthodontic treatment was carried out

by using the pre-adjusted 0.022-inch edgewise appliances.

Before orthodontic treatment, the maxillary right third

molar was extracted. Leveling, alignment, and arch

coordination were then performed to achieve dental

decompensation. Preoperative orthodontic treatment

lasted for 12 months and was completed using 0.017 ×

0.022 inch stainless steel (SS) arch wires (Figure 4).

The orthognathic surgery consisted of two-

jaw surgery including LeFort I osteotomy, BSSO and

genioplasty. The surgical procedure on the maxilla

involved a one-piece LeFort I osteotomy with maxillary

advancement of about 3 mm on the right side and 5 mm

on the left side to correct the paranasal depression. The

posterior maxilla was impacted about 5 mm on the right

side and 3 mm on the left side to alter the occlusal plane

and correct the anterior open bite. BSSO was performed

on the mandible with backward of 9 mm on the right side

and 12 mm on the left side to establish the correct skeletal

and dental relationships. Genioplasty was performed with

chin advancement 3 mm and reduction 3 mm to correct

the excessive lower facial height and improve the chin

contour.



Postoperative orthodontic treatment started 6 weeks

after surgery (Figure 5 and Figure 6). The orthodontic

treatment kept progressing with detailing and finishing,

achieving Class I canine relationship, normal overbite and

overjet, and coincident facial and dental midlines. After

16 months for detailing and finishing, the patient was

debonded, and Hawley retainers were used for retention

(Figure 7). The total treatment duration was 28 months.

The skeletal and dental conditions were stable after 2

years of follow-up (Figure 8).

Figure 4. A Lateral cephalometric film, B panoramic radiographs before surgery and after presurgical leveling.



Figure 5. Facial and intraoral photographs, after OGS.

Figure 6. A Lateral cephalometric film, B panoramic radiographs after completion of treatment.



Figure 7. The intraoral photographs, after treatment.

Figure 8. The facial and intraoral photographs in 2 years after debond.



surgery. However, this procedure cannot resolve midfacial

deficiency. In addition, long-term reports indicated that

the relapse rate for orthodontic molar intrusion is about

30%.20,22

Park et al. reported that 2 to 3 mm of posterior

teeth intrusion can be obtained easily and precisely using

TADs.21

While cases of severe anteroposterior discrepancy

and vertical maxillary excess still require skeletal

posterior maxillary impaction. This procedure increases

the amount of surgical mandibular setback and distal

movement of the chin by changing the occlusal plane in

a clockwise direction.21

In this case, clockwise rotation of

the MMC was performed using LeFort I osteotomy and

BSSO to achieve better facial balance.

Preoperative orthodontic decompensation treatment

could increase the severity of the Class III malocclusion

and facial profile.23

The quality of preoperative dental

decompensation determines the quality, quantity, and

type of OGS, was considered as one of the factors to the

success of the treatment.24,25

In this case, decompensation

of the maxillary and mandibular arches, without

extraction, required 12 months. The overjet changed from

-6 mm to -12 mm. The large negative overjet increased

the amount of surgical mandibular setback.

Several additional orthodontic parameters must be

considered while planning dental decompensation before

orthognathic surgery. The inclination of the anterior teeth

would change after surgical alteration of the occlusal

plane angle. If the maxillary occlusal plane angle is to be

altered using counter-clockwise rotation, the angulation of

the upper anteriors should be decreased before surgery. In

other hand, if the maxillary occlusal plane angle is altered

clockwisely, the angulation of the upper anteriors should

be increased before surgery. However, if the maxilla is

segmentalized, the surgeon could change the angulation

of the maxillary anterior teeth with wider range.26

In the

case presented here, the angulation of the upper anteriors

decreased from 109° to 103° because of clockwise rotation

of the maxilla. It also contributes to the improvement of

the smile arc from from flat to favorable.

TREATMENT RESULTS

The facial profile, excess vertical facial height,

and anterior open bite were improved (Figure 8). A

normal overbite, overjet, Class I canine relationships,

and coincident facial and dental midlines were achieved

(Figure 9). A considerable increase in the nasolabial angle

was observed. The flat labiomental fold was changed to an

acceptable contour. The superimposition of cephalometric

tracings revealed that the maxilla had advanced, thereby

improving the paranasal depression. The impacted

posterior maxilla was affected by changes in the occlusal

plane and improvement in the reverse smile arc. The

anterior nasal spine osteotomy was performed to prevent

widening of the nose. The mandible was set back to

eliminate the mandibular prognathism. Genioplasty was

performed to improve the chin contour. Cephalometric

analysis comparing the initial and final conditions

indicted that the ANB angle increased from -5.1° to 3.8°.

The angle between the maxillary incisor and S-N plane

decreased from 109° to 102.9°. The mandibular incisor

to mandibular plane angle increased from 74.7° to 89.2°

(Figure 10 and Table 1).

DISCUSSION

Accurate diagnosis of the skeletal and dentoaloveolar

components of Class III malocclusion, including maxillary

deficiency, mandibular prognathism, or a combination

of both, is essential for accurate planning and effective

treatment.14,18

Anterior open bite varies from case to case

and is one of the most challenging dentofacial deformities

to treat.19

If severe skeletal class III malocclusion is

combined with anterior open bite, orthodontic correction

is further complicated. Several cases have recently

been reported in which mandibular setback combined

with TADs for maxillary molar intrusion to reduce the

posterior vertical dimension instead of using maxillary

surgical impaction.20,21

This method was reported as less

invasive and effective alternative other than the two-jaw



Figure 9. The study models, after treatment.

Figure 10. Superimposition of cephalometric tracings. Black line, before treatment; red line, after treatment.



tissue advancement was greater in patients who had both

anterior chin repositioning and vertical chin reduction

than in those who had only anterior chin repositioning.37

Performing both mandibular setback and vertical chin

reduction together has been reported to double the effect

to deepening of the labiomental fold. Hence, without

a proper treatment plan, mandibular setback combined

with superior–anterior repositioning of the chin may

result in overcorrection of the chin prominence.36

In our

case, the patient had mandibular prognathism and long

lower anterior face with a long and flat chin. Thus the

mandibular setback combined with superior–anterior

chin reposition genioplasty was performed to achieve a

balanced facial profile.

In this patient, black triangles developed in the

mandibular incisors. Black triangles, or open gingival

embrasures, are an undesirable outcome of orthodontic

treatment. Black triangles are more frequent in adult

patients than in younger patients and are associated with

alveolar bone resorption.38

Kim et al. reported that in

surgical skeletal Class III patients, vertical alveolar bone

loss was more severe in the mandibular incisors than in

the maxillary incisors. In a 3D cone beam CT study, the

authors observed that lingual alveolar bone loss increased

during orthodontic treatment.39

In another study, the

same authors reported that excessive forward movement

of the lower incisors during pre-surgical orthodontic

treatment results in alveolar bone loss around the incisors.

Therefore, extra attention should be paid to reduce the

risk of alveolar bone loss.40

If the symphysis is narrow

and high and the mandibular incisors undergo pronounced

sagittal movements and derotation, progressive bone

loss may occur over the lingual and labial cortical plates

during orthodontic treatment with a fixed appliance.41

Liou et al. also reported that orthognathic surgery triggers

a 3- to 4-month period of higher osteoclastic activities and

metabolic changes in the dentoalveolar region;42

it may be

also be one of the reason for alveolar bone loss.

Only a few cases in the literatures described

the s tabi l i ty of the changes af ter c lockwise or

counterclockwise rotation of the jaws. Chemello et al. and

Reyneke et al. reported stable results after both clockwise

rotation and counterclockwise rotation of the MMC.27,28

However, Schendel and Epker reported that postsurgical

stability is poor after counterclockwise rotation of the

mandible.29

This resulted from the procedures to increase

in the posterior facial height and stretching of the pterygo-

masseteric musculature. In our case, clockwise rotation

of the maxilla and slight counterclockwise rotation of

the mandible with BSSO setback were performed. This

procedure neither changed the posterior facial height nor

stretched the pterygo-masseteric musculature.

In this case, we stripped the muscle and ligament

attachment to the medial side of the mandibular angle.

This procedure allowed greater mandibular distal segment

setback and prevented rotation of the proximal segment

posteriorly, which might decrease postsurgical stability.30

BSSO osteotomy should be secured with rigid fixation.

The changes in proximal segments might tend to return to

their presurgical position following surgery.31

In addition,

Proffit et al. reported that there is better control of the

ramus position when two-jaw surgery is performed.30

In this case, the ramus position was not changed and the

condyle was in the glenoid fossa. After 2 year follow up

after surgery, a stable skeletal relationship and occlusion

were maintained.

Sarver reported that clockwise rotation of the

occlusal plane can improve a flat or reverse smile arc.32

Tooth display relative to upper lip relation is important

during smile. In this case, clockwise rotation of the

maxillary occlusal plane was performed to achieve a

better smile.

Mandibular setback could increase the depth of

labiomental fold and increase facial convexity.33,34

Vertical

shortening of the chin can also increase the fold depth

and chin projection.35,36

Gallagher et al. reported that soft



appliance in severe skeletal Class III cases. Am J

Orthod Dentofacial Orthop. 1987; 92:304-312.

10. A l lwr igh t WC, Burndred WH. A su rvey o f

handicapping dentofacial anomalies among Chinese in

Hong Kong. Int Dent J. 1964; 14:505-519.

11. Lin JJ. Prevalence of malocclusion in Chinese

children age 9-15. Clin Dent. (Chinese) 1985; 5:57-65.

12. Baik, HS. Limitations in Orthopedic and Camouflage

Treatment for Class III Malocclusion. Semin Orthod.

2007; 13:158-174.

13. McIntyre GT. Treatment planning in Class III

malocclusion. Dental Update. 2004; 31: 13-20.

14. Bilodeau JE. Nonsurgical treatment of a Class III

patient with a lateral open-bite malocclusion. Am J


15. Erverdi N, Usumez S, Solak A. New generation

openbite treatment with zygomatic anchorage. Angle

Orthod. 2006; 6:519–526.

16. Kuroda S, Katayama A, Takano-Yamamoto T. Severe

anterior open-bite case treated using titanium screw

anchorage. Angle Orthod. 2004; 74:558–567.

17. Moldez MA, Sugawara J, Umemori M, Mitani H,

Kawamura H. Long-term dentofacial stability after

bimaxillary surgery in skeletal Class III open bite patients.

Int J Adult Orthodon Orthognath Surg. 1999; 15:309-19.

18. Tsai IM, Lin CH, Wang YC. Correction of skeletal

Class III malocclusion with clockwise rotation of the

maxillomandibular complex. Am J Orthod Dentofacial

Orthop. 2012; 141:219-27.

19. Bisase B, Johnson P, Stacey M. Closure of the anterior

open bite using mandibular sagittal split osteotomy. Br

J Oral Maxillofac Surg. 2010; 48:352-5

20. Togawa R, Iino S, Miyawaki S. Skeletal Class III and

open bite treated with bilateral sagittal split osteotomy

and molar intrusion using titanium screws. Angle

Orthod. 2010; 80:1176-84

21. Park HS, Kim JY, Kwon TG. Occlusal plane

change after intrusion of maxillary posterior teeth

by microimplants to avoid maxillary surgery with

skeletal Class III orthognathic surgery. Am J Orthod

Dentofacial Orthop. 2010; 138:631-40.

CONCLUSION

Skeletal Class III malocclusion combined with

anterior open bite is difficult to treat. In this case, the

patient was corrected with two-jaw surgery, excellent

facial profile and dental relationship was achieved.

Clockwise rotation of the occlusal plane can increase

the amount of surgical mandibular setback and distal

movement of the chin. Mandibular setback can also

deepen the labiomental sulcus to correct a long, flat chin,

achieving a balanced facial profile. Factors that cause

black triangles should be considered, and communication

with patients before treatment is very important.

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