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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 38-42

Case report on the surgical correction of skeletal Class III by maxillary advancement


1 Department of Orthodontic and Dentofacial Orthopedic, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
2 Department of Orthodontic and Dentofacial Orthopedic, Sri Balaji Dental College, Hyderabad, Telangana, India

Date of Submission16-Oct-2019
Date of Acceptance18-Jan-2020
Date of Web Publication10-Apr-2020

Correspondence Address:
Dr. Venkata Naga Sravanthi Jonnalagadda
Sri Sai College of Dental Surgery, Kothrepally, Vikarabad - 501 101
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijor.ijor_35_19

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  Abstract 

Class III malocclusion is exhibited either due to excessive mandibular growth, deficient maxillary growth, or both. Neither growth modification nor camouflage offers a solution for patients with severe Class III malocclusion. Surgery to realign the jaws or reposition dentoalveolar segments is the possible and stable treatment option. A combination of orthodontic and orthognathic phases offers remarkable results along with enhanced psychosocial acceptance. In this case report, Lefort I osteotomy was performed with maxillary inferior repositioning and advancement in a 25-year-old patient with skeletal Class III.

Keywords: Lefort-I osteotomy, maxillary advancement, skeletal Class III malocclusion


How to cite this article:
Jonnalagadda VN, Goskonda VR, Vallapareddy D, Garepally S, Jayabharath Reddy B. Case report on the surgical correction of skeletal Class III by maxillary advancement. Int J Orthod Rehabil 2020;11:38-42

How to cite this URL:
Jonnalagadda VN, Goskonda VR, Vallapareddy D, Garepally S, Jayabharath Reddy B. Case report on the surgical correction of skeletal Class III by maxillary advancement. Int J Orthod Rehabil [serial online] 2020 [cited 2020 Sep 19];11:38-42. Available from: http://www.orthodrehab.org/text.asp?2020/11/1/38/282181


  Introduction Top


Skeletal Class III malocclusion may either be associated with maxillary retrusion, mandibular protrusion, or a combination of the two.[1] These complex cases require careful treatment planning, an integrated approach, and patient cooperation. A poor facial appearance is often the patient's chief complaint, but it may be accompanied by functional problems. The combination of orthodontic treatment and orthognathic surgery is often used for adult patients with severe skeletal Class III discrepancies. The Class III malocclusion was originally thought to be caused by excessive mandibular growth. More recently, the diagnosis and treatment planning paradigms have shifted to indicate a greater role for maxillary deficiency alone or combined with mandibular growth excess.[2],[3] In maxillary deficient cases, decreased vertical development of the maxilla increases the prominence of the chin by allowing the mandible to rotate upward and forward. This is accompanied by minimal incisal and gingival visibility which adds to the esthetic problems associated with skeletal Class III. Reduced lower anterior face height, deep overbite, and passive lip seal associated with a Class III malocclusion have a better prognosis because treatment-induced backward rotation of the mandible will assist in camouflaging the Anteroposterior (AP) discrepancies.[4]

The aim of the present article is to emphasize the importance of surgical intervention in maxillary deficient case.


  Case Report Top


A 25-year-old female patient reported to the department of orthodontics and dentofacial orthopedics, with the chief complaint of backwardly placed upper front teeth. She also complained of mild forward positioning of the lower jaw along with anterior crossbite. On extraoral examination, the patient revealed to have a mild concave profile and a clinically low Frankfort mandibular plane Angle (FMA) which could be attributed to vertically deficient maxilla leading to the upward and forward rotation of the mandible. The patient exhibited a normal nasolabial angle, competent lips with mild protrusion of the lower lip. During smile, decreased incisal exposure without revealing gingiva was other relevant findings. Intraoral examination revealed Class III molar and canine relation with anterior crossbite of 2 mm and mild crowding in the lower anterior region and missing maxillary left second molar [Figure 1].
Figure 1: Pretreatment photographs

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Diagnosis and treatment plan

The patient was diagnosed as a skeletal Class III with ANB of −6° and hypodivergent jaw bases with FMA of 20° [Figure 2]. It was planned to treat the patient surgically by maxillary down fracture and advancement. Advancing the maxillary base would allow the correction of anterior crossbite and bring about fullness in the malar region. This would also increase the incisor exposure.
Figure 2: Pretreatment radiographs

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Treatment objectives

The following treatment objectives were planned:

  1. Correct the skeletal Class III anteroposterior jaw relationship
  2. Coordinate the widths of the dental arches
  3. Achieve an ideal overjet and overbite relationship
  4. Relieve dental compensation by straightening the mandibular incisors to an upright position over the basal bone
  5. Increase incisor exposure and enhance smile esthetics.


Treatment progress

The preoperative orthodontic preparation was performed with preadjusted, 0.022 inch, edgewise appliances [Figure 3]. The leveling and alignment procedures were performed over 8 months. Facebow transfer and mock surgery was performed to assess the amount of maxillary advancement, and surgical splint was made on the mounted models [Figure 4]. LeFort I procedure with clockwise rotation, 8 mm advancement, and 3 mm anterior inferior repositioning was performed [Figure 5] and [Figure 6]. Six weeks after the surgery, finishing was performed with 0.014-inch stainless steel maxillary and mandibular archwires. The appliances were removed after 14 months of active treatment. Fixed lingual retainers were bonded to the lingual surfaces of the anterior teeth in both arches. Maxillary and mandibular Essix retainers were delivered with instructions to use them 24 h/day for the next 12 months.
Figure 3: Treatment progress with initial aligning 0.016 NiTi archwires

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Figure 4: Mock surgery for maxillary advancement and surgical splint

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Figure 5: Presurgical photographs

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Figure 6: Lefort I surgical photographs

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Treatment results

The ideal overjet and overbite was established after the surgery. Class I canine and molar relationships were established. The cephalometric changes included an increase in the ANB angle and the correction of inclinations of maxillary and mandibular incisors. The profile was remarkably improved along with increase in the midfacial height. The advancement of the maxilla also improved the mid-face deficiency sagittally. Down fracturing the maxilla led to opening of the mandibular plane angle, thereby rotating the mandible downward and backward. The maxillary incisor exposure was increased at rest and smile esthetics improved [Figure 7], [Figure 8], [Figure 9], [Figure 10] and [Table 1].
Figure 7: Postsurgical photographs

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Figure 8: Posttreatment photographs

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Figure 9: Posttreatment cephalogram

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Figure 10: Posttreatment orthopantamogram

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Table 1: Pre and post treatment cephalometric values comparison

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  Discussion Top


The combined orthodontic orthognathic treatment is the option for severe skeletal Class III cases. In isolated maxillary advancement, there is an 80% chance of no significant change (<2 mm) in the position of the maxilla postsurgically and essentially no chance of more than a 4-mm change.[5] The results gathered from the University of North Carolina clinical trial suggested that half of the sample had only the maxilla advanced. The rest of the sample had the mandible setback, although mandibular surgery usually was combined with maxillary surgery. Less than 10% of the patients had mandibular surgery alone.[6] Therefore, maxillary deficiency is as important or more important in the development of Class III problems as compared to mandibular excess as shown in the present case report. According to the research, horizontal maxillary advancement had excellent stability at 1 year; a relapse of 0%–100% was reported in cases of maxillary inferior repositioning with wire fixation; therefore, it has been observed that rigid fixation is much more stable.[7],[8],[9] The amount of mandibular relapse was also found to be correlated to the amount of setback in the wire fixation sample, but not in rigid fixation sample.[10],[11]


  Conclusion Top


In the present case report, combined orthodontic and surgical treatment of maxillary advancement with inferior positioning provided the patient with improved facial esthetics and stable functional occlusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sugawara J, Mitani H. Facial growth of skeletal class III malocclusion and the effects, limitations, and long-term dentofacial adaptations to chincap therapy. Semin Orthod 1997;3:244-54.  Back to cited text no. 1
    
2.
Conley RS, Edwards SP. Three-dimensional treatment planning for maxillary and mandibular segmental surgery for an adult class III: Where old meets new. Angle Orthod 2019;89:138-48.  Back to cited text no. 2
    
3.
Bailey LJ, Proffit WR, White R Jr. Assessment of patients for orthognathic surgery. Semin Orthod 1999;5:209-22.  Back to cited text no. 3
    
4.
Yang Z, Ding Y, Feng X. Developing skeletal class III malocclusion treated nonsurgically with a combination of a protraction facemask and a multiloop edgewise archwire. Am J Orthod Dentofacial Orthop 2011;140:245-55.  Back to cited text no. 4
    
5.
Proffit WR, White RP Jr. Combined surgical-orthodontic treatment: How did it evolve and what are the best practices now? Am J Orthod Dentofacial Orthop 2015;147:S205-15.  Back to cited text no. 5
    
6.
Proffit WR, White RP, Sarver DM. Contemporary Treatment of Dent Facial Deformity. 1st ed. St. Louis, MO: Mosby 2008. p. 521-3.  Back to cited text no. 6
    
7.
Perez MM, Sameshima GT, Sinclair PM. The long-term stability of LeFort I maxillary downgrafts with rigid fixation to correct vertical maxillary deficiency. Am J Orthod Dentofacial Orthop 1997;112:104-8.  Back to cited text no. 7
    
8.
Costa F, Robiony M, Sembronio S, Polini F, Politi M. Stability of skeletal Class III malocclusion after combined maxillary and mandibular procedures. Int J Adult Orthodon Orthognath Surg 2001;16:179-92.  Back to cited text no. 8
    
9.
Wagner S, Reyneke JP. The Le Fort I downsliding osteotomy: A study of long-term hard tissue stability. Int J Adult Orthodon Orthognath Surg 2000;15:37-49.  Back to cited text no. 9
    
10.
Satrom KD, Sinclair PM, Wolford LM. The stability of double jaw surgery: A comparison of rigid versus wire fixation. Am J Orthod Dentofacial Orthop 1991;99:550-63.  Back to cited text no. 10
    
11.
Egbert M, Hepworth B, Myall R, West R. Stability of Le Fort I osteotomy with maxillary advancement: A comparison of combined wire fixation and rigid fixation. J Oral Maxillofac Surg 1995;53:243-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1]



 

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