Download Orthognatic Surgery of Severe Skeletal Open Bite with a Class III

Orthognatic Surgery of Severe Skeletal Open Bite with
a Class III Malloclusion
Salma Ghassan El Khairy – DDS
MSc student, Department of Orthodontics, Faculty of Dentistry | University of Damascus, Syria - [email protected]
Salah Mahaini – DDS
Resident and PhD student, Department of Oral- and Maxillofacial Surgery | Ludwig-Maximilians-University, Munich, Germany
Luai Mahaini – DDS, MSc, PhD
Assistant Professor, Department of Orthodontics, Faculty of Dentistry | University of Damascus, Syria
ABSTRACT
Patients requiring correction of large anterior open bites have historically been among the most challenging
treatments for orthodontists. Adding to that fundamental challenge for the adult patient in this case was a sever
skeletal open bite with a class III malocclusion.
This case demonstrates the relationship of a severe skeletal open bite with a class III malocclusion.
Considerations regarding the use of segmental maxillary osteotomy vs vertical mandibular osteotomy to raise the
occlusal plane and allow for mandibular autorotation with a nose cosmetic surgery.
This case illustrates the importance of proper diagnosis and treatment planning. A team approach between the
orthodontist and the surgeon, all having input before the initiation of treatment is the best way to achieve stable,
functional, and esthetic results.
KEYWORDS
Orthognatic Surgery; Severe Skeletal Open Bite; Class III Malloclusion.
INTRODUCTION
Anterior open bite is one of the most difficult Anterior
open bite is one of the most difficult malocclusions to treat
and maintain in orthodontics. The morphologic pattern
usually demonstrates increased vertical dimensions and
an increase in development of the maxillary posterior
dentoalveolar structure.1–3 The surgical correction of
skeletal open bite often requires maxillary impaction to
achieve reduction of anterior facial height.4
Treatment modalities cover a broad spectrum, including
bite blocks (with or without magnets),5,6 vertical pull
chin cup,7 extraction therapy,8 multiple loop edgewise
archwire (MEAW) therapy,9 and surgery.10
Unfortunately, many of these techniques are of limited
use in adult non-growing patients and in patients with
significant vertical skeletal dysplasia. These procedures
have been effective in passive intrusion of the maxillary
posterior segment,11-14 But the correction of the
malocclusion was achieved primarily through extrusion
of the incisors or by preventing passive eruption of
posterior teeth.
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In adult patients, treatment of severe skeletal anterior
open bite consists mainly of surgically repositioning both
the maxilla and the mandible.
This is true in the adult because adults have little growth
potential, and often open bites are combined with long
face tendency.15,16
Treatment stability is always a concern when open bites
are corrected with guided eruption. Patients who have
excellent results upon appliance removal will often show
a gradual decrease in overbite.
Successful treatment with functional appliances, MEAW
therapy, extraction therapy, and other treatment methods
often requires both extrusion of anterior teeth and
patient compliance. Stability studies of each of these
treatment methods have shown that over time there can
be significant reduction of the overbite.17 Much research
has also been conducted on the stability of orthognathic
surgery for the correction of skeletal open bite.18
Depending on the magnitude of the open bite and
the relative anterior-posterior positions of the jaws, surgery
can vary from relatively routine single jaw surgery to
complex three-dimensional double jaw surgery.
CASE SUMMARY
A female patient 20 years and nine months of age came
to oral and maxillofacial surgery hospital in Damascus
University and reffered to orthodontic department (fig 1).
The patient’s chief complaints were a chewing problem,
anterior open bite and increased lower facial height.
Occlusal examination revealed severe anterior open
bite with an overjet of 7mm and overbite of 2mm was
observed. In addition, two distinct occlusal planes were
present in the upper arch. No crowding was present,
Class III malocclusion with an anterior open bite was
noticed. The maxillary arch form was constricted with a
slight saddle shape.
The upper dental midline almost coincided with the
facial midline.
Facial and cephalometric examination, revealed an
excessively long lower facial height, large interlabial
gap, excessive incisal display at rest, and an excessive
incisal and gingival display upon smiling. When
compared with the Syrian norms, the patient showed a
skeletal Class I relationship (ANB 1)(SNA 83) (SNB 82)
(fig 2). The mandibular plane angle was steep, and the
Gonial angle was large (MP/FH 45), but the mandibular
body length and ramus height were within the normal
range. The upper incisors were labially inclined (U1/
SN119, U1-SPP 124). Both upper and lower molars were
significantly extruded (U6/NF 31.6, L6/MP 37.4), and
the molar relationship was Angle Class III on both sides.
Diagnosis and treatment objectives
The patient was diagnosed as having an Angle Class
III malocclusion, with a skeletal Class I jaw base
relationship, a skeletal anterior open bite.
The treatment objectives were:
1. To
correct the anterior open bite and establish ideal
overjet and overbite.
2. To achieve an acceptable occlusion with a good
functional Class I occlusion.
3. Correction of vertical maxillary excess with a
superiorly repositioned Le Fort I osteotomy and with
vertical mandibular osteotomy to raise the occlusal
plane and allow for mandibular autorotation.
4. Cosmetic nose surgery.
A
B
(Fig. 1) Pre-treatment photographs (age: 20 years nine months)
(Fig. 2) A: Pre-treatment cephalograph. B: Pre-treatment
Panoramic radiograph
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(Table 1) Pre-treatment and Post-treatment Cephalometric
Measurementsa
Pre-treatment
Post-treatment
SNA
83
86
SNB
82
84
ANB
1
2
U1/SPP
124
117
L1/ML
85
84
B
42
32
Bjorek Sum
407
397
Treatment progress
The patient and her mother were presented with the
treatment outlined above. Both agreed to pursue a onestage surgical correction for the malocclusion. Spacers
were placed, and the patient returned one week later for
banding. Appropriately sized bands were selected and
placed on the maxillary, and mandibular first molars.
The maxillary and mandibular arches were bonded and
aligned. Preorthognathic surgical models, radiographs,
and photographs were obtained. The patient was
referred to surgery which involved a segmental LeFort
1 procedure with approximately five mm of posterior
impaction to allow mandibular autorotation and vertical
ramus osteotomy (IVRO) was performed to close the
gonial angle and accommodate the occlusal plane
change. The autorotation serves to correct the anterior
open bite, decrease lower face height, and steepen
the maxillary dentition, no attempt was made to level
the maxillary arch orthodontically. The patient was
placed in intermaxillary fixation for two weeks, and the
surgical splint was wired to the maxillary arch for a total
of six weeks. The day that the splint was removed, a
continuous maxillary archwire was placed in addition to
a passive 0.036-inch stainless steel heat-treated.
(Fig. 3)
Post-treatment photographs.
Note the dramatic change
in facial height as well as
the relative maxillary and
mandibular projection
RESULTS
A dramatic improvement in facial height and occlusal
function was achieved with the completion of treatment
(fig 3). The lip competency, tooth-to-lip at rest, and at
smile and facial contour have significantly improved. The
patient was very satisfied with the results of treatment.
The excessive vertical height was dramatically reduced,
and most of the cephalometric values were brought into
the normal range. The mandibular plane angle was
significantly reduced, mandibular anterior-posterior
position was improved (fig 3), and an ideal overjet and
overbite were established (fig 4).
DISCUSSION
The classical technique of closing a skeletal open bite in
a patient with a long face involves a LeFort I osteotomy,
impaction of the maxillary posterior dentition to allow
mandibular autorotation, an increased steepness of
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(Fig. 4) Post-treatment photographs. Note the ideal overjet and
overbite
A
CONCLUSIONS
This case illustrates the importance of proper diagnosis
and treatment planning. A team approach with the
orthodontist and surgeon, 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 her appearance.
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1.
2.
B
3.
4.
5.
6.
(Fig. 5) A: Post-treatment cephalograph. B: Post-treatment
Panoramic radiograph
7.
8.
the maxillary occlusal plane, and then performing a
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One possible variation to the proposed treatment plan
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