IP Indian Journal of Orthodontics and Dentofacial Research

Print ISSN: 2581-9356

Online ISSN: 2581-9364

CODEN : IIJOCV

IP Indian Journal of Orthodontics and Dentofacial Research (IJODR) open access, peer-reviewed quarterly journal publishing since 2015 and is published under the Khyati Education and Research Foundation (KERF), is registered as a non-profit society (under the society registration act, 1860), Government of India with the vision of various accredited vocational courses in healthcare, education, paramedical, yoga, publication, teaching and research activity, with the aim of faster and better more...


  • Article highlights
  • Article tables
  • Article images

Article statistics

Viewed: 33

PDF Downloaded: 26

Kalra, Kalra, Tikku, Srivastava, and Khanna: Ortho-surgical management of class iii malocclusion: A case report


Introduction

Class III malocclusion is considered to be one of the most difficult and complex orthodontic problems to treat. Prevalence of class III malocclusion in Caucasians ranges from 0.8 to 4.0% and rises up to 1213% in Chinese and Japanese populations, while in North Indian population, class III malocclusion is found in up to 3.4% of the population.1 The features of Class III malocclusion patients may be short anterior cranial base, short and retrusive maxilla, proclined maxillary incisors, retroclined mandibular incisors.1

These complex cases require careful treatment planning, an integrated approach and patient cooperation.2 A poor facial appearance is often the patient's chief complaint, but it may be accompanied by functional problems, temporomandibular disorders, or psychosocial handicaps.3 Now a day’s shift is occurring towards viewing the patient as co decision maker. Ackerman says that we should “talk with” rather than “talk to” the patient. 2D imaging software and 2 D printing has made the process of diagnosis, treatment planning and patient involvement in their treatment much simpler, more accurate, acceptable and reliable for both Orthodontist and patient.4

Treatment modalities in Orthodontics include growth modification procedures in growing children, Orthodontic camouflage and Ortho surgical procedures in non-growing individuals. Combined treatment of Orthodontics with surgery had been the only answer to achieve the desired predictive results in adults with severe skeletal discrepancy.5

In this case report a 19 yrs old boy was treated with ortho-surgical method for management of class III malocclusion.

Case Report

A19 years old boy who reported with chief complaint of poor smile because of forwardly placed lower jaw from 2 years. Extra oral examination revealed, patient was well built, mesomorphic boy with symmetrical face, mesoprosopic facial form and incompetent lips with 1mm of mandibular incisors exposure at rest. On lateral examination, the mandibular prognathism with obtuse nasolabial angle were noted [Fig 1].

Intraorally patient was having posterior cross bite wrt upper posteriors on left side and premolars and 1st molar on right side. Both the arches were U shaped with rotated molars in upper arch and premolar rotation in lower arch with reverse overjet of 1 mm and 0.5 mm of overbite with bilateral class III molar and canine relation. The deviation of 1.5 mm midline to left side was also present [Fig 2].

To know about the quality and quantity of skeletal discrepancy, cephalogram tracing was done using manual method and Nemoceph software and values of Steiner’s, COGS and Arnett analysis were interpreted [Table 1, Table 2, Table 3]. Cephalometric findings revealed retrognathic maxilla sagittally and normal vertically and prognathic mandible with horizontal growth pattern. Maxillary central incisors were both protruded and proclined whereas mandibular central incisors were retroclined.

Treatment plan

Considering the extent of skeletal discrepancy, amount of reverse overjet and chief complaint, the treatment plan to correct the skeletal class III malocclusion by doing Orthodontic treatment initially followed by mandibular set back surgery later (FOSLA) was made. With the aim of achieving facial aesthetics and optimal functional occlusion, surgical treatment was planned. The objective was to achieve ideal occlusal relationships, in terms of canine class, molar relationship, overjet, overbite, and matching dental midlines.4

After performing a scaling, treatment was begun with 0.022” × 0.028” Roth system. The upper and lower arches were aligned using 0.016” followed by 0.020” Niti wire followed by rectangular Niti of 0.017” x 0.025” and 0.019”x 0.025” until a 0.019” x 0.025” stainless steel archwire could be placed [Fig 3]. The mandibular incisors were decompensated by proclining them in normal inclination and the arch forms were coordinated.

Prediction of the final outcome was done using predictive tracing by both manual and computerized methods.5, 6 The value for mandibular set back as predicted using both the methods was 5 mm. Following this, a model mock surgery was done for visualizing 3-dimensional post-operative relationship of jaws with positive overjet and class I molar relation []Figure 4 . The surgical stent was made at this position.

Surgical procedure

Surgery was performed with the support of oral & maxillofacial surgeons. Retromolar area was exposed, bilateral sagittal split osteotomy with short lingual split was done using surgical burs. Medial pterygoid muscle was detached after performing the split, 5 mm setback was achieved and rigid fixation was placed in the mandible through the use of four-hole miniplates on both sides [Figure 5]. To keep the mandible in the correct position, the use of intermaxillary elastics for 30 days were given to achieve maximum stability. The patient was under observation after the procedure and was guided subsequently to perform opening and lateral movements. Active orthodontic treatment was resumed four weeks after surgery. Class III and settling elastics were given. Six months later, fixed appliances were removed and a retention appliance was delivered [Figure 6].

Figure 1

Extraoral frontal and lateral picture showing mandibular prognathism

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/67950f17-c10a-4566-b1f4-4cba76ed4d32image1.png
Figure 2

Showing the reverse overjet

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/67950f17-c10a-4566-b1f4-4cba76ed4d32image2.png
Figure 3

Showing the orthodontic compensation before surgery

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/67950f17-c10a-4566-b1f4-4cba76ed4d32image3.png
Figure 4

Showing the mock surgery

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/67950f17-c10a-4566-b1f4-4cba76ed4d32image4.png
Figure 5

Showing the setback of 5 mm

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/67950f17-c10a-4566-b1f4-4cba76ed4d32image5.png
Figure 6

Showing the post op after debonding

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/67950f17-c10a-4566-b1f4-4cba76ed4d32image6.png
Table 1

Steiner’s

Mean

Indians

Manual tracing Pre

Nemoceph Tracing Pre

Inference

SNA

82

82.28

80

81.6

SNB

80

78.52

84

84.1

Prognathic mandible

ANB

2

3.52

- 4

-2.5

Class III skeletal Pattern

SND

76

77

84.3

Mx l to NA

4mm/22

5.65/23.17

7mm/43

5.7/33.9

Proclined Maxillary Central incisors

Md l to NB

4mm/25

6.02/27.80

3.5mm/20

4.4/19.6

Retroclined mandibular incisors

Pog to NB

0mm

3mm

2.6

Prognathic mandible

Pog-NB:Md l-NB

1:1

3:3.5

2.6:4.4

OP to SN

14.5

10

23.2

Go-GN to SN

32

26.83

29

30.4

Horizontal Grower

U1 to SN

104+ 7

104.8

122

Proclined maxillary CI

U1 to FH

107

133

Proclined maxillary CI

Table 2

Cephalometrics for orthognathic surgery (COGS) (Hard Tissue)

Measurements

Mean + SD (Male)

Mean + SD (Female)

Manual Tracing Pre

Nemoceph Tracing Pre

Inference

Cranial Base

Ar-Ptm(II HP)

37.1 +2.8 mm

32.8 +1.9 mm

30 mm

28.6

PTM-N (II HP)

52.8 +4.1 mm

50.9 +3.0 mm

55 mm

51.6

Increased ant cranial base length

Horizontal (Skeletal)

N-A-Pg (Angle)

3.9 + 6.40

2.6 + 5.10

-12

-7.6

Protruded mandible

N-Pg (II HP)

-4.3 + 8.5 mm

-6.5 + 5.1 mm

5.5

8.3

Vertical (Skeletal, Dental)

N-ANS (I HP)

54.7 + 3.2 mm

50.0 + 2.4 mm

51

49

ANS-Gn (I HP)

68.6 + 3.8 mm

61.3 + 3.3 mm

66

64.3

PNS-N (I HP)

53.9 + 1.7 mm

50.6 + 2.2 mm

52

50.5

U1-NF (I NF)

23.0 + 5.9 mm

27.5 + 1.7 mm

25

23.6

L1-MP (I MP)

30.5+ 2.1 mm

40.8 + 1.8 mm

37

37.4

U6-NF (I NF)

45.0 + 2.1 mm

23.0 + 1.3 mm

21

23.6

Decreased Maxillary posterior vertical height

L6-MP (I MP)

26.2 + 2.0 mm

32.1 + 1.9 mm

32

30.4

Increased mandibular posterior vertical height

Maxilla- Mandible

PNS-ANS(II HP)

57.7 + 2.5 mm

52.6 + 3.5 mm

54

Ar-Go (Linear)

52.0 + 4.2 mm

46.8 + 2.5 mm

50

47.1

Go-pog (Linear)

83.7 + 4.6 mm

74.3 + 5.8 mm

84

80.5

B-Pg (II MP)

8.9 + 1.7 mm

7.2 + 1.9 mm

4

8.5

Ar-Go-Gn (Angle)

119 + 6.50

122 + 6.90

1250

126.8

Dental

OPUpper-HP (Angle)

OP lower-HP (Angle)

6.2 + 5.10

7.1 + 2.50

4

14.3

A-B (II OP)

-1.1 + 2.00

-0.4 + 2.50

60

14.5

U1-NF (Angle)

110.0 + 4.70

112.5 + 5.30

130

122.9

L1- MP (angle)

95.9 + 5.20

95.9 + 5.70

92

83.7

Table 3

Cephalometrics for orthognathic surgery (COGS) (Soft Tissue)

Facial Form

Mean

Manual Tracing Pre

Nemoceph Tracing Pre

Facial convexity angle (G-Sn-Pg’)

120

90

10.1

Concave Profile

Maxillary Prognathism (G-Sn) (II HP)

6 mm

10 mm

10

Mandibular Prognathism (G-Pg) (II HP)

0 mm

-7 mm

-8.6

Mandibular prognathism

Vertical height ratio (G-Sn/Sn-Me) (I HP)

1

1.04

1

Lower face- throat angle (Sn-Gn’-C)

1000

950

86.2

Lower vertical height- depth ratio (Sn-Gn’/C-Gn’)

1.2

1.11

1.3

Lip position and facial form

Nasolabial angle (Cm-Sn-Ls)

1020

1150

114

Upper Lip Protrusion (Ls to Sn-Pg’)

3 mm

0.5

0.6

Lower Lip Protrusion (Li to Sn-Pg’)

2 mm

-2

-3.5

Mentolabial sulcus (Si to Li-Pg’)

4 mm

3.5

-4.2

Vertical Lip- Chin ratio (Sn-Stms/ Stmi-Me’)

0.5

-0.4

-0.5

Maxillary Incisor exposure

2 mm

0

0.7

Interlabial Gap (Stms-Stmi)

2 mm

2

2.9

Table 4

Arnett’s Analysis

Measurement

Mean

Manual Tracing Pre

Nemoceph Tracing Pre

Inference

Dentoskeletal Factors

Mx1 projection to TVL

-9.2mm

-12

-13

Mx1 inclination (Mx1-Mx OP)

56.80

47

53.6

Protruded maxillary incisor

Overjet

3.2 mm

-2

-2.5

Prognathic mandible

Md1 projection to TVL

-12.4 mm

-10

-11

Prognathic mandible

Md1 inclination (Md1-Md OP)

64.30

72

77

Overbite

3.2 mm

0.5

-1.7

Post height (Mx OP-TVL angle)

95.6 mm

91

92

Mx1 exposure relaxed lip

4.7 mm

2

0.7

Soft Tissue thickness

Upper lip (UL inside –ULA)

12.6 mm

12

12.3

Lower lip (LL inside- LLA)

13.6 mm

12.5

14.7

Pogonion-chin (Pg-Pg’)

11.8

9

9.7

Shows decreased soft tissue thickness over chin area

Menton (Me-Me’)

7.4 mm

5.5

6.6

Facial height or length

Upper lip length (Sn –ULI)

21 mm

17

21.6

Interlabial gap (ULI-ULS)

0.0 mm

2

1.3

Upper incisor exposure relaxed lip

4.7 mm

2

0.7

Lower lip length (LLS-Me’)

46.9 mm

48

46.2

Lower 1/3 height

71.1 mm

72

69.1

Total facial height (N’-Me’)

124.6 mm

122

118.8

Maxillary height (Sn-Mx1 tip)

25.7 mm

24

22.2

Mandibular Height(Md1 tip-Me’)

48.6 mm

46

38

Post height (Mx-OP-TVL angle)

95.6 mm

91

92

Decreased posterior maxillary height

True vertical line projections

Glabella (G’-TVL)

--18.6 mm

-10.5

-10

Soft Tissue A point (A’-TVL)

-0.1 mm

-3

-2.5

Upper incisor tip (Mx1-TVL)

-9.2

-12

-13

Upper lip anterior (ULA-TVL)

3.7 mm

0

0.2

Upper lip angle (UL-TVL)

12.10

-.9

0.8

Nasolabial angle (Cm-Sn-ULA)

103.50

112

114.7

Lower incisor tip (Md1-TVL)

-12.4 mm

-10

-11

Shows uprighting of mandibular incisors

Lower lip anterior (LLA-TVL)

1.9 mm

3.5

3.9

Soft tissue B point (B’-TVL)

-5.3 mm

-4

-3

Soft tissue pogonion (Pog’-TVL)

-2.6 mm

-0.5

-1.4

Mandibular prognathism

Throat length (NTP-Pog’)

58.2 mm

58

56.9

Harmony values

Facial Angle (G’-Sn-Pog’)

169.30

172

169.9

Forehead to maxilla (G’-A’)

8.4 mm

16

7.5

Forehead to mandible (G’-Pog’)

5.9 mm

20

8.6

Prognathic mandible

Nasal Base to chin (Sn-Pog’)

3.2 mm

7

1.4

Max base – Md base (A’-B’)

5.2 mm

5

0.6

Upper lip-lower lip (ULA-LLA)

1.8 mm

6

3.7

Incisor tip anterior to chin (Md1 tip-Pog’)

9.8 mm

-15

-11.6

Lower lip anterior –chin (LLA-Pog’)

0.0 mm

0

5.3

Chin Contour (B’-Pog)

0.0 mm

4

1.6

Discussion

When the skeletal or dentoalveolar deformity is so severe that the magnitude of the problem lies outside the envelop of possible correction by Orthodontics alone and even the camouflage is also not the option then Orthognathic surgery is the best plan. 4

This case report describes the treatment of a boy with dental and skeletal class III relationships. In this case ortho- surgical treatment was the best option for achieving good esthetic result and an acceptable occlusion. Presurgical orthodontics involves removal of all the dental compensations and also suggests the extent of skeletal discrepancy. 1 With osteotomy and setback of the prognathic mandible, normal skeletal base relationship is achieved. Postsurgical orthodontics involves the normal occlusal rehabilitation.

Conclusion

A careful prediction and treatment planning are mandatory prior to planning for an Orthognathic case. A multidisciplinary team approach ensures a satisfactory and acceptable outcome.

Source of Funding

No financial support was received for the work within this manuscript.

Conflicts of interest

The author declares that they do not have any conflict of interests.

References

1 

R Katiyar G K Singh D Mehrotra A Singh Surgical orthodontic treatment of class III malocclusionNatl J Maxillofac Surg2010121439

2 

C Phillips W R Proffit WR Proffit RP Jr White DM Sarver Psychosocial aspects of dentofacial deformity and its treatmentContemporary Treatment of Dentofacial Deformity2003St. Louis: Mosby6969

3 

L J Bailey D M Sarver T A Turvey W R Proffit W R Proffit WR Proffit RP Jr White DM Sarver Contemporary Treatment of Dentofacial DeformitySt. Louis: Mosby2003507

4 

S Kalra T Tikku R Khanna RP Maurya S Verma K Srivastava Prediction in an ortho surgical case: A reportInt J Orthod Rehab201910142810.4103/ijor.ijor_23_18

5 

BN Epker LC Fish Dentofacial deformities, Intergrated orthodontic and Surgical Correction2nd Edn.II1980

6 

S K Chen Y J Chen C C Yao H F Chang Enhanced speed and precision of measurement in a computer-assisted digital cephalometric analysis systemAngle Orthod2004745017



jats-html.xsl

© 2021 Published by Innovative Publication Creative Commons Attribution 4.0 International License (creativecommons.org)


Article type

Case Report


Article page

62-67


Authors Details

Shilpa Kalra, Ashish Kalra, Tripti Tikku, Kamna Srivastava, Rohit Khanna


Article Metrics


View Article As

 


Downlaod Files