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Case Report

Surgical correction of class II skeletal


malocclusion in an adult patient
Ramakrishnan Balachander, Kandapalanivel Karthik, Anilkumar Katta1, Kandasamy Rajasigamani
Departments of Orthodontics and Dentofacial Orthopaedics, Raja Muthiah Dental College and Hospital,
Annamalai University, Chidambaram, Tamil Nadu, 1Sibar Institute of Dental Sciences, Takkellapadu, Guntur,
Andhra Pradesh, India

ABSTRACT
Correction of skeletal deformities in adult patients with orthodontics is limited. Orthognathic
surgery is the best option for cases when camouflage treatment is questionable and growth
modulation is not possible. This case report illustrates the benefit of the team approach
in correcting vertical maxillary excess along with class II skeletal deformity. A cosmetic
correction was achieved by superior repositioning of maxilla with LeFort I osteotomy and
augmentation genioplasty, along with orthodontic treatment. The patients facial appearance
was markedly improved along with functional and stable occlusion.

Key words: Camouflage, genioplasty, orthognathic

INTRODUCTION

Address for correspondence:


Dr. Anilkumar Katta,
Department of Orthodontics
and Dentofacial Orthopaedics,
Sibar Institute of Dental Sciences,
Takkellapadu, Guntur - 522 509,
Andhra Pradesh, India.
E-mail: anilchow82@gmail.com

Access this article online


Website:
www.jofs.in
DOI:
10.4103/0975-8844.132587
Quick Response Code:

Todays orthodontics not only gives


importance to esthetics and function
but also to establish harmony between
craniofacial structures.[1] Facial appearance
is an important factor in determining
social relationships and improving their
self-confidence.[2] Vertical maxillary excess
is commonly seen in orthodontics with
the gummy smile as the major problem
from patients perspective. The envelope
of discrepancy[3] for the maxillary and
mandibular arches in three planes of
space determines the treatment plan by
orthodontic or by orthognathic correction.
Surgical intervention to reposition the
jaws and dento alveolar segments becomes
the only option to treat patients with
severe skeletal deformity where growth
modulation is not possible and camouflage
treatment is questionable.[4] Considering
the limitations of the orthodontic
treatment for severe skeletal deformity
combined orthodontic and surgical
treatment was planned, which resulted in
a stable outcome.

CASE REPORT
The present case report is about a 20-yearold female patient who came to the
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Department of Orthodontics with a chief


complaint of forwardly placed upper front
teeth and excessive visibility of gums in
the upper arch during smile.

Extra oral examination


Dolichocephalic
head
pattern
and
leptoprosopic
facial
form.
Frontal
examination showed lip incompetence and
full crown exposure during rest and 6 mm
of gingival display during smile. Profile
was convex with posterior divergence and
increased lower anterior facial height.
Clinical (Frankfort mandibular plane
angle) was high and chin was retruded,
with acute nasolabial angle [Figure 1].
Normal breathing, deglutition and speech
were diagnosed on functional examination.
Intraoral examination revealed U shaped
arches with bimaxillary dento alveolar
proclination of upper and lower anteriors.
Lower incisors showed mild crowding with
exaggerated curve of spee. Angles class I
molar and canine relation on both sides
with over jet of 4 mm and over bite of 5 mm
[Figures 2 and 3].
Cephalometric examination revealed class
II skeletal base due to orthognathic maxilla
with vertical excess and mild retrognathic
mandible. Vertical growth pattern with
Journal of Orofacial Sciences
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Balachander, et al.: Surgical correction of class II skeletal malocclusion

excess lower anterior facial height and increased


mandibular plane angle. Dento alveolar analysis showed
proclined upper and lower anteriors. Soft-tissue analysis
indicates lip strain and protrusive lower lip [Figure 4].
Space analysis showing 10 mm of space discrepancy in
the upper arch and 13 mm in the lower arch.

Diagnosis
Angle class I malocclusion on a class II skeletal base
between orthognathic maxilla and retrognathic
mandible with vertical growth pattern and increase
lower anterior facial height, with over jet of 4 mm and
over bite of 5 mm and lower anterior crowding.

Treatment objectives
To obtain class I skeletal base, to level and align the
teeth, to obtain the ideal over jet and over bite, to
maintain class1 molar and canine relation, improvement
of soft-tissue profile.

Treatment plan
Phase I

Pre surgical orthodontics, extraction of upper


and lower 1st premolars.

Phase II

Orthognathic surgery, anterior superior


repositioning of maxilla with Lefort I
osteotomy and advancement genioplasty.
Phase III Post surgical stabilization.

Treatment progress
The case was started with pre adjusted edgewise appliance
using 0.022 slot MBT prescription. Upper and lower
premolars were extracted as planned for pre surgical
orthodontics. 0.016 initial nickel-titanium (Ni-Ti) arch
wires were placed for alignment followed by 0.016 0.022
Ni-Ti and 0.017 0.025 Ni-Ti wires. Retraction was done
on 0.019 0.025 stainless steel (ss) wire. 0.021 0.025 ss
wires were placed for 2 months to achieve proper torque.
Anterior superior repositioning of 5 mm was done along
with advancement genioplasty [Figure 5]. The patient was
put on settling elastics post surgically.

Treatment results
The total treatment duration was 18 months with
10 months of pre-surgical orthodontics and 8 months of
post-surgical management. Outcome of the treatment
was a significant improvement in the patients smile and

Figure 1: Pre-treatment extra-oral photographs

Figure 2: Pre-treatment intra-oral photographs

Figure 3: Pre-treatment occlusal photographs

Figure 4: Pre surgical lateral cephalogram and orthopantomogram

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Balachander, et al.: Surgical correction of class II skeletal malocclusion

profile [Figure 6]. Class I molar and canine relation was


maintained, ideal over jet and over bite established.proper
root parelleling and torque has been established. Upper
and lower lingual retainers were given. [Figures 7, 8 and 9].

DISCUSSION
There are certain limitations how far a tooth can be
moved and these become important when the problem
is of severe skeletal deformity.[5] The essential steps in
pre-surgical orthodontics are to align the arches and
make them compatible to establish the antero-posterior
and vertical position of the incisors. The extraction of
first premolars aided in the correction of the upper
incisor proclination and alignment and leveling the
cuve of spee in the lower arch.

forward, hinging at the temporomandibular joint, which


simultaneously shortens facial height and provides more
chin prominence. The clinical and cephalometric values
showed that there is mild mandibular deficiency. Along
with maxilla surgery, we considered the treatment
option of sliding augmentation genioplasty by preventing
extensive Bijaw surgery as auto rotation of the mandible
helps in improving her profile. The results satisfied the
primary complaint of the patient. Once satisfactory
range of motion and stability were achieved, the finishing
stage of orthodontics was done with settling elastics. The
pre-surgical and post-surgical cephalometric values and
superimpositions showed a dramatic skeletal and dental
improvement [Table 1 and Figure 10].

CONCLUSION

Superior repositioning of the maxilla was done with


LeFort I osteotomy to reduce the gummy smile.
In patients whose mandible is normal in size, the
retrognathic appearance results from downward and
backward rotation of the chin. Superior repositioning of
the maxilla allows the mandible to rotate upward and

Orthognathic surgery is a possible option in patients


with severe skeletal deformities. Treatment planning
according to the level of discrepancy ensures stability
and good outcome. The patient has reported a greater
degree of pleasure related to her appearance.

Figure 5: Surgical photographs showing Lefort I osteotomy and


genioplasty

Figure 6: Post-treatment extra-oral photographs

Figure 7: Post-treatment intra-oral photographs

Figure 8: Post-surgical lateral cephalogram and orthopantomogram

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Journal of Orofacial Sciences


Vol. 6 Issue 1 January 2014

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Balachander, et al.: Surgical correction of class II skeletal malocclusion

Figure 9: post treatment occlusal photographs with lingual retainers

Table 1: Comparison of pre- and post-surgical


cephalometric variables
Variable
Sagittal skeletal relationship
SNA ()
SNB ()
ANB ()
Dental base relationship
Upper incisor to NA ()
Lower incisor to NB ()
Upper incisor to SN plane ()
Lower incisor to mandibular plane
angle ()
Dental relationship
Inter-incisal angle ()
Lower incisor to APo line (mm)
Over bite (mm)
Over jet (mm)
Vertical skeletal relationship
Maxillary-mandibular plane angle ()
SN plane mandibular plane ()
Upper anterior facial height (mm)
Lower anterior facial height (mm)
Facial height ratio (%)
Maxillary length (mm)
Mandibular length (mm)
Soft-tissues sub heading
Lower lip to ricketts E plane (mm)
Nasolabial angle ()

Journal of Orofacial Sciences


Vol. 6 Issue 1 January 2014

Normal

PrePostsurgical surgical

822
802
2

81
75
6

80
79
1

Figure 10: Pre- and post-treatment superimpositions

22
25
102
90

30
32
111
95

23
26
104
91

1.

131
12
2-3
2-3

111
10
3
4

130
4
3
2

3.

25
32
47-52
57-65
62-65
48-56
715

34
42
52
70
58
55
67

27
34
50
68
60
54
70

5.

2
90-110

12
83

4
108

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How to cite this article: Balachander R, Karthik K, Katta A,


Rajasigamani K. Surgical correction of class II skeletal malocclusion in
an adult patient. J Orofac Sci 2014;6:58-61.
Source of Support: Nil, Conflict of Interest: None declared

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