To cite this article: Oueis R, et al.

Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary

protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002
International Orthodontics 2019; //: ///

Websites:
www.em-consulte.com
www.sciencedirect.com

Case Report
Orthodontic-Orthognathic Management of a
patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary
excess: A multi-faceted case report of
difficult treatment management issues

Rawan Oueis 1, Peter D. Waite 2, Jue Wang 1, Chung H. Kau 1

Available online: 1. University of Alabama, School of Dentistry, Department of Orthodontics, 1919 7th
Ave S, SDB 305, Q1 35294-0007 Birmingham, AL, USA
2. University of Alabama, School of Dentistry, Department of Oral and Maxillofacial
Surgery, Birmingham, AL, USA

Correspondence:
Chung H. Kau, University of Alabama, School of Dentistry, Department of
Orthodontics, 1919 7th Ave S, SDB 305, Q1 35294-0007 Birmingham, AL, USA.
ckau@uab.edu

Keywords Summary
Orthognathic surgery
Second surgery This case reports the unsuccessful first treatment and the subsequent retreatment of a 35-year old
3D Surgery Planning Asian female with a skeletal class II with bimaxillary protrusion, complicated by a deep bite and vertical
maxillary excess. This case report highlights the multiple facets of a challenging treatment plan and
discusses the ramifications of treatment when treatment does not go as planned. The initial treatment
plan consisted of a surgical approach with a maxillary Le Fort I surgery to correct the malocclusion as per
the patient's requests without mandibular surgery due to the inherent risk of paraesthesia. The second
treatment plan consisted of a bimaxillary surgery with genioplasty. The surgical treatment utilized
virtual surgical planning (VSP). The orthodontic treatment was concluded with a corrected overjet and
overbite achieving optimum function and balancing the facial profile aesthetically. This case report
highlights the need for clear communication of the treatment plan and also the unpredictability of
certain treatment outcomes especially when the literature does not provide for definitive conclusions.
In addition, it sheds light on the challenge of unpredictable response of soft tissue after surgical
treatment and the importance of patient expectations of outcomes. It is hoped that the paper provides
a platform for future discussions of difficult malocclusions.

Mots clés Résumé

Chirurgie orthognathique
Reprise chirurgicale Le cas clinique montre l'échec d'une première prise en charge et la reprise thérapeutique d'une
Planification chirurgicale patiente asiatique de 35 ans présentant une classe squelettique avec une biprotrusion maxillaire
tridimensionnelle compliquée d'une supraclusion et un excès vertical maxillaire. Ce cas clinique montre les multiples
facettes d'un plan de traitement complexe et traite des répercussions du traitement quand il ne se

tome xx > 000 > xx 2019

1

https://doi.org/10.1016/j.ortho.2019.09.002
© 2019 CEO. Published by Elsevier Masson SAS. All rights reserved.

ORTHO-436
 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002

R. Oueis, P.D. Waite, J. Wang, C.H. Kau

Case Report

déroule pas comme prévu. Le plan de traitement initial consistait en une approche chirurgicale de
type Le Fort pour corriger la malocclusion selon le désir de la patiente sans chirurgie mandibulaire
en raison du risque inhérent de paresthésie. Le second plan de traitement consistait en une
chirurgie bimaxillaire avec génioplastie. Le traitement chirurgical a utilisé la planification chir-
urgicale virtuelle (VSP). Il a été conclu que le traitement orthodontique devait apporter une
correction des surplombs horizontal et vertical avec une fonction optimale et un équilibre
esthétique faciale du profil. Ce cas clinique soulève le besoin d'une bonne compréhension du
plan de traitement et aussi le côté imprédictible de certains résultats thérapeutiques surtout
quand la littérature n'apporte pas de conclusions définitives. De plus, il met l'accent sur la réponse
imprédictible des tissus mous après le traitement chirurgical et sur l'importance des attentes du
patient en matière de résultat. Nous espérons que le présent article fournira une plateforme de
discussion des malocclusions difficiles à traiter.

Introduction osteotomy, bilateral sagittal split osteotomy (BSSO), and upper

Developmental dentofacial deformities (DFD) are deformities that
primarily affect the maxillary and mandibular jaws and dentition
[1]. (DFD) affects populations of all ethnicities (some more than
others) and its presentation may be the result of genes, idiopathic
condylar resorption, idiopathic juvenile arthritis, fracture of the
condyle, or asymmetry of the face and is more commonly seen in
females [2]. DFD is seen in the form of hyperplasia or hypoplasia
of the facial skeletal structures and may cause deformation in one
or both of the jaws. This can lead to problems in the upper airway
space and requires the patient to put in more effort for the simple
acts of mastication and speech [3,4].
Bimaxillary protrusion is a distinctive DFD commonly prevalent
in various ethnicities, specifically African and Asian populations
[1]. The characteristic convex face is the product of skeletal
retrognathism, microgenia and maxillary and mandibular den-
toalveolar protrusion that result in excessive gingival display, lip
incompetence, and mentalis strain. These features produce a
socially unacceptable aesthetic that lead the patients to seek
treatment for a more harmonious facial balance. The antero-
posterior relationship of bimaxillary protrusions is usually
related to a class II malocclusion associated with a mandibular
deficiency [5].
Accurate diagnosis is important for achieving treatment goals.
Diagnosis of DFD relies on the patient's history and clinical
examination. The severity of this condition varies and therefore
there are many treatment options. Mild cases of DFD may be
camouflaged through orthodontic treatment alone, while
severe cases will require presurgical orthodontics for alignment
and level of the dentition in the arch, orthognathic surgery, and
postsurgical orthodontic treatment for the correction of minor
details of occlusion. Orthodontically, bimaxillary protrusion with
vertical maxillary excess is treated by extraction of the four first
premolars followed by the retraction and/or up-righting of the
incisors. Surgically, treatment involves a combination of Le Fort I
2
and lower anterior segmental osteotomies (ASOs) [5].
Virtual surgical planning (VSP) allows the three-dimensional
(3D) replication of the surgical procedures to more accurately
show the estimated final outcome to the orthodontist, oral
maxillofacial surgeon, and the patient. VSP has been used in
many complex cases and shows accurate skeletal results with
high patient satisfaction [6–10]. Despite the best joint efforts of
the orthodontic and surgical teams, there are still some unde-
sired outcomes from unpredictable and uncontrollable factors. It
is inaccurate to assume all surgeries produce the perfectly
planned outcome. It is naïve to assume that the patient has
the ability to perceive the treatment outcome even with better
imaging and VSP. This patient was very focused on the vertical
maxillary excess (VME) and did not perceive the retrognathia in
the frontal view.
Regardless of the 3D virtual planning, certain psychological and
physiological aspects cannot be calculated accurately. Physio-
logically, the soft tissue reacts unpredictably from the bony
surgery and this could compromise the aesthetics of the patient
profile [11–14]. Psychologically, there is no way to factor in
patient expectations, patients' beliefs, family recommendations
and patients' layman definition of aesthetics which is compli-
cated by ethnicity as each population has its own view on what
is aesthetically acceptable within societal norms [15–18].
This paper discusses the case of a patient that had skeletal class
II with bimaxillary protrusion further complicated by vertical
maxillary excess and the previous extraction of a left mandibular
first molar. Here we present a case that was the sum of the
following critical factors: the importance of patient compliance,
treatment plan compromise, and surgical retreatment. Not com-
monly discussed in publications, surgical retreatments are con-
sidered a taboo topic of the surgical community. However, it is
within the practice's and patients' best interests that we, as a
professional community, are aware that surgical retreatment

tome xx > 000 > xx 2019

 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002
Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary protrusion,
complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues

Case Report

Figure 1
Initial photos and radiographs
3

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 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002

R. Oueis, P.D. Waite, J. Wang, C.H. Kau

Case Report

should not be off-limits and is sometimes necessary for the best

possible outcome.

Diagnosis and aetiology

In January 2016, a 35-year old woman presented at the depart-
ment of orthodontics at the University of Alabama, Birmingham,
with the chief complaint of gummy smile and wanted to be able
to put her lips together without effort. Clinical evaluation
showed a skeletal class II with a convex profile and a high facial
angle, incompetent lips, severe gingival display on smiling, an
increase in the lower facial height, and a strained mentalis
muscle.
Intra-oral examination revealed a 75% overbite, a 6 mm over-
jet, with mild crowding in the maxillary and mandibular arches.
There was an occlusal cant to the right side, the mandibular
dental midline was deviated to the left by 5.5 mm, and there
were no signs of TMJ disorder despite a condylar asymmetry. The
patient has a midline deviation in the lower arch due to the loss
of the mandibular left first molar. An irregularity of bone archi-
tecture from the first molar extraction is visible on the pan-
oramic radiograph. The right side was a class I canine and ¼ Step
Figure 2 Class II molar relationship and the left side was a class II molar
Pre-treatment radiograph and cephalometric tracing and canine relationship (figure 1).

Figure 3
Virtual surgical planning (VSP): 2 options of treatment simulation (Le Fort I surgery/Le Fort I and bilateral sagittal split osteotomy)
4

tome xx > 000 > xx 2019

 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002
Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary protrusion,
complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues

Lateral cephalometric analysis revealed a normal maxillary rela-
tion to the cranial base but a retrognathic mandibular relation-
ship (72.98). Skeletal and Class II were evident (ANB 9.38, WITS
7.0 mm) upper and lower incisors were upright (figure 2).
Treatment plan
The patient was diagnosed with a mild right maxillary canting of
the occlusal plane, skeletal class II, vertical maxillary excess,
moderate maxillary crowding, and mild mandibular crowding.
After evaluating all the diagnostic records, the following treat-
ment plan was developed:
 alignment and levelling of the dentition in the upper and
lower arches;
 correction of the open bite and over jet;
 correction of the dental midline deviation;
 bimaxillary surgery;
 treatment of the malocclusion post-surgically.
After through consultation and careful consideration of all the
treatment options with the patient, a non-extraction, single jaw
surgery approach was selected by the patient, against the
advice of the orthodontist and the surgeon. The patient's main
Case Report
complaint was the gummy smile, VME and lip incompetence.
Her family discouraged her from mandibular advancement and
genioplasty due to the more extensive procedure and risk of
nerve damage. A Le Fort I to impact the posterior maxilla
followed by orthodontics to correct any postsurgical occlusal
discrepancies was decided on. The preoperative virtual surgical
planning was conducted and empower brackets would be used
to accomplish inter-arch settling (figure 3).
Treatment Progress
The treatment started with presurgical orthodontic treatment
using clear American Orthodontics Empower brackets bonded on
the upper arch followed by the lower arch after two months.
The first and the second molars were banded. Initial levelling
was begun with the use of 0.016-inch NiTi and progressed
to 0.01  0.016-inch NiTi, 0.018  0.018-inch NiTi to
0.017  0.025-inch NiTi before surgery. The maxillary arch
was expanded which relieved the crowding, and the teeth in
the mandibular arch were realigned. Five months after bonding,
initial alignment was complete and presurgical CBCT, records,
and impressions were taken for medical modelling.

TABLE I
Occlusal and bony anatomic landmarks and their summarized movements (mm) from preoperative position (with mandible autorotated
close) to simulated postoperative position for first surgery.

Point Name Anterior/Posterior Left/Right Up/Down

ANS Anterior nasal spine 3.04 mm posterior 0.90 mm right 4.46 mm up

A A point 2.57 mm posterior 0.37 mm RIGHT 4.63 mm up

ISU1 Midline of UPPER INCISOR 0.93 mm posterior 1.27 mm left 5.00 mm up

U3L Upper left canine 2.30 mm posterior 0.50 mm right 5.24 mm up

U6L Upper LEFT ANTERIOR MOLAR 2.88 mm posterior 1.28 mm right 4.01 mm up
(mesiobuccal cusp)
U3R Upper right canine 0.24 mm anterior 0.58 mm left 3.57 mm up

U6R Upper right anterior molar 0.71 mm anterior 0.92 mm right 1.87 mm up
(mesiobuccal cusp)
ISL1 Midline of lower incisor 2.37 mm anterior 0.16 mm left 3.64 mm up

L6L Lower left anterior molar 2.21 mm anterior 0.13 mm left 2.31 mm up
(mesiobuccal cusp)
L6R Lower right anterior molar 2.28 mm anterior 0.14 mm left 2.54 mm up
(mesiobuccal cusp)
B B Point 3.52 mm anterior 0.20 mm left 3.11 mm up

Pog Pogonion 3.84 mm anterior 0.21 mm left 3.10 mm up

5

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 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002

R. Oueis, P.D. Waite, J. Wang, C.H. Kau

Case Report

Figure 4
After first surgery photographs and superimposition of initial (black) and intermediate (blue) cephalometric tracings

A Le Fort I osteotomy was preformed where 4–5 mm of bone was
removed from the lateral wall of the maxilla and the maxilla was
impacted by 4.5 mm (table I). The maxilla was then fixated with
four KLS Martin 1.5 plates and the mandible was articulated
nicely into its predetermined position. A small amount of the
nasal septum was removed to account for the impaction. This
procedure resulted in a two-degree rotation of the occlusal plane.
The patient was discharged without any complications. The
postsurgical follow up took place four weeks after the procedure
and post-surgical records and CBCT images were taken. The hard
tissues demonstrated the expected results of the virtual surgical
6
planning, however, the soft tissue results proved unpredictable.
Synching of the muscles of the alar of the nose increased the
patient's soft tissue protrusion in the maxillary area and overall
facial convexity causing an anaesthetic facial imbalance. Poor
chin projection and a shorter vertical facial dimension did not
improve the convex profile (figure 4). The patient was dissatisfied
with the outcome and was psychologically depressed by the
resulting profile. Extensive counselling and re-treatment plan-
ning according to the Orthodontist (CHK)/Oral Maxillofacial Sur-
geon (PDW) were carried out. Five months following the first
surgical procedure, a second VSP guided surgical procedure to

tome xx > 000 > xx 2019

 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002
Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary protrusion,
complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues

Case Report

Figure 5
VSP workflow showing Retreatment surgery plan of Le Fort I, BSSO and genioplasty
7

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 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002

R. Oueis, P.D. Waite, J. Wang, C.H. Kau

Case Report

TABLE II
Occlusal and bony anatomic landmarks and their summarized movements (mm) from preoperative position (with mandible autorotated
close) to simulated postoperative position for second surgery.

Point Name Anterior/Posterior Left/Right Up/Down

ANS Anterior nasal spine 4.70 mm posterior 2.00 mm right 1.83 mm up

A A point 4.47 mm posterior 2.00 mm right 1.89 mm up

ISU1 Midline of upper incisor 4.00 mm posterior 2.00 mm right 2.00 mm up

U3L Upper left canine 4.03 mm posterior 2.00 mm right 1.79 mm up

U6L Upper left anterior molar 4.10 mm posterior 2.00 mm right 1.35 mm up
(mesiobuccally cusp)
U3R Upper right canine 4.03 mm posterior 2.00 mm right 1.82 mm up

U6R Upper right anterior molar 4.09 mm posterior 2.00 mm right 1.41 mm up
(mesiobuccal cusp)
ISL1 Midline of lower incisor 0.53 mm posterior 2.60 mm right 1.02 mm up

L6L Lower left anterior molar 0.39 mm anterior 1.18 mm left 0.08 mm Down
(mesiobuccal cusp)
L6R Lower right anterior molar 1.66 mm posterior 1.37 mm left 1.65 mm up
(mesiobuccal cusp)
B B point 0.38 mm posterior 2.95 mm right 0.99 mm up

Pog Pogonion 8.09 mm anterior 0.87 mm right 0.76 mm up

correct the facial balance and improve the bite was performed
(figure 5, table II). It took 5 months for the patient to make the
decision to proceed with the second procedure and it required
extensive counselling and treatment planning. A bilateral sagittal
split and a secondary maxillary procedure were performed. The
new incision was made through the existing scar line and old
hardware was removed. The maxilla was moved backwards by
5 mm and impacted by an additional 2 mm. The maxilla and
mandible were then placed in intermaxillary fixation. A horizon-
tal genioplasty was performed that advanced the chin point by
8.5 mm and moved laterally to the right by 2.5 mm. After
symmetry was verified and the chin point was fixated with
six 7 mm KLS Martin screws. Post-surgery, the teeth were aligned
and finished with the progressive use of 0.016-NiTI,
0.016  0.022-inch NiTi and 0.018-NiTi. Orthodontic treatment
was concluded 5 months after surgery. A retainer was delivered
at the last appointment and orthodontic records were done.
8
Treatment Results
Post-treatment records show a successfully well-balanced and
harmonious facial profile and occlusion. Intraorally, the VME was
corrected after the first Le Fort I surgical procedure, while the
extraoral profile and aesthetics were improved after the second
surgical procedure with the posterior movement of the maxilla,
BSSO and genioplasty. The final records reveal a pleasing profile
with competent lips, and an aesthetic smile arc with upright
incisors and limited gingival display (figure 6). Posttreatment
cephalometric findings show that the soft tissue convexity signi-
ficantly decreased while skeletally, the SNB improved from
72.48 to 80.98 and the ANB angle had decreased from 98 to
2.28 (figure 7, table III). Debonding of the case took place eleven
months after the initiation of orthodontic treatment.
The treatment was successful in addressing the patient's chief
complaint, as it addressed both the aesthetic and functional
needs. The goals of the patient's treatment were accomplished.

tome xx > 000 > xx 2019

 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002
Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary protrusion,
complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues

Case Report
Figure 6
Post second surgery cephalometric radiograph with tracing and superimposition of initial (black) and final (red) cephalometric
tracings

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 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002

R. Oueis, P.D. Waite, J. Wang, C.H. Kau

Case Report

Figure 7
Final intra-oral and extra-oral photographs

TABLE III
Cephalometric measurements.

Initial Intermediate Final Normal

SNA 81.7 86.1 75.1 82

SNB 72.4 74.8 77,3 80.9

SN-MP 50.1 44.2 42.9 32.9

FMA (MP-FH) 34 28.2 26.9 23.9

ANB 9.2 11.3 2.2 1.6

Discussion preferred treatment plan consisted of extraction of the 4 pre-

This particular case study sheds spotlight on the various aspects
of treatment planning and treatment management. Class II
malocclusions with open bite and vertical maxillary excess
are most commonly treated with a combination of maxillary
Le Fort I, mandibular BSSOs and/or maxillary and mandibular
osteotomies, along with extraction of four premolars [5]. Kahn-
berg et al. and Enacar et al. stated that bimaxillary surgical
procedures are almost always more preferable to single jaw
surgery, especially in cases where the occlusal plane, or vertical
dimension needed to be altered [19]. Based on the cephalo-
metric findings and clinical examination of this patient, the
10
molars and a double jaw surgery. The patient was determined to
not extract any teeth and was only willing to proceed with a
one-jaw surgery against the strong recommendations of the
orthodontist and oral surgeon. This decision was based on the
patient's cultural beliefs and unrealistic expectations, which may
be unpredictable factors in any case. After extensive consulta-
tion with the orthodontic and orthognathic teams where the
limitations of the single jaw surgery in providing the desired
outcomes were discussed, the patient opted for a single jaw
surgery. The patient signed the informed consent and the treat-
ment was carried out.

tome xx > 000 > xx 2019

 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002
Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary protrusion,
complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues

Surgical preparation was done using virtual surgical planning,
allowing the surgeon and orthodontist to accurately visualize
the hard and soft tissue changes that would occur with the
surgery. The facial areas of the nose, lip and chin are the most
critical regions that affect facial aesthetics. However, despite
hard tissue predictions being accurate, soft tissue changes
remain an unpredictable factor on the outcome of treatment,
especially in the previously mentioned facial areas [11,20–23].
This can be due to the algorithms of the predicative software
being population specific resulting in an outcome that does not
correspond with different ethnicities [24].
This autonomous decision led to an overall unfavourable out-
come for the patient and orthodontic and orthognathic teams,
and negatively affected the patient's psychology and self-
esteem. Bonanthaya et al. have stated the benefit of refusing
to provide treatment to patients that demonstrate unrealistic
Case Report
expectations to prevent the physical dangers that may accom-
pany an impacted psychology and lowered self-esteem that
result from the unsatisfactory treatment results [25]. The second
surgical procedure to compensate for the unfavourable outcome
was critical to relive the patient's distress, and lower the high
stakes of this unplanned complication in the treatment. The goal
of virtual planning was to increase balance and decrease the
patient's dissatisfaction with the surgical outcome [23]. The
establishment of the E-line (Rickett's) was absolutely para-
mount in the success of the final outcome.
In many instances, the goal of orthognathic surgery is to correct
occlusal discrepancies, but more importantly for the patient, to
correct facial imbalances and significantly enhance the facial
profile. 89–95% of patients that undergo orthognathic surgery
report satisfying outcomes. However, this leaves approximately
5–11% that may be dissatisfied or seeking more. According to

Figure 8
Initial, intermediate, final soft tissue profile and frontal smile
11

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 To cite this article: Oueis R, et al. Orthodontic-Orthognathic Management of a patient with skeletal class II with bimaxillary
protrusion, complicated by vertical maxillary excess: A multi-faceted case report of difficult treatment management issues.
International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.09.002

R. Oueis, P.D. Waite, J. Wang, C.H. Kau

Case Report

Schendel and Mason, unsatisfactory results of orthognathic
surgery are the result of either skeletal deviations that occur
or unforeseen soft tissue changes [26]. Postoperative defects
include bone defects of the maxilla or the mandible, asymmetry,
soft tissue defects of the nasal base, chin, and lips or a combi-
nation [27].
Re-operation of orthognathic surgery proves more of a chal-
lenge than primary surgery due to factors that include: repeti-
tion of planning, the need to remove existing plates and
hardware, the concern for extensive scarring, further fixation,
and additional financial burden or costs to the patient [28].
However due to the increase of importance of aesthetics in
our time, patients have been found to be generally accepting of
repeat surgeries.
Due to the intensity of reoperation, patients undergoing a
second surgery should be screened to ensure their psychological
and mental state is suitable to grasp/understand outcome
expectations as seen fit by the orthodontic and orthognathic
doctors. If a patient is diagnosed with body dysmorphia [29], a
"red flag'' to treatment expectations should be raised warrant-
ing careful treatment planning and extensive counselling [30].
Raffaini et al. proposed different approaches of secondary sur-
gery for the corresponding defects that resulted from the pri-
mary surgery. For excessive maxillary jaw prominence with good
occlusion, as in the case of our patient, a bimaxillary surgical
procedure is recommended, with the mandible being adjusted
first and the maxilla being readjusted accordingly [31].
Our patient, with the resulted increase in jaw prominence and
convexity, underwent a secondary bimaxillary surgery to bal-
ance her facial profile (figure 8).
Conclusion
Facial aesthetics is the key reason for patients seeking orthog-
nathic treatment. It is important to recognize that the goal of
combined orthodontic and orthognathic treatment lies not only
in the correction of the occlusion, but even more so in the
improvement of the soft tissue profile. Although the best surgi-
cal results are those that we see after primary surgery, some
results may be diminished due to unanticipated soft tissue
response. This case report highlights the need for clear commu-
nication of the treatment plan and also the unpredictability of
certain treatment outcomes especially when the literature does
not provide for definitive conclusions. In addition, it sheds light
on the challenge of unpredictable response of soft tissue after
surgical treatment and the importance of patient expectations
of outcomes. It is hoped that the paper provides a platform for
future discussions of difficult malocclusions.
Disclosure of interest: the authors declare that they have no competing
interest.

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