|Year : 2014 | Volume
| Issue : 1 | Page : 58-61
Surgical correction of class II skeletal malocclusion in an adult patient
Ramakrishnan Balachander1, Kandapalanivel Karthik1, Anilkumar Katta2, Kandasamy Rajasigamani1
1 Departments of Orthodontics and Dentofacial Orthopaedics, Raja Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India
2 Sibar Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh, India
|Date of Web Publication||15-May-2014|
Department of Orthodontics and Dentofacial Orthopaedics, Sibar Institute of Dental Sciences, Takkellapadu, Guntur - 522 509, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Correction of skeletal deformities in adult patients with orthodontics is limited. Orthognathic surgery is the best option for cases when camouflage treatment is questionable and growth modulation is not possible. This case report illustrates the benefit of the team approach in correcting vertical maxillary excess along with class II skeletal deformity. A cosmetic correction was achieved by superior repositioning of maxilla with LeFort I osteotomy and augmentation genioplasty, along with orthodontic treatment. The patient's facial appearance was markedly improved along with functional and stable occlusion
Keywords: Camouflage, genioplasty, orthognathic
|How to cite this article:|
Balachander R, Karthik K, Katta A, Rajasigamani K. Surgical correction of class II skeletal malocclusion in an adult patient. J Orofac Sci 2014;6:58-61
|How to cite this URL:|
Balachander R, Karthik K, Katta A, Rajasigamani K. Surgical correction of class II skeletal malocclusion in an adult patient. J Orofac Sci [serial online] 2014 [cited 2019 May 20];6:58-61. Available from: http://www.jofs.in/text.asp?2014/6/1/58/132587
| Introduction|| |
Today's orthodontics not only gives importance to esthetics and function but also to establish harmony between craniofacial structures.  Facial appearance is an important factor in determining social relationships and improving their self-confidence.  Vertical maxillary excess is commonly seen in orthodontics with the gummy smile as the major problem from patient's perspective. The envelope of discrepancy  for the maxillary and mandibular arches in three planes of space determines the treatment plan by orthodontic or by orthognathic correction. Surgical intervention to reposition the jaws and dento alveolar segments becomes the only option to treat patients with severe skeletal deformity where growth modulation is not possible and camouflage treatment is questionable.  Considering the limitations of the orthodontic treatment for severe skeletal deformity combined orthodontic and surgical treatment was planned, which resulted in a stable outcome.
| Case report|| |
The present case report is about a 20-year-old female patient who came to the Department of Orthodontics with a chief complaint of forwardly placed upper front teeth and excessive visibility of gums in the upper arch during smile.
Extra oral examination
Dolichocephalic head pattern and leptoprosopic facial form. Frontal examination showed lip incompetence and full crown exposure during rest and 6 mm of gingival display during smile. Profile was convex with posterior divergence and increased lower anterior facial height. Clinical (Frankfort mandibular plane angle) was high and chin was retruded, with acute nasolabial angle [Figure 1]. Normal breathing, deglutition and speech were diagnosed on functional examination.
Intraoral examination revealed U shaped arches with bimaxillary dento alveolar proclination of upper and lower anteriors. Lower incisors showed mild crowding with exaggerated curve of spee. Angle's class I molar and canine relation on both sides with over jet of 4 mm and over bite of 5 mm [Figure 2] and [Figure 3].
Cephalometric examination revealed class II skeletal base due to orthognathic maxilla with vertical excess and mild retrognathic mandible. Vertical growth pattern with excess lower anterior facial height and increased mandibular plane angle. Dento alveolar analysis showed proclined upper and lower anteriors. Soft-tissue analysis indicates lip strain and protrusive lower lip [Figure 4]. Space analysis showing 10 mm of space discrepancy in the upper arch and 13 mm in the lower arch.
Angle class I malocclusion on a class II skeletal base between orthognathic maxilla and retrognathic mandible with vertical growth pattern and increase lower anterior facial height, with over jet of 4 mm and over bite of 5 mm and lower anterior crowding.
To obtain class I skeletal base, to level and align the teeth, to obtain the ideal over jet and over bite, to maintain class1 molar and canine relation, improvement of soft-tissue profile.
Phase I Pre surgical orthodontics, extraction of upper and lower 1 st premolars.
Phase II Orthognathic surgery, anterior superior repositioning of maxilla with Lefort I osteotomy and advancement genioplasty.
Phase III Post surgical stabilization.
The case was started with pre adjusted edgewise appliance using 0.022 slot MBT prescription. Upper and lower premolars were extracted as planned for pre surgical orthodontics. 0.016 initial nickel-titanium (Ni-Ti) arch wires were placed for alignment followed by 0.016 × 0.022 Ni-Ti and 0.017 × 0.025 Ni-Ti wires. Retraction was done on 0.019 × 0.025 stainless steel (ss) wire. 0.021 × 0.025 ss wires were placed for 2 months to achieve proper torque. Anterior superior repositioning of 5 mm was done along with advancement genioplasty [Figure 5]. The patient was put on settling elastics post surgically.
|Figure 5: Surgical photographs showing Lefort I osteotomy and genioplasty|
Click here to view
The total treatment duration was 18 months with 10 months of pre-surgical orthodontics and 8 months of post-surgical management. Outcome of the treatment was a significant improvement in the patient's smile and profile [Figure 6]. Class I molar and canine relation was maintained, ideal over jet and over bite established.proper root parelleling and torque has been established. Upper and lower lingual retainers were given. [Figure 7], [Figure 8] and [Figure 9].
| Discussion|| |
There are certain limitations how far a tooth can be moved and these become important when the problem is of severe skeletal deformity.  The essential steps in pre-surgical orthodontics are to align the arches and make them compatible to establish the antero-posterior and vertical position of the incisors. The extraction of first premolars aided in the correction of the upper incisor proclination and alignment and leveling the cuve of spee in the lower arch.
Superior repositioning of the maxilla was done with LeFort I osteotomy to reduce the gummy smile. In patients whose mandible is normal in size, the retrognathic appearance results from downward and backward rotation of the chin. Superior repositioning of the maxilla allows the mandible to rotate upward and forward, hinging at the temporomandibular joint, which simultaneously shortens facial height and provides more chin prominence. The clinical and cephalometric values showed that there is mild mandibular deficiency. Along with maxilla surgery, we considered the treatment option of sliding augmentation genioplasty by preventing extensive Bijaw surgery as auto rotation of the mandible helps in improving her profile. The results satisfied the primary complaint of the patient. Once satisfactory range of motion and stability were achieved, the finishing stage of orthodontics was done with settling elastics. The pre-surgical and post-surgical cephalometric values and superimpositions showed a dramatic skeletal and dental improvement [Table 1] and [Figure 10].
| Conclusion|| |
Orthognathic surgery is a possible option in patients with severe skeletal deformities. Treatment planning according to the level of discrepancy ensures stability and good outcome. The patient has reported a greater degree of pleasure related to her appearance.
| References|| |
|1.||Hegde M, Hegde C, Parajuli U, Kamath P, D MR. Combined orthodontic and surgical correction of an adolescent patient with thin palatal cortex and vertical maxillary excess. Kathmandu Univ Med J (KUMJ) 2012;10:88-92. |
|2.||Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthod 1985;87:21-6. |
|3.||Thomas M Graber, Robert L Vanarsdall, Katherine W.L. VIG Orthodontics Current Princples and Techniques. 4 th ed. Elsevier 2005. |
|4.||Abraham J, Bagchi P, Gupta S, Gupta H, Autar R. Combined orthodontic and surgical correction of adult skeletal class II with hyperdivergent jaws. Natl J Maxillofac Surg 2012;3:65-9. |
|5.||Senthil Kumar KS, Deepika, Triveni, (initials didn't mentioned in the publication) Jayakumar P. Management of vertical maxillary excess in an adult patient by combined orthodontics and orthognathic surgery- A case report. J Indian Orthod Soc 2007 41; 7-16. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]