Download Treatment of a periodontally compromised adult patient with severe

ISSN 0975-8437
INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(4):56-58
CASE REPORT
Treatment of a periodontally compromised adult patient with severe bimaxillary protrusion
H. Jyothikiran, Suruchi Kalra, Shivalinga.B.M, Rami Reddy M.S
Abstract
This paper reports the management of a periodontally compromised adult male with convex profile,
proclined upper and lower incisors and severe lip incompetency with a combination of orthodontics and
orthognathic surgery.
Key Words: Bimaxillary protrusion;Facial :rofile;Orthognathic Surgery
Introduction
During recent times, the number of adults
seeking orthodontic treatment has increased
significantly.(1,2) Treatment of periodontally
compromised adults with a skeletal Class II
occlusion has always been a clinical challenge with
alveolar bone loss.(3-7) In addition, the loss of
attachment will relocate the center of resistance
further apically, which affects the moment
generated by a respective force.(8-10) Thus,
biomechanics in a periodontally compromised
patient differ from a healthy one, requiring lighter
forces and relatively larger moments.(11-12)
Treatment alternatives to correct a skeletal
Class II in adults are orthodontic camouflage and
combined orthodontic-orthognathic surgery therapy.(13) The final decision depends mainly upon
the severity of the malocclusion and the amount of
required tooth movements.(6,13,14) If the skeletal
discrepancy is beyond the boundaries of
camouflage, any dental compensation may produce
a reasonably good occlusion16 but only at the cost
of compromised facial esthetics.(4,15) This paper
reports the management of a periodontally
compromised adult male with convex profile,
proclined upper and lower incisors and severe lip
incompetency with a combination of orthodontics
and orthognathic surgery.
Case Report
A healthy, 26-year old male reported to
the orthodontic clinic with the complaint of
forwardly placed upper and lower front teeth. His
family history revealed that his mother had a
similar malocclusion. On extra oral examination,
the patient showed a dolichofacial pattern with
convex profile, acute nasolabial angle and severe
lip incompetency. Intraoral examination revealed
severely flared anterior teeth in both arches. Both
sides revealed class I molar and class I canine
relationship with an over jet of 5-mm, overbite of
3-mm and a curve of spee of 3mm. Both arches
were U- shaped, showing crowding owing to the
rotations. The facial and maxillary dental midline
coincided, lower midline shifted to left by 2 mm
(Figure1). The pretreatment cast also showed the
dental relationship.
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VOLUME 3 ISSUE 4
2011
Fig-1 Pretreatment intraoral photograph revealing flared
anterior teeth in both arches with class I molar relation
bilaterally, canine relation class-I right side and end on in left
side.
The panoramic radiograph showed the
presence of all permanent teeth except 38 and a
horizontal impaction of 48. The cephalogram
revealed a skeletal class II relationship with an
average growth pattern. The dental analysis
showed proclined maxillary and mandibular
incisors and an increased anterior dental height in
both arches.
Treatment objectives are a) periodontal
Flap surgery to eliminate existing pockets and thus
achieve a favorable periodontal environment for
good oral hygiene with a regular follow up. b)
alignment and leveling of both arches, c) on table
extraction of the maxillary first premolar with
anterior maxillary osteotomy and extraction of
mandibular first premolar with sub-apical
osteotomy, d) to achieve optimal facial esthetics,
and to obtain an optimal over jet-over bite
relationship, e) correction of the Bolton
discrepancy and f) finishing and detailing.
Treatment: Open flap surgery with root
planning was performed on the mandibular
anteriors from canine to canine and in mandibular
first molars on right and left sides. The patient was
motivated for intensive oral hygiene care and
recalled periodically for follow-up. When the
gingival inflammation was eliminated and the
probing depth reduced for three continuous
months, orthodontic treatment commenced.
In pre-surgical orthodontics, a fully
programmed 0.022 x 0.028-inch ROTH appliance
was placed with a non-extraction treatment plan
(Maxillary and mandibular arches banding and
bonding was done with roth 0.022 slot appliance.
The wire sequence was 0.014NiTi,
0.016Niti,
0.017x0.025NiTi, and 0.017x0.025S.S.followed by
0.019x0.025 S.S wire in both the arches. Second
molar banding with 0.017 x 0.025NiTi followed by
0.021 x 0.025 SS wire in place before surgery was
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INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(4):56-58
done(Figure2). Mock surgery was done on semi
adjustable Hanau articulator for making the
surgical splints.
Fig-2 Pre surgical intraoral photographs after alignment of teeth
During surgery, on table extraction of
maxillary first premolar was done and anterior
maxillary osteotomy cuts were given and the
anterior maxilla was set back by 7.5 mm to close
down the extraction space using the intermediate
splint. Extraction of first premolar was done in
mandibular arch and sub apical osteotomy cut was
given to take the anterior segment back by 7.5mm
to close down the extraction space using the final
splint.
The post-surgical orthodontics involved
the positioning of final splint and stabilizing arch
wires with intermaxillary fixation done for three
weeks and patient advised to wear elastics.
0.021x0.025 TMA wire with mild artistic bends
was placed and settling of occlusion done with
vertical elastics. For retention in both arches, a
0.018 inch coaxial 3-to-3 retainer was bonded.
Active treatment lasted 16 months (Figure3).
Fig-3 Posttreatment intraoral photographs revealing class I
molar and canine relationship with optimal over jet and over
bite and mild gingival recession in mandibular anterior region
The overall changes were as follows.
There was a decrease in maxillary and mandibular
length, as well as a reduction of facial convexity
with competent lips. Optimal overbite and over jet
were achieved, crowding relieved, and all spaces
were closed. Acceptable root parallelism was
attained and no further bone loss occurred during
the treatment. Cephalometrically there was a
significant decrease in maxillary prognathism by 4
degree and mandibular prognathism by 1 degree
with an ANB angle of 3 degrees. Reduction in
proclination of upper incisor by 10 mm and 13
degree and in lower incisor by 14 mm and 17
degree was appreciated. Inter-incisal angle also
increased to 32 degree. The soft tissue changes
showed the upper lip retraction by 5 mm and lower
lip retraction by 9 mm. The profile of the patient
changed from convex to straight. There were no
significant changes in vertical skeletal relationship.
Superimpositions of the pre and post treatment
cephalometric tracings show the decrease in
proclination of upper and lower anterior teeth with
©INTERNATIONAL JOURNAL OF DENTAL CLINICS
VOLUME 3 ISSUE 4
2011
a normal inter-incisal angle without any change in
molar relationship.
Discussion
The facial changes resulting from
treatment were profound and improved the
patient’s
self-image
significantly.
Many
retrospective studies have been done to evaluate
soft and hard tissue changes following anterior
segmental osteotomy on the maxilla and mandible.
The results were as follow.(16,17) a) through
segmental osteotomy technique, the upper lip was
moved backward at a ratio of 67% to the upper
incisor with the posterior movement of the anterior
maxilla, b) the lower lip moved at a ratio of 89% to
the lower incisor, c) the nasolabial angle was
increased by an average of 14.1o, d) although the
nasal change could be kept as small as possible,
slight widening of the nasal width and anti-tip
rotation of the nasal tip were observed and e) the
philtrum length was increased, while lip thickness
and lip width were decreased.
The same amount of upper lip changes are
not possible with first premolar extraction and
camouflage treatment because point A does not
move back by the same distance as the teeth.
Moreover, some premolar extraction space can also
be lost due to mesial movement of the posterior
segment, although use of absolute anchorage has
removed this limitation to a great extent. In
contrast to camouflage, the entire premolar
extraction space can be utilized for retraction of
anterior segment through anterior segmental
osteotomy. The posterior impaction of the entire
maxilla through Lefort I osteotomy would have
changed the molar relation, which was undesirable
in the present case. So for optimum changes in the
nasolabial angle and upper lip-lower lip relation,
anterior maxillary osteotomy with anterior
segmental setback was the ideal procedure for this
case.
Even in the mandibular arch, first
premolar was extracted and subapical osteotomy
cut given to take the anterior segment posteriorly.
The lower lip followed the incisors and was
retracted by a considerable distance. In general,
adults1 with normal periodontal tissues but also
those with reduced but healthy periodontal tissues
can undergo comprehensive orthodontic treatment
without incurring any greater risk for accelerated
periodontal breakdown. However this requires that
these patients first receive periodontal treatment
before orthodontic therapy to arrest active disease.
Secondly monthly recalls for plaque removal during orthodontic treatment and finally a subgingival
debridement at 3-month intervals during
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INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(4):56-58
orthodontic treatment to maintain gingival tissue
health is necessary.(1, 11, 18-20)
The rationale for a 3-month periodontal
maintenance schedule is based on the observation
that repopulation of subgingival pathogenic
bacteria generally occurs 6 to 8 weeks after all
pockets were thoroughly cleansed. A problem
arises during the 6 to 8-week period of intermaxillary fixation where plaque removal is more difficult1. This patient was highly motivated and
maintained his periodontal health with various
plaque control measures including chlorhexidine
mouthwash.
Conclusion
Periodontally compromised adult patient
with severe bimaxillary protrusion beyond the
boundaries of orthodontic camouflage treatment
was treated successfully by orthodonticorthognathic surgical therapy. There was drastic
improvement in facial profile with decreased
proclination of upper and lower incisors to the jaw
bases. Profound improvement in patient
psychology with an improved functionally stable
occlusion was achieved.
Authors Affiliations: 1. Dr. H. Jyothikiran, M.D.S,
Associate Professor, 2. Dr.Suruchi Kalra, M.D.S, Former
Post Graduate Student, 3. Dr. Shivalinga.B.M, M.D.S,
Professor, Dept. of Orthodontics, J.S.S. Dental College
and Hospital, Mysore, Karnataka, 4. Dr. Rami Reddy
M.S, M.D.S, Professor, Department of Orthodontics,
Sibar Institute of Dental Sciences, Guntur, Andhra
Pradesh. India
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Address for Correspondence
Dr. H. Jyothikiran, M.D.S,
Associate Professor,
Department Of Orthodontics,
J.S.S. Dental College and Hospital,
Mysore, Karnataka, India.
e-mail:[email protected]
Source of Support: Nil, Conflict of Interest: None Declared
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