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Case Report
Journal of Dentistry and Orofacial Surgery
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Copyright: © 2016 Singh A, et al.
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An Orthodontic-Surgical Approach to Class II Malocclusion Treatment
with Vertical Growth Pattern - A Case Report
Abhishek Singh1, Rohit Kulshrestha2*, Ragni Tandon2, Ashish Goel2 and Ankit Gupta2
1
Private Practice, New Delhi, India
2
Department of Orthodontics and Dentofacial Orthopedics, Saraswati Dental College, Lucknow, Uttar Pradesh, India
Received Date: May 13, 2016, Accepted Date: August 18, 2016, Published Date: August 29, 2016.
*Corresponding author: Rohit Kulshrestha, Saraswati Dental College, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Case Report
Abstract
The traditional technique for the correction of Class II malocclusion
in a growing patient is by growth modification with functional appliances.
In adults Class II malocclusions are treated either by orthodontic
camouflage or by orthognathic surgery. Class II malocclusions with
vertical maxillary excess can be treated surgically by Le Fort 1 osteotomy.
A female patient, age 25, came to the department with the complaint of
forward positioned upper front teeth and excessive gingival display on
smiling. On examination patient had a vertical maxillary excess and a
retrognathic mandible with skeletal and dental Class II patterns. Intra
orally patient presented with a Class II molar and canine relationships
with excessive overjet. The treatment plan of a combination of
orthodontics and orthognathic surgery was employed to correct the
skeletal and dental discrepancies and also to obtain an aesthetic,
harmonious facial profile. Surgery consisted of the Le Fort 1 osteotomy
to accomplish the treatment objectives. Limitations and compromises in
treatment objectives are described to achieve a pleasing result.
Keywords: Le Fort 1 Osteotomy; Class II Malocclusion; Vertical
Maxillary Excess
Introduction
Patients with Class II malocclusions with protrusive maxillary
teeth, deficient mandible, excess overjet and normal overbite can
sometimes be successfully treated non-surgically. However, when
vertical maxillary excess is seen with a gummy smile, orthognathic
surgery may be indicated if camouflage treatment would not
compensate for the skeletal problem [1]. In vertical maxillary excess,
clinically recognizable smile features are manifested by a gummy
smile, exposure of the maxillary incisors, incompetent lips, increased
lower facial height and high mandibular plane angle. Such cases of
skeletal Class II malocclusion require a combination of orthodontics
and orthognathic surgical treatment [2]. The treatment of severe
dentofacial deformities in adult patients is a challenging task for both
the orthodontist and the oral surgeon. Treatment is difficult because
of the skeletal and facial disharmony, absence of jaw growth and
a tendency toward relapse which can be due to an unstable result
after treatment [3]. The surgical orthodontic correction of vertical
maxillary excess by superior repositioning of the maxilla is generally
an acceptable treatment plan on the basis of skeletal stability and
aesthetic soft tissue changes. The goal of present day orthodontics
is not only to bring about dental corrections but also to achieve a
balance between the craniofacial structures. Surgical management
of patients with significant skeletal deformities has been widely
practiced worldwide [4,5]. Facial appearance acceptance is a very
important factor in determining social relationships. Significant
dentofacial deformities are seen to be less attractive leading to
non-acceptance of an individual [6]. Differences of behavior toward
attractive and unattractive people has been well documented [7,8].
This case report describes the orthodontic-surgical approach in the
treatment of a female patient with vertical maxillary excess, gummy
smile and a deficient mandible.
J Dent Oro Surg
Diagnosis
The patient, a female, 25 years of age, came to the department of
orthodontics with a complaint of a maxillary dental protrusion and
gummy smile. Pre-treatment facial photographs showed a convex
profile with posterior facial divergence. Intraoral photographs
revealed a 9 mm overjet and a 1 mm overbite (Figure 1). Inter
labial gap of 7 mm was present. The amount of incisor exposure
during rest was 6 mm and on smiling displaying a full incisor. Upon
smiling the patient showed buccal corridors caused by the narrow
maxillary arch. The right and left molar relationships were Class
II. The upper and lower dental midlines coincided with the facial
midline. On smiling 7 mm of gingiva was visible. The maxillary lip
length of the patient was short being 17 mm. Clinical examination
revealed an excessively long lower facial height, large inter labial
gap, excessive incisal display at rest, and an excessive incisal and
gingival display upon smiling. The panoramic view x-ray showed
a horizontally impacted lower right third molar (Figure 2). The
maxillary right third molar and mandibular left third molar had
erupted completed. The maxillary left third molar was absent. The
cephalometric evaluation revealed a Class II skeletal pattern with
a steep mandibular plane of 43 degrees relative to the horizontal
plane and an ANB angle of 12 degrees (Figure 2 and Table 1). Patient
was diagnosed to have a convex facial profile with a retropositioned
mandible secondary to the vertical maxillary excess. Orthodontic
treatment was recommended as a prerequisite to orthognathic
surgery involving maxillary impaction and set back. The study
was approved by the Ethics Committee of Saraswati Dental College
PrePostChange
treatment treatment
FMA
25
43
35
8
IMPA
90
97
103
6
Facial Angle
87.8
79
86
7
ANB
2
12
9
3
Angle of Covexity
8
24
17
7
AB plane angle
-4.6
-15
-10
5
Mand plane angle
21.9
43
33
10
“Y” axis
59.4
70
62
8
Inter-incisal angle
135.4
104
117
13
U l to A Pog
2.7 mm
15 mm
8 mm
7 mm
Mx l to NA mm/angle
4 mm/22 5 mm/27
0 mm/9 5 mm/18
Go-Gn to SN
32
50
45
5
Skeletal convexity at Point A 0-1 mm
5 mm
0 mm
5 mm
H-line angle
7-15
34
10
24
Nose tip to H line
12 mm
12 mm
3 mm
9 mm
Parameter
ISSN: 2470-9735
Mean
Table 1: Cephalometric analysis.
Page 1 of 6
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Vol. 1. Issue. 4. 32000120
Figure 1: Pre-treatment extra oral and intraoral photos.
Figure 2: Pre-treatment lateral cephalogram and panoramic radiograph.
and Hospital, and informed consent from the patient was obtained
before the start of orthodontic treatment.
Treatment objectives
Considering the findings with the diagnosis, it was
recommended to first create a stable dentition from right second
molar to left second molar in both arches. This would require
the removal of the third. The patient was advised about the need
to remove the impacted molar but refused this in her treatment.
Treatment objectives involved providing orthodontic therapy to
level and align the teeth in both arches to prepare for orthognathic
surgery. With ideal upper and lower arch, the teeth could be set in
an ideal position via a splint with the impaction and distalization
of the maxilla when a Le Forte 1 osteotomy was performed. This
would reduce the excessive gingival exposure on smiling. It would
also lead to autorotation of the mandible which would improve the
facial aesthetics. Dental corrections included achieving an ideal
overjet, Class I molar and canine relations correct lip incompetency
and provide an aesthetic and pleasing profile. A surgical prediction
tracing was performed for surgical treatment planning (Figure 3).
The surgery required would be maxillary superior repositioning
of 6 mm and 4 mm posteriorly by Le Fort 1 osteotomy along with
posterior positioning of the whole maxilla by 2 mm.
Treatment progress
Orthodontic therapy was started with an 0.022 × 0.028
Edgewise orthodontic appliance with banding of the first molars
and MBT (Liberal Centrion series) brackets bonded from 5-5.
Second molars were not banded. Levelling and alignment was
started using Niti wires. The arch-wire size in the maxilla and
mandible was gradually sequenced until 0.019 × 0.025” stainless
steel wires were placed. This resulted in a decrease in the maxillary
anterior teeth proclination and deepening of the bite. After 10
months of pre-surgical orthodontics, a face-bow transfer was
Citation: Singh A, Kulshrestha R, Tandon R,Goel A, Gupta A (2016) An Orthodontic-Surgical Approach to Class II Malocclusion Treatment with Vertical Growth Pattern - A Case Report. J Dent Oro Surg 1(4): 120.
Page 2 of 6
J Dent Oro Surg
ISSN: 2470-9735
performed and the casts transferred to an articulator (Figure 4).
A surgical splint was fabricated out of acrylic (Figure 5) and then
surgery was performed. The Le Forte I osteotomy positioned the
maxilla superiorly and posteriorly. The maxilla was positioned
superiorly so that 2 to 3 mm of maxillary incisor exposure at rest
would be seen. Surgery was performed without any complications,.
Correction was maintained by rigid fixation (Figure 6). Post surgery
the patient recovered well and was pleased with her appearance
(Figure 7, 8). After 8 months of post-surgical finishing and detailing,
the patient was retained (Figure 9, 10). Total treatment time was
18 months. Permanent retention was using fixed lingual bonded
retainers in both arches.
Vol. 1. Issue. 4. 32000120
Treatment results
After completion of eight months of post-surgical orthodontics,
an improved facial symmetry with more balanced facial thirds, an
aesthetic smile and lip fullness were seen. Due to the short upper
lip length lip seal was not achieved. Incisor display on rest and
on smiling was improved. Superimposition of the pre and post
surgical cephalometric tracing (Figure 11) showed the amount
of setback of the maxillary segment and dental changes. It also
highlighted the amount of superior repositioning of the maxilla
along with the autorotation of the mandible. Relapse was seen
with the molar and canine relation between the post surgical
photos and photos after debonding. The molar relation had
Figure 3: Surgical prediction tracing. Maxilla need to be placed superiorly by 6 mm from its anterior half, 4 mm superiorly from posterior half and
2 mm forwardly.
Figure 4: Face bow transfer and articulation of pre-surgical casts.
Figure 5: Surgical splint fabrication.
Citation: Singh A, Kulshrestha R, Tandon R,Goel A, Gupta A (2016) An Orthodontic-Surgical Approach to Class II Malocclusion Treatment with Vertical Growth Pattern - A Case Report. J Dent Oro Surg 1(4): 120.
Page 3 of 6
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a
.
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b
.
c
.
d
.
Figure 6: Orthognathic surgery (a) down fracture of maxilla, (b) superior repositioning, (c) stabilizing, (d) fixation.
Figure 7: Post surgery extra oral and intra oral photos.
relapsed to end on relation as it was at the start of treatment. The
canine relation after surgery was Class I but after debonding it
relapsed to end on. The overjet after the surgery was ideal 1 mm
but after debonding relapse took place and a significant increase
in overjet was seen. This shows the limitations of orthognathic
surgery in relation to dental corrections. Some amount of relapse
may occur after any surgical procedure. In this case, it occurred
between the surgery and debonding. Planning over-correction
would be a possible treatment objective to overcome the possible
relapse but this is difficult to determine.
Discussion
Two treatment plans were presented prior to beginning
treatment. The first plan was orthodontic therapy alone by the
extraction of all first premolars and retraction of incisors. The main
drawback of this plan was dental goals would have been achieved
Citation: Singh A, Kulshrestha R, Tandon R,Goel A, Gupta A (2016) An Orthodontic-Surgical Approach to Class II Malocclusion Treatment with Vertical Growth Pattern - A Case Report. J Dent Oro Surg 1(4): 120.
Page 4 of 6
J Dent Oro Surg
ISSN: 2470-9735
Vol. 1. Issue. 4. 32000120
Figure 8: Four months post surgery lateral cephalogram and panoramic radiograph.
Figure 9: Post treatment extra oral and intra oral photos.
Figure 10: Post treatment lateral cephalogram and panoramic.
Citation: Singh A, Kulshrestha R, Tandon R,Goel A, Gupta A (2016) An Orthodontic-Surgical Approach to Class II Malocclusion Treatment with Vertical Growth Pattern - A Case Report. J Dent Oro Surg 1(4): 120.
Page 5 of 6
J Dent Oro Surg
ISSN: 2470-9735
Vol. 1. Issue. 4. 32000120
rotation. In this case, superior repositioning of the maxilla autorotated the mandible which lead to an improved facial profile,
without performing mandibular surgery like of mandibular
advancement (BSSO) or genioplasty. In treating a patient surgically
the retention and stability of the surgical procedure is essential.
With rigid fixation (IMF), the maxilla is very stable during the
first year after superior repositioning to prevent any clinically
significant relapse [11]. In this case, however dental relapse was
evident in the molar, canine relations. This indicated the limitations
of orthognathic surgery having the possibility of relapse even
though superior repositioning of the maxilla falls into the more
stable category of surgeries. Also, soft tissue changes noted after
one year of surgery are likely to remain stable for the next six years
[10]. This stability is hopeful for the results achieved in this case.
Conclusion
Figure 11: Superimposition of tracing at start of treatment and that
of post treatment.
but the gummy smile along with the vertical maxillary excess would
not be corrected. The second plan was not to extract any teeth, do
levelling and alignment of both the arches followed by orthognathic
surgery for superior and posterior repositioning of the maxilla.
Handelman [9], reported that patients with narrow alveolar
arches or severe skeletal discrepancies are difficult to correct and
they demonstrate limitations in orthodontic treatment and require
surgical intervention. Thin alveolar arches are found both labially
and lingually to the mandibular incisors of patients with a high
mandibular plane angle. It is also seen lingually to the maxillary
incisors in class II high angle cases. This patient presentation
had severe skeletal discrepancy along with a narrow maxillary
arch. Handelman9 also stated that a narrow alveolus is seen in
patients with high mandibular plane angle which was seen in
this case. Orthodontic correction would have been difficult in this
case especially in the mandibular anterior region and chances of
iatrogenic damage would have been high.
Wessberg et al [10], mentioned that occlusal programming
feedback mechanism operates within the CNS mediating the
compensatory autorotation of the mandible after surgical
superior repositioning of the maxilla. When planning for superior
repositioning of maxilla the orthodontist must decide based on
aesthetics and cephalometric prediction criteria, the amount of
autorotation required and the effect of this rotation towards the
desired ideal occlusal and aesthetic results.
Superior repositioning of the maxilla is frequently performed.
It is a useful method for treating patients with vertical maxillary
excess. The relationship of the upper lip line to the incisor is the
most important factor in planning treatment that will achieve an
attractive smile. Superior repositioning of the maxilla will lead
to autorotation of the mandible with the condyle as the centre of
This case report highlights the importance of careful diagnosis,
appropriate treatment planning, surgical methods and techniques
so that the malocclusion is identified and treated in the right
manner. There were some limitations in the treatment result. The
patient’s short upper lip was a factor in achieving a more improved
lip seal. Relapse in many dental parameters such as overjet canine
and molar relation occurred. The aesthetic improvement achieved
with this treatment approach is acceptable and it requires a good
understanding between the orthodontist, the maxillofacial surgeon
and, most importantly, the patient.
References
1. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ. The Long
face syndrome: vertical maxillary excess. Am J Orthod. 1976;70(4):398408.
2. Radney LJ, Jacobs JD. Soft tissue changes associated with surgical total
maxillary intrusion. Am J Orthod. 1981;80(2):191-212.
3. Wolford LM, Karras SC, Mehra P. Consideration for orthognathic surgery
during growth, Part 2 : Maxillary Deformities. Am J Orthod Dentofacial
Orthop. 2001;119(2):102-5.
4. Mac Gregor FC. Transformation and identity: the face and plastic
surgery. New York: Quadrangle; 1974.
5. Fish LC, Wolford LM, Epker BN. Surgical-orthodontic correction of
vertical maxillary excess. Am J Orthod. 1978;73(3):241-57.
6. Bell WH, Dann JJ. Correction of dentofacial deformities by soft-tissue
changes. Am J Orthod. 1973;64(2):162-187.
7. Cunningham SJ, Feinmann C, Ibbetson R. Disorders of appearance.
In: Feinmann C, editor. The mouth, The face and The mind. Oxford
University Press; 1999. p. 131-56.
8. Shaw WC. Influence of children’s dento facial appearance on social
attractiveness. Am J Orthod. 1981;79(4):399-415.
9. Handelman CS. The anterior alveolus: its importance in limiting
orthodontic treatment and its influence on the occurrence of iatrogenic
sequelae. Angle Orthod. 1996;66(2):95-109; discussion 109-10.
10. Wessberg GA, Washburn MC, LaBanc JP, Epker BN. Autorotation of
themandible: effect of surgical superior repositioning of the maxilla on
mandibular resting posture. Am J Orthod. 1982;81(6):465-72.
11. Profit WR, fields HW, Sarver DM. Contemporary Orthodontics. 4th ed. St.
Louis: Elsevier; 2007.
*Corresponding Author: Rohit Kulshrestha, Saraswati Dental College, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Copyright: © 2016 Singh A, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Citation: Singh A, Kulshrestha R, Tandon R,Goel A, Gupta A (2016) An Orthodontic-Surgical Approach to Class II Malocclusion Treatment with Vertical Growth Pattern - A Case Report. J Dent Oro Surg 1(4): 120.
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