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Table of Contents
CASE REPORT
Year : 2010  |  Volume : 1  |  Issue : 2  |  Page : 143-149  

Surgical-orthodontic treatment of a skeletal class III malocclusion


1 Department of Orthodontics, FODS, CSMMU, Lucknow, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, FODS, CSMMU, Lucknow, Uttar Pradesh, India

Date of Web Publication9-Apr-2011

Correspondence Address:
Radha Katiyar
Department of Orthodontics, FODS, CSMMU, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.79217

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   Abstract 

For patients whose orthodontic problems are so severe that neither growth modification nor camouflage offers a solution, surgery to realign the jaws or reposition dentoalveolar segments is the only possible treatment option left. One indication for surgery obviously is a malocclusion too severe for orthodontics alone. It is possible now to be at least semiquantitative about the limits of orthodontic treatment, in the context of producing normal occlusion as the diagrams of the "envelope of discrepancy" indicate. In this case report we present orthognathic treatment plan of an adult female patient with skeletal class III malocclusion. Patient's malocclusion was decompensated by orthodontic treatment just before the surgery and then normal jaw relationship achieved by bilateral sagittal split osteotomy.

Keywords: Class III malocclusion, decompensation, prognathism


How to cite this article:
Katiyar R, Singh G K, Mehrotra D, Singh A. Surgical-orthodontic treatment of a skeletal class III malocclusion. Natl J Maxillofac Surg 2010;1:143-9

How to cite this URL:
Katiyar R, Singh G K, Mehrotra D, Singh A. Surgical-orthodontic treatment of a skeletal class III malocclusion. Natl J Maxillofac Surg [serial online] 2010 [cited 2019 Jul 22];1:143-9. Available from: http://www.njms.in/text.asp?2010/1/2/143/79217


   Introduction Top


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],[2],[3]

Individuals with class III malocclusion frequently show combinations of skeletal and dentoalveolar components. Several distinct cephalometric features have been reported in class III patients, such as a short anterior cranial base length, acute cranial base angle, a short and retrusive maxilla, proclined maxillary incisors, retroclined mandibular incisors, an excessive lower anterior face height and obtuse gonial angle.

Skeletal class III malocclusion may either be associated with maxillary retrusions, mandibular protrusion, or a combination of the two. [4],[5] These complex cases require careful treatment planning, an integrated approach and patient cooperation. [6] A poor facial appearance is often the patient's chief complaint, but it may be accompanied by functional problems, temporomandibular disorders, or psychosocial handicaps. [7] In this case report, we present the treatment of an adult girl with skeletal class III malocclusion.


   Case Report Top


A 21-year-old female presented with the chief complaint of an unesthetic facial and dental appearance [Figure 1],[Figure 2],[Figure 3],[Figure 4]. Her parents pointed that she was greatly dissatisfied by her appearance. She had a severe class III malocclusion with 2-mm anterior crossbite and 2-mm reverse overbite. The family had no history of skeletal class III malocclusion. When viewed from the front, the patient's face was oval. Lateral view and oblique view showed pronounced mandibular prognathism and midface deficiency with concave profile. Intraorally, the molar relationship was class III with a complete anterior crossbite [Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9].
Figure 1: Pretreatment extraoral fontal view

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Figure 2: Pretreatment extraoral oblique view

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Figure 3: Pretreatment extraoral lateral view

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Figure 4: Pretreatment extraoral smile view

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Figure 5: Pretreatment intraoral frontal view

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Figure 6: Pretreatment intraoral right lateral view

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Figure 7: Pretreatment intraoral left lateral view

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Figure 8: Pretreatment intraoral maxillary occlusal view

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Figure 9: Pretreatment intraoral mandibular occlusal view

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Cephalometric analysis [Table 1] showed maxillary deficiency and mandibular protrusion. The ANB angle was −4΀, suggesting a skeletal class III malocclusion.
Table 1: Cephalometric findings before and after surgery


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The skeletal problem was due to a combination of maxillary deficiency and mandibular prognathism [Figure 10],[Figure 11],[Figure 12].
Figure 10: Pretreatment lateral cephalogram

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Figure 11: Pretreatment orthopantogram

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Figure 12: Pretreatment posteroanterior cephalogram

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Treatment

Bilateral sagittal split osteotomy with presurgical and postsurgical orthodontics was planned to achieve esthetically acceptable and functionally optimum occlusion with straight facial profile and minimum traumatic surgical exposure to the patient. Presurgical orthodontics in both the arches was done to relieve maxillary and mandibular crowding. Maxillary and mandibular arches were aligned upto 0.019 Χ 0.022 stainless steel wire with 0.022 slot edgewise appliances. The mandibular incisors were decompensated by proclining them in normal inclination and the archforms were coordinated [Figure 13],[Figure 14],[Figure 15],[Figure 16],[Figure 17]. Mandibular third molars were extracted one month prior to the orthognathic surgery.
Figure13: Presurgical orthodontics, intraoral frontal view

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Figure 14: Presurgical orthodontics, intraoral right lateral view

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Figure 15: Presurgical orthodontics, intraoral left lateral view

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Figure 16: Presurgical orthodontics, intraoral maxillary occlusal view

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Figure 17: Presurgical orthodontics, intraoral mandibular occlusal view

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Before orthognathic surgery, the template was prepared using tracing paper. Skeletal profile of maxillae and mandible was traced. Profile tracing was then transferred using a carbon paper to a thin cardboard. This outline was then cut to produce cardboard template. From these templates, trial sections were made until desirable location and amount for osteotomy was found. The cut section of mandible was then fitted back to tracing in desired occlusal relation and the probable postsurgical changes were checked. In this case, 8 mm of mandibular setback brought class I molar relation with an esthetically pleasing profile. Hence, 8 mm setback of mandible was planned for osteotomy.

Surgical procedure

Retromolar area was exposed using modified third molar incision. Bilateral sagittal split osteotomy with short lingual split was carried out using surgical saws. [8] Medial pterygoid muscle was detached after performing the split and 8 mm setback was achieved.

Fixation was done using four hole miniplates and screw on both sides. Intermaxillary elastics were placed on braces for 14 days in immediate postoperative phase. The patient was followed closely after the procedure and was guided to perform opening and lateral movements. Orthodontic treatment was resumed 6 weeks after surgery. One year later, fixed appliances were removed and a retention appliance was delivered [Figure 18],[Figure 19],[Figure 20],[Figure 21],[Figure 22],[Figure 23],[Figure 24],[Figure 25],[Figure 26],[Figure 27],[Figure 28].
Figure 18: Postsurgical extraoral frontal view

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Figure 19: Postsurgical extraoral oblique view

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Figure 20: Postsurgical extraoral lateral view

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Figure 21: Posttreatment extraoral smile view

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Figure 22: Postsurgical extraoral frontal view

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Figure 23: Postsurgical intraoral right lateral view

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Figure 24: Postsurgical intraoral left lateral view

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Figure 25: Postsurgical intraoral maxillary occlusal view

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Figure 26: Postsurgical intraoral mandibular occlusal view

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Figure 27: Postsurgical lateral cephalogram

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Figure 28: Postsurgical orthopantogram

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Figure 29: Superimposition of pre- and post-treatment cephalometric tracings

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Patient's cooperation was excellent throughout the treatment. Cephalometric finding show the normal jaw relationship [Table 1],[Figure 29].


   Discussion Top


This case report describes the treatment of an adolescent girl with dental and skeletal class III relationships. Surgical-orthodontic treatment was the best option for achieving an acceptable occlusion and a good esthetic result in this case. An experienced multidisciplinary team approach ensures a satisfactory outcome. Presurgical orthodontics removes all the dental compensations and suggests the location and extent of the skeletal discrepancy. Normal skeletal base relationship is achieved by osteotomy and setback of the prognathic mandible, postsurgical orthodontics guides the normal occlusal rehabilitation by correcting any emerging dental discrepancies.


   Acknowledgment Top


We would like to thank Dr. Ranjit Singh for his valuable cooperation.

 
   References Top

1.Lew KK, Foong WC. Horizontal skeletal typing in an ethnic chinesepopulation with true class III malocclusion. Br J Orthod 1993;20:19-23.  Back to cited text no. 1
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2.Kharbanda OP, Sidhu SS, Sundaram KR, Shukla DK. Prevelance of malocclusion and its traits in delhi children. J Indian Orthod Soc 1995;26:98-103.   Back to cited text no. 2
    
3.Ishii N, Deguchi T, Hunt N. Craniofacial difference between Japanese and british Caucasian females with a skeletal class III malocclusion. Eur J Orthod 2002;24:493-9.  Back to cited text no. 3
    
4.Vig KD, Ellis E 3rd. Diagnosis and treatment planning for the surgicalorthodontic patient. Dent Clin North Am 1990;34:361-84.  Back to cited text no. 4
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5.Sinclair PM. Orthodontic considerations in adult surgical orthodontic cases. Dent Clin North Am 1988;32:509-28.  Back to cited text no. 5
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6.Phillips C, Proffit WR. Psychosocial aspects of dentofacial deformity and its treatment. In: Proffit WR, White RP Jr, Sarver DM, editors. Contemporary Treatment of Dentofacial Deformity. St. Louis: Mosby; 2003. p. 69.  Back to cited text no. 6
    
7.Bailey LJ, Sarver DM, Turvey TA, Proffit WR. Class III problems. In: Proffit WR, White RP Jr, Sarver DM, editors. Contemporary Treatment of Dentofacial Deformity. St. Louis: Mosby; 2003. p. 507.  Back to cited text no. 7
    
8.Epker BN. Modifications in the sagittal osteotomy of the mandible. J Oral Surg 1977;35:157-9.  Back to cited text no. 8
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29]
 
 
    Tables

  [Table 1]


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