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ISSN 0975-8437 INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(3):65-66 CASE REPORT Anterior maxillary excess correction with ASMO – A case report Joby Paulose, Rhea Mini Jayan Abstract Anterior maxillary excess presents with excessive gummy smile with increased over jet and deep overbite. Surgical approach with ASMO has produced excellent treatment results. This clinical case typically exemplifies the effect of ASMO on improving the skeletal, dental, soft tissue and over all aesthetics of the patient. Key Words: Anterior Maxillary Segmental Osteotomy; Maxillary Excess; Gummy Smile Introduction The first report of an anterior segmental maxillary osteotomy (ASMO) was published by Cohn Stock in 1921.(1) Currently, mainly three variations of ASMO are used; the Wassmund, Wunderer, and down fracture methods.(2, 3) The usual indications for ASMO are excessive vertical or sagittal development of the maxillary alveolar process in patients where the relationships between the posterior teeth are acceptable. Anterior maxillary excess presents with excessive gummy smile with increased over jet and deep overbite. Surgical approach with ASMO has produced excellent treatment results. This clinical case typically exemplifies the effect of ASMO on improving the skeletal, dental, soft tissue and over all aesthetics of the patient. Case report A male patient aged 24 years came to the orthodontic clinic with a chief complaint of forwardly placed upper front teeth. On extra-oral examination (Fig1-8), patient had a leptoprosopic facial form with posteriorly divergent convex profile, mild recessive chin, deep mento-labial sulcus, severe gummy smile (gingival exposure of 4-5 mm on smile) with incompetent lips (hypotonic upper lip). Intra-oral examination revealed severely proclined upper and lower incisors, over bite of 2-3mm, over jet of 7-8 mm, end on molar relationship on right and class I on left (Fig 1-8). Discolouration observed on 21, but the tooth was vital with no periapical pathology. Cephalometric evaluations (Table 1) revealed a class II skeletal pattern with a prognathic maxilla and mild retrognathic mandible with an anterior maxillary excess, average growth pattern. As the patient was 16years, surgical mode of treatment was considered. Fig 1-8: Pre - treatment extra oral and intra oral photographs of the patient, Fig 9-11: Intra-oral view after lower anterior retraction - prior to surgery, Fig 12-14: Mock surgery performed on study model, Surgery correction (AMO& advancement genioplasty) Fig 15-17: Post-surgical intra-oral view, Fig 18-20: mild intrusion in upper anteriors post surgically, Fig 21-28: Extra oral and intra oral photographs of the patient after treatment, Fig 29-30: Profile change, pre and post treatment. ©INTERNATIONAL JOURNAL OF DENTAL CLINICS VOLUME 3 ISSUE 3 JULY- SEPTEMBER 2011 65 ISSN 0975-8437 Parameter INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(3):65-66 Pre - Rx Post - Rx Skeletal 1. SNA 860 820 2. SNB 790 800 3. ANB 70 20 4. N Perp to Pt. A 6 mm 2mm 5. N Perp to Pog -8mm -3mm 6. GoGn to SN 320 330 7. UAFH 52 mm 46 mm 8. LAFH 48 mm 54 mm 9. AO ahead of BO 7 mm 3 mm Dental 10. U1 to NA (Angle, 400, 12mm 230, 5mm Linier) 11. L1 to NB (Angle, 410, 13mm 240, 5mm Lenier) 12. U1 to SN 1280 1040 13. L1 To Mand Plane 1140 930 0 14. Inter-incisal Angle 88 1270 Soft Tissue 15. Nasolabial Angle 670 890 16. S line to upper lip 6mm -1mm 17. S line to lower lip 3 mm 0 mm Table 1: Pretreatment and Post - treatment Cephalometric Measurements. Pre-surgical phase: Extraction of 34 and 44 followed by levelling & aligning of both arches. Retraction of lower anteriors (maximum anchorage) was done to create sufficient over jet to facilitate surgical correction.(Fig 9-11) Surgical phase: Study models were articulated and a mock surgery (Fig 12) was performed to view the occlusion after surgery. On table extraction of 14 and 24 was done, followed by AMO with superior and posterior positioning of pre-maxillary segment with a clockwise rotation to compensate the severe proclination of upper incisors.(Fig 13) The clockwise rotation of pre-maxillary segment resulted in an anterior deep bite with disocclusion in the canine region which was corrected in post-surgical orthodontic phase. An advancement genioplasty was done to address the deficient chin.(Fig 14) Post-surgical Phase: Three months after surgery, upper arch was aligned to correct the occlusal discrepancy (Fig 15-17) and mild intrusion was done in upper anteriors to correct the deep bite and to reduce the incisal exposure during smile.(Fig 18-20) Debonding was done after final finishing and detailing. Hawley’s retainer was given in both arches for retention. At the time of appliance removal, 21 appeared to have a slight grayish color. Examination of the radiographs before surgery, immediately after surgery, and at the day of appliance removal showed no periapical pathology. Discussion A dramatic improvement in facial esthetics and occlusal function was realized with the completion of treatment.(Figure 21-28) The lip competency, gingival exposure on smile and facial contour was significantly improved. The patient was very satisfied with the results of treatment. The excessive vertical dysplasia was dramatically reduced, and most of the cephalometric values were brought into the normal range.(Table 1) The anterior maxillary excess was significantly reduced, an ideal over jet and overbite and the chin deficiency was well addressed. Conclusion This case illustrates the importance of proper diagnosis and treatment planning. A team approach with the orthodontist, surgeon, and restorative dentist all having input before the initiation of treatment is the best way to achieve stable, functional, and esthetic results. Through this combined approach, the patient had a dramatic skeletal, dental, and occlusal improvement. As an added benefit, the patient has reported a better self-esteem and a greater degree of pleasure related to his appearance. Authors Affiliations: 1. Dr. Joby Paulose,M.D.S., Senior Lecturer, 2. Dr. Rhea Mini Jayan, Lecturer, Mar Baselios Dental College and Hospital, Kothamangalam, Kerala, India. References 1. Leibold D, Tilson HB, Rask K. A subjective evaluation of the re-establishment of the neurovascular supply of teeth involved in anterior maxillary osteotomy procedures. Oral Surgery, Oral Medicine, Oral Pathology. 1971;32(4):5314. 2. Rosenquist B. Anterior segmental maxillary osteotomy:: A 24-month follow-up. International journal of oral and maxillofacial surgery. 1993;22(4):210-3. 3. Jayaratne YSN, Zwahlen RA, Lo J, Cheung LK. Facial soft tissue response to anterior segmental osteotomies: A systematic review. International Journal of Oral and Maxillofacial Surgery. 2010;39(11):1050-8. Address for Correspondence Dr. Joby Paulose, M.D.S., Senior Lecturer, Mar Baselios Dental College and Hospital, Kothamangalam, Kerala, India. Email: [email protected] Source of Support: Nil, Conflict of Interest: None Declared ©INTERNATIONAL JOURNAL OF DENTAL CLINICS VOLUME 3 ISSUE 3 JULY- SEPTEMBER 2011 66