See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/326101040

Conventional surgical-orthodontic approach with double-jaw surgery for a

patient with a skeletal Class III malocclusion: Stability of results 10 years
posttreatment

Article  in  American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American
Board of Orthodontics · July 2018
DOI: 10.1016/j.ajodo.2016.12.034

CITATIONS READS

0 668

4 authors:

Susana Maria Deon Rizzatto Luciane M Menezes

Pontifícia Universidade Católica do Rio Grande do Sul Pontifícia Universidade Católica do Rio Grande do Sul
69 PUBLICATIONS   280 CITATIONS    147 PUBLICATIONS   1,245 CITATIONS   

SEE PROFILE SEE PROFILE

João Julio da Cunha Filho Susiane Allgayer

1 PUBLICATION   0 CITATIONS   
Pontifícia Universidade Católica do Rio Grande do Sul
24 PUBLICATIONS   105 CITATIONS   
SEE PROFILE
SEE PROFILE

Some of the authors of this publication are also working on these related projects:

publication View project

Interceptive Orthodontics View project

All content following this page was uploaded by Susiane Allgayer on 02 July 2018.

The user has requested enhancement of the downloaded file.

CASE REPORT

Conventional surgical-orthodontic
approach with double-jaw surgery
for a patient with a skeletal Class III
malocclusion: Stability of results
10 years posttreatment
~o Julio da Cunha Filho,b and Susiane Allgayerc
Susana Maria Deon Rizzatto,a Luciane Macedo de Menezes,a Joa
Porto Alegre, Rio Grande do Sul, Brazil

This case report presents the treatment of a young man with a skeletal Class III malocclusion. He was treated
with a conventional surgical-orthodontic approach in which 2 jaw surgeries were performed. The esthetic facial
profile, pleasant smile, appropriate occlusion, and overall good treatment outcome remained stable 10 years af-
ter active orthodontic treatment. (Am J Orthod Dentofacial Orthop 2018;154:128-39)

A
lthough various types of skeletal and dental pro-
files are associated with Class III malocclusions,1
the mandible is typically the aberrant skeletal
component of the patient's craniofacial anomaly.2-6
The standard approach for adults with dentofacial
deformities is surgical-orthodontic treatment.2-9 Most
dentofacial deformities requiring 2 jaw surgeries can be
corrected with conventional orthognathic treatment.10
However, currently, some clinicians are again advocating
surgery first to reduce treatment time and prevent wors-
ening of the profile during decompensation.2,3,8,11-14
Proper evaluation of patients requires examination of
facial soft and hard tissues.4 When planning surgery
for Class III patients, the lip position is an important
point to consider.4,15-18 Many factors are involved in
lip protrusion, and the amount of protrusion can
a
Department of Orthodontics, Pontifıcia Universidade Catolica do Rio Grande do
Sul, Porto Alegre, Rio Grande do Sul, Brazil.
b
Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre,
Rio Grande do Sul, Brazil; private practice, Porto Alegre, Brazil.
c
Department of Orthodontics, Associaç~ao Brasileira de Odontologia Seç~ao Rio
Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; private practice, Lajeado,
Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Susiane Allgayer, Department of Orthodontics, Pon-
tificial Catholic University, Av. Ipiranga, 6681, Predio 6, Sala 503, Porto Alegre,
Rio Grande do Sul, Brazil; e-mail, susianeallgayer@gmail.com; susiane.
allgayer@acad.pucrs.br.
Submitted, July 2016; revised and accepted, December 2016.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2016.12.034
128
be controlled by various orthodontic and surgical
procedures.17-20 After treatment, orthognathic surgery
patients benefit from an improved smile, more positive
esthetics, increased self-esteem, and consequently a bet-
ter quality of life.3,9,19,21-25
Orthodontists and surgeons should be experienced,
and teamwork is necessary to achieve the treatment ob-
jectives. The successful attainment of treatment goals
was achieved for this patient with an interdisciplinary
approach.20,23
This article describes the treatment of a Class III pa-
tient including the combination of 2 jaw surgeries. Bilat-
eral sagittal split osteotomy procedures were performed
to set back the mandible and correct the occlusal cant; a
LeFort I osteotomy was performed for advancement and
anterior inferior repositioning to correct the maxillary
anterior vertical tooth display, the smile anatomy, and
the fullness of the upper lip. The esthetics and occlusal
results achieved and their stability are shown in a
10-year follow-up. See Supplemental Materials for a
short video presentation about this study.
DIAGNOSIS AND ETIOLOGY
A male patient, aged 19 years, came for orthodontic
treatment at the dental school in Associaç~ao Brasileira
de Odontologia, Porto Alegre, Rio Grande do Sul, in
Brazil with the chief complaint of the unesthetic
appearance of his teeth. He also complained of chew-
ing difficulties and impaired nasal function. He re-
ported that he had undergone orthodontic treatment
Rizzatto et al
Fig 1. Pretreatment facial and intraoral photographs. Facial photograph shows occlusal cant to the left.
when both maxillary first premolars were extracted
because of lack of space for the canines. The facial
photographs showed an increased lower facial third, a
concave profile, and incompetent lips in a relaxed po-
sition.4,15-18 The upper lip was retruded by 1.5 mm,
and the lower lip was protruded by 5 mm in relation
to the S-line. The intraoral photographs and dental
casts showed Class II molar and Class III canine
relationships, 3.5-mm negative overjet, 1-mm overbite,
and occlusal cant. The maxillary arch was relatively
constricted, and a midline diastema could be seen. Pos-
terior and anterior crossbites, extending from the right
first molar to the left second molar, were associated
with the transverse maxillary deficiency (Figs 1 and 2).
The cephalometric analysis showed a Class III jaw-
base relationship (ANB angle, 1 ; Wits appraisal,
7 mm). The maxillary incisors were relatively well posi-
tioned, whereas the mandibular incisors were protruded
(1: NA, 6 mm and 19 ; 1: NB, 10 mm and 32 ; IMPA,
American Journal of Orthodontics and Dentofacial Orthopedics
129
90 ). The Steiner26 (SNA angle, 86 ; SNB angle, 85 )
and McNamara27 analyses showed both maxillary and
mandibular protrusion in relation to the cranial base
(Co-A, 102 mm; A-NPerp, 5 mm; Co-Gn, 145 mm;
Pog-Nperp, 11 mm). A remarkable maxillomandibular
discrepancy was noticed, with Co-A to Co-Gn of
43 mm, when the normal range is 30 to 33 mm. The
measurements also highlighted an increased lower facial
height (82 mm). The panoramic radiograph showed all
teeth, except for the third molars and maxillary first pre-
molars (Fig 3; Table).
TREATMENT OBJECTIVES
The treatment objectives were to (1) correct the max-
illomandibular discrepancy to obtain a normal occlu-
sion, (2) resolve the crossbite, and (3) achieve ideal
overjet and overbite, thus improving function and es-
thetics.
July 2018  Vol 154  Issue 1
130 Rizzatto et al

Fig 2. Initial dental casts.

Fig 3. Initial panoramic radiograph, lateral cephalometric radiograph and tracing, and posteroanterior
cephalometric radiograph and tracing.

July 2018  Vol 154  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Rizzatto et al 131

4. Conventional surgical-orthodontic approach. Double-

Table. Cephalometric summary
jaw surgeries would combine bilateral sagittal spilt
10-year osteotomy to set back the mandible with LeFort I
Measurement Norm Pretreatment Posttreatment follow-up osteotomy for advancement and inferior repositioning
SNA ( ) 82 86 84 84
of the maxilla.5,23,31,32
SNB ( ) 80 85 80 81
ANB ( ) 2 1 4 3
1-NA (mm) 4 6 4 6
TREATMENT PROGRESS
1:NA ( ) 22 19 18 22
1-NB (mm) 4 10 7 7 Before orthodontic treatment, the patient was
1:NB ( ) 25 32 26 30 referred to an oral surgeon (J.J.C.F.) for a clinical exam-
1:1 ( ) 131 129 133 126
ination. Based on the diagnostic data and according to
Occl:SN ( ) 14 15 13 13
GoGn.SN ( ) 32 33 37 33 the patient's and parent's decision, the fourth treatment
S-LS (mm) 0 1.5 0 1 plan was chosen.
S-LI (mm) 0 5 3 2 Before orthognathic surgery, the maxillomandibular
y-axis to FH ( ) 59.4 59 60 60 tooth axes were improved during preoperative ortho-
NPog.FH ( ) 87.8 94 92 91
dontics by fixed edgewise appliances with
Angle of 0 1 4 2
convexity ( ) 0.022 3 0.028-in slot brackets in both arches (Fig 4).
Wits (mm) 1.17 7 1 1 In the maxillary arch, a typical sequence of archwires,
FMA ( ) 25 28 30 29 starting with 0.0175-in coaxial, followed by 0.014-in,
FMIA ( ) 65 62 63 58 0.016-in, 0.018-in, 0.020-in, and 0.019 3 0.025-in
IMPA ( ) 90 90 87 92
stainless steel archwires (3M Unitek, Monrovia, Calif),
Nasolabial 102 109 110 110
angle ( ) was used. The mandibular arch followed the same
A-NPerp (mm) 1 5 4 2 sequence of archwires to eliminate crowding and pro-
Co-A (mm) 102 104 104 vide alignment and leveling. The anterior maxillary dia-
Co-Gn (mm) 145 138 138 stema was closed with 0.019 3 0.025-in stainless steel
ALFH (mm) 82 81 81
archwires with sliding mechanics.
Pog -NPerp 2.2 11 4 3
(mm) Subsequent impressions were obtained to evaluate
the intercuspation and simulate the surgical movements.
ALFH, Anterior lower facial height; Occl:SN, occlusal plane angle. After cast surgery and predictive tracing, it was planned
to perform a 1-mm maxillary advancement with a slight
TREATMENT ALTERNATIVES posterior impaction, which led to 8 mm of inferior repo-
sitioning of the anterior part of the maxilla (anterior
The following alternatives were presented to the pa-
nasal spine), and an 8-mm mandibular setback. The pa-
tient and his parents.
tient received 0.020 3 0.025-in rectangular archwires
1. Maxillary expansion followed by maxillary protrac- with clipped hooks (TP Orthodontics, LaPorte, Ind) and
tion with a facemask. Little or no orthopedic maxil- postoperative recommendations (Figs 4-6).
lary response could be expected because the patient Surgery was performed including bilateral sagittal
was already 19 years old.6,28 In addition, his strong split osteotomy to achieve the planned mandibular posi-
mandible required reduction to improve his profile. tion and also for mandibular centering. Next, the
2. Surgically assisted rapid maxillary expansion fol- segmented LeFort I maxillary osteotomy with advance-
lowed by maxillary protraction with a facemask.29 ment and posterior impaction was performed. Titanium
The Steiner26 SNA and McNamara27 analyses miniplates were used for rigid internal fixation.
showed maxillary protrusion in relation to the cranial After surgery, the patient was monitored closely for
base at pretreatment; therefore, this approach would 1 month and was then referred for postsurgical ortho-
worsen the profile. Moreover, the patient did not dontics. At that point, with the same archwires placed,
want 2 separate surgeries for surgically assisted rapid he wore light posterior vertical elastics full time for
maxillary expansion and mandibular setback.2,3 3 months. The postoperative stage aimed at finalization;
3. Surgery first. This was not common 10 years ago, therefore, coordination of the maxillary and mandibular
when this patient came to our clinic; also, studies arches was followed by finishing and detailing of the oc-
suggested that it was less stable than conventional clusion. After a total treatment time of 48 months, all
orthognathic surgery for mandibular progna- brackets were debonded. A wraparound retainer was
thism.30 placed in the maxillary arch, and a lingual retainer was

American Journal of Orthodontics and Dentofacial Orthopedics July 2018  Vol 154  Issue 1
132 Rizzatto et al

Fig 4. Presurgical facial photograph of mandibular asymmetry and intraoral photographs showing the
0.020 3 0.025-in rectangular archwires with clipped hooks.

Fig 5. Presurgical dental casts.

bonded in the mandibular anterior segment. From this
moment on, the patient was placed in a retention control
program with periodic visits (Figs 7-10).
TREATMENT RESULTS
This interdisciplinary approach to manage the
occlusal and esthetic discrepancies in this patient al-
lowed the team to achieve all objectives established
before treatment. The posttreatment photographs of
the patient and his smile confirmed that good esthetic
and facial results and dental relationships were achieved.
Posttreatment intraoral photographs and dental casts
showed bilateral Class II molar and Class I canine rela-
tionships with good interdigitation of the lateral seg-
ments, competent lips, and ideal overjet and overbite
(Figs 7 and 8).

July 2018  Vol 154  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Rizzatto et al
Fig 6. Presurgical lateral cephalometric radiograph.
The panoramic radiographs confirmed the correct par-
allel root positioning, and the radiographs, cephalometric
tracings, and superimpositions confirmed the dental and
skeletal changes after treatment (Figs 9 and 10).
The most significant cephalometric changes were the
8-mm mandibular setback (Fig 10) and the maxillary
posterior impaction, which led to the 8-mm inferior re-
positioning of the anterior nasal spine (Fig 10, A and B).
As a result, the ANB angle increased from 10 to 40 ,
and the Wits appraisal increased from 7 to 1 mm.
Not only both jaws improved their positions (Co-A,
104 mm; A-NPerp, 4 mm; Co-Gn, 138 mm; Pog–Nperp,
4 mm), but also the maxillomandibular discrepancy
decreased (Co-A to Co-Gn, 34 mm). All measurements
were near average values, thus straightening the profile
(Fig 10; Table).
The superimposition showed improvement in the
positioning of the maxillary and mandibular incisors
(1:NA, 4 mm and 18 ; 1:NB, 7 mm and 26 ; IMPA,
87 ) (Fig 10, B and C; Table). Furthermore, a more
harmonious facial profile was obtained (Figs 10, A, and
13); the upper lip was 0 mm, and the lower lip was
3 mm in relation to the S-line (Figs 10, A). The patient
gained balanced respiratory and lingual functions. The
retention records obtained 10 years after debonding
showed generally stable results (Figs 11 and 12).
DISCUSSION
Patients with dentofacial deformities have a disadvan-
tage in society because of low self-esteem, decreased
confidence levels, and associated physiologic problems.
American Journal of Orthodontics and Dentofacial Orthopedics
133
Facial and dental deformities impair mastication, speech,
and swallowing and affect the person's social behavior
in many aspects,9 thus affecting the entire spectrum
that constitutes quality of life.8,19,21,22,25 Esthetics
motivates patients with dentofacial deformities to
seek orthodontic treatment and guides the indication
of orthognathic surgery as a treatment alternative
(Fig 1).33-35 Knowledge of the patient's chief complaint
and expectations, and proper diagnostic examinations,
are important factors in determining the ideal treatment
plan and achieving the final treatment outcome among
the alternatives.26
Proper diagnosis begins with the facial soft tissues and
skeleton, followed by intraoral evaluations of teeth and
their relationship with the lips and respiratory condi-
tions.4,24 Examination of the facial skeleton indicates
maxillary or mandibular dysmorphia, including horizontal
and vertical skeletal deformities (Fig 1).4 Facial beauty is
a subjective concept, and treatment cannot be based
only on cephalometric or facial normative values, which
are the objective methods available for clinicians as a start-
ing point (Table).4,24 Arnett and Gunson15 suggested that a
combination of clinical, facial, and soft tissue cephalomet-
rics is effective at guiding the treatment of occlusion and
face in the 3 planes of space for an improved esthetic
outcome. They also added 7 steps that are involved in
the cephalometric treatment planning to optimize the
facial and occlusal results: (1) correct the torque of the
maxillary incisors, (2) correct the torque of the mandibular
incisors, (3) position the maxillary incisor (LeFort I), (4)
autorotate the mandible to 3 mm of overbite, (5) move
the mandible to 3 mm of overjet, (6) set the maxillary
occlusal plane, and (7) assess chin projection and height.15
In adult patients with skeletal Class III, the outcome may
not always be successful with orthodontic therapy alone,
and a surgical approach for correction of dentofacial defor-
mities is usually the treatment of choice.3,15,22,29,31,36-39 A
simple surgery may not produce the necessary facial
changes for some patients, as for this one.10,40 Because
the anteroposterior prognathism had the greatest
negative impact on facial esthetics in our patient, it was
decided to perform setback in the mandible4,36,39
combined with maxillary repositioning,2,10,16 thus solving
his main problems: mandibular prognathism, concave
profile, and deficient smile (Fig 1). The orthognathic sur-
gery straightened the profile (Figs 7 and 10, A), improved
the smile (Figs 1 and 7) and respiratory function,
increased his self-esteem and thus the quality of
life.8,19,21,22,24
Ellis and McNamara1 found that the typical adult
with a Class III malocclusion clinically appears to have
a midface deficiency. Most of this deficiency has been
attributed to the soft tissue draping effect of a protruded
July 2018  Vol 154  Issue 1
134 Rizzatto et al

Fig 7. Posttreatment facial and intraoral photographs. Notice the occlusal relationship with the social-
spontaneous smile.

Fig 8. Posttreatment dental casts.

July 2018  Vol 154  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Rizzatto et al
Fig 9. Posttreatment lateral radiograph, lateral cephalometric radiograph and tracing, panoramic
radiograph, and periapical radiographs.
mandible, in which the inferior origin of the orbicularis
oris musculature is anteriorly located, giving a flat
appearance to the face (Fig 1). In accordance with this
previous statement, Lira et al7 added that the middle
facial third is influenced by the lower facial third. The
dentoskeletal mandibular changes cause a greater effect
on the profile, as in this patient, in which the setback re-
sulted in a decrease in the anteroposterior position of B
point (Steiner SNB angle 80 and Steiner ANB angle
4 ),26 a decrease in maxillomandibular discrepancy
(Co-Gn, 138 mm; Co-A to Co-Gn, 34 mm), and retrac-
tion at Pog-Nperp (4 mm), in addition to improvement
in the anteroposterior position of the mandibular inci-
sors (1:NB: 7 mm and 26 ; IMPA, 87 ). When the incisors
are upright, the lower lip is retracted and the deep sulcus
is reduced, achieving concordant lip position (Fig 7).17
Furthermore, since the upper lip achieved 0 mm and
the lower lip achieved 3 mm in relation to the S-line
(Figs 9 and 10, A; Table),38 a more harmonious facial
profile was achieved, confirming the statement in a pre-
vious study: “Mandibular dentoskeletal measurements
showed a greater correlation with the profile.”7
American Journal of Orthodontics and Dentofacial Orthopedics
135
On the other hand, Ackerman and Ackerman16 stated
that surgical correction of a Class III malocclusion in-
cludes maxillary advancement, inferior repositioning,
and clockwise rotation. In addition, rotation of the max-
illomandibular complex is a valuable alternative to
obtain satisfactory esthetic results.10,32 In accordance
with these treatment principles, in our patient the
maxillary occlusal plane was steepened; note the effect
on anterior tooth display (Figs 1 and 7). We also
established an age-appropriate vertical anterior tooth
display, with the smile arc curve parallel to the inner con-
tour of the lower lip, which is the goal for beauty.16,24 As
is often said, “In a youthful smile, 75-100% of the
maxillary central incisors should be positioned below
an imaginary line drawn between the commissures”
(Fig 7).16
To maximize the stable postoperative occlusion,
conventional surgical-orthodontic treatment includes
preoperative orthodontics for dental decompensa-
tion.2,3,5,10,13,23,30,37,39 In this context in our patient,
appropriate decompensation (Fig 4) provided surgical
correction without limitation (Fig 5),23 and orthognathic
July 2018  Vol 154  Issue 1
136 Rizzatto et al

Fig 10. Superimposition tracings before treatment (black line) and after treatment (red line) according
the American Board of Orthodontics directions: A, cranial base superimposition to evaluate surgical
changes in bone and soft tissues; B, maxillary superimposition; C, mandibular superimposition to eval-
uate tooth movement, extrusion and incisor repositioning; and D, superimposition, with the sella-nasion
plane parallel and at the articular point to evaluate the quantity of mandibular setback.

surgery improved the facial esthetics and provided
good bone-base relationships to support the teeth
(Figs 7-10).16,17,19 However, worsening of the facial
profile during long-term presurgical orthodontics is a
limitation (Fig 6).8,9,30 To avoid this part of the
treatment, some authors have suggested a surgery-first
procedure in recent years.13,14 However, it is difficult
to match the dentition without proper orthodontic
decompensation before surgery, especially when dental
alignments do not coordinate well between the 2
arches. This could lead to underestimation of the
magnitude of surgery required for the best skeletal
harmony.2 Moreover, the postsurgical occlusion is
unstable, and its influence on relapse has not been
fully investigated.2,8,30 Conversely, when orthodontic
mechanics are performed preoperatively, the postoperative
orthodontic treatment aims to provide support to aid the
surgical stability and achieve detailing of the occlusion.
Finally, regarding the interdisciplinary approach, the
orthodontist and the surgeon should communicate on
the progress toward surgery throughout the presurgical
orthodontic treatment stage. In addition, both clinicians
should agree on the presurgical tooth alignment and the
desired jaw position after surgery.3,30 Surgeons should
consider the preoperative soft tissue characteristics of
their patients to help predict the soft tissue changes
(Fig 13),38 mainly the length and fullness of the lips,
when determining the ideal position of teeth (Fig 1).4
Ultimately, surgery can be used to treat different types
of deformities with excellent results. Complications are
rare when surgery is done by well-trained and experi-
enced oral and maxillofacial surgeons in well-equipped

July 2018  Vol 154  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Rizzatto et al 137

Fig 11. Facial and intraoral photographs at the 10-year follow-up.

Fig 12. Dental casts at the 10-year follow-up.

American Journal of Orthodontics and Dentofacial Orthopedics July 2018  Vol 154  Issue 1
138
Fig 13. Tracing of posttreatment (red line) and 10-year
follow-up (brown line) showing the stability of the
facial profile.
hospitals. Long-term immobilization provides sufficient
time for the musculature to adapt to its new functional
length, which is obtained postoperatively.41 The rigid in-
ternal fixation made surgical outcomes more stable and
predictable,2,3,30 in addition to allowing earlier active
postsurgical orthodontic treatment, when necessary,
without disturbing the new jaw positions (Fig 9).3,30
Patients should be told that the postoperative
orthodontic stage of combined surgical-orthodontic
treatment may last approximately 5 to 11 months.9,42
CONCLUSIONS
This case report has shown how orthodontics and sur-
gery can accomplish treatment results that would not have
been possible if either discipline had been applied inde-
pendently. Correcting the maxillomandibular discrepancy
to obtain normal occlusion, establishing anterior guid-
ance, and improving function and esthetics were only
possible by the combined efforts of both disciplines.
Through careful planning using occlusal analysis,
cephalometric findings, functional and facial analyses,
dental casts, and prediction of soft tissue changes, the
various problems diagnosed could be treated effectively
and efficiently. Analysis of the treatment outcomes
shows that the technique used for this patient—a con-
ventional surgical-orthodontic approach with double-
jaw surgery for skeletal Class III—allowed successful
and stable results.
July 2018  Vol 154  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Rizzatto et al
SUPPLEMENTARY DATA
Supplementary data related to this article can be
found online at https://doi.org/10.1016/j.ajodo.2016.
12.034.
REFERENCES
1. Ellis E, McNamara JA Jr. Components of adult Class III open-bite
malocclusion. J Oral Maxillofac Surg 1984;42:295-305.
2. Ngan P, Moon W. Evolution of Class III treatment in orthodontics.
Am J Orthod Dentofacial Orthop 2015;148:22-36.
3. Proffit WR, White JR. Combined surgical-orthodontic treatment:
how did it evolve and what are the best practices now? Am J Or-
thod Dentofacial Orthop 2015;147(Suppl):S205-15.
4. Panossian AJ, Block MS. Evaluation of the smile: facial and dental
considerations. J Oral Maxillofac Surg 2010;68:547-54.
5. Ueki K, Hashiba Y, Marukawa K, Yoshida K, Shimizu C,
Nakagawa K, et al. Comparison of maxillary stability after Le
Fort I osteotomy for occlusal cant correction surgery and maxillary
advanced surgery. Oral Surg Oral Med Oral Pathol Oral Radiol En-
dod 2007;104:38-43.
6. Turley PK. Treatment of the Class III malocclusion with maxillary
expansion and protraction. Semin Orthod 2007;13:143-57.
7. de Lira AL, de Moura WL, de Barros Vieira JM, Nojima MG,
Nojima LI. Surgical prediction of skeletal and soft tissue changes
in Class III treatment. J Oral Maxillofac Surg 2012;70:e290-7.
8. Zhou Y, Li Z, Wang X, Zou B, Zhou Y. Progressive changes in pa-
tients with skeletal Class III malocclusion treated by 2-jaw surgery
with minimal and conventional presurgical orthodontics: a
comparative study. Am J Orthod Dentofacial Orthop 2016;149:
244-52.
9. Rizzatto SM. Class III malocclusion with severe anteroposterior
discrepancy. Dent Press J Orthod 2012;17:178-89.
10. Reyneke JP, Bryant RS, Suuronen R, Becker PJ. Postoperative
skeletal stability following clockwise and counter-clockwise rota-
tion of the maxillomandibular complex compared to conven-
tional orthognathic treatment. Br J Oral Maxillofac Surg 2007;
45:56-64.
11. Uribe F, Agarwal S, Shafer D, Nanda R. Increasing orthodontic and
orthognathic surgery treatment efficiency with a modified surgery-
first approach. Am J Orthod Dentofacial Orthop 2015;148:838-48.
12. Janakiraman N, Feinberg M, Vishwanath M, Nalaka Jayaratne YS,
Steinbacher DM, Nanda R, et al. Integration of 3-dimensional surgi-
cal and orthodontic technologies with orthognathic “surgery-first”
approach in the management of unilateral condylar hyperplasia.
Am J Orthod Dentofacial Orthop 2015;148:1054-66.
13. Huang C, Hsu S, Chen YR. Systematic review of the surgery-first
approach in orthognathic surgery. Biomed J 2014;37:184-90.
14. Nagasaka H, Sugawara J, Kawamura H, Nanda R. “Surgery first”
skeletal Class III correction using the skeletal anchorage system.
J Clin Orthod 2009;43:97-105.
15. Arnett GW, Gunson MJ. Facial planning for orthodontists and oral
surgeons. Am J Orthod Dentofacial Orthop 2004;126:290-5.
16. Ackerman MB, Ackerman JL. Smile analysis and design in the dig-
ital era. J Clin Orthod 2002;36:221-36.
17. Legan HL, Burstone CJ. Soft tissue cephalometric analysis for or-
thognatic surgery. J Oral Surg 1980;38:744-51.
18. Burstone CJ. Lip posture and its significance in treatment plan-
ning. Am J Orthod 1967;53:262-84.
19. Tavares CA, Allgayer S, Calvete ES, Polido WD. Orthodontic treat-
ment for a patient with advanced periodontal disease: 11-year
follow-up. Am J Orthod Dentofacial Orthop 2013;144:455-65.
 Rizzatto et al
20. Kokich VG, Spear FM. Interdisciplinary management of anterior guid-
ance: a case report. Adv Esthetics Interdisciplinary Dent 2007;3:2-6.
21. Ataç M, Asvaro glu K, Y€
ucel E. Prospective evaluation of quality of
life in orthognathic surgery patients. Int J Oral Maxillofac Surg
2015;44(Suppl 1):e31.
22. Soh CL, Narayanan V. Quality of life assessment in patients with
dentofacial deformity undergoing orthognathic surgery—a sys-
tematic review. Int J Oral Maxillofac Surg 2013;42:974-80.
23. Pinho T, Figueiredo A. Orthodontic-orthognathic surgical treatment
in a patient with Class II subdivision malocclusion: occlusal plane
alteration. Am J Orthod Dentofacial Orthop 2011;140:703-12.
24. Zachrisson BU. Esthetic factors involved in anterior tooth display
and the smile: vertical dimension. J Clin Orthod 1998;32:432-45.
25. Palomares NB, Celeste RK, Miguel JA. Impact of orthosurgical
treatment phases on oral health–related quality of life. Am J Or-
thod Dentofacial Orthop 2016;149:171-81.
26. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;39:
729-55.
27. McNamara JA Jr. A method of cephalometric evaluation. Am J Or-
thod 1984;86:449-69.
28. Ngan P. Biomechanics of maxillary expansion and protraction in
Class III patients. Am J Orthod Dentofacial Orthop 2002;121:582-3.
29. Rizzatto SM, de Menezes LM, Farret MM, de Lima EM, Belle R,
Lanes MA. Surgically assisted rapid maxillary expansion combined
with maxillary protraction in an adult: a patient report. World J Or-
thod 2009;10:334-44.
30. Kim CS, Lee SC, Kyung HM, Park HS, Kwon TG. Stability of
mandibular setback surgery with and without presurgical ortho-
dontics. J Oral Maxillofac Surg 2014;72:779-87.
31. Bell WH. Le Forte I osteotomy for correction of maxillary defor-
mities. J Oral Surg 1975;33:412-26.
32. Enacar A, Taner T, Manav O. Effects of single- or double-jaw sur-
gery on vertical dimension in skeletal Class III patients. Int J Adult
Orthodon Orthognath Surg 2001;16:30-5.
American Journal of Orthodontics and Dentofacial Orthopedics
View publication stats
139
33. Magro-Filho O, Magro-Ernica N, Queiroz TP, Aranega AM,
Garcia IR Jr. Comparative study of 2 software programs for pre-
dicting profile changes in Class III patients having double-jaw
orthognathic surgery. Am J Orthod Dentofacial Orthop 2010;
137:452.e1-5.
34. Smith JD, Thomas PM, Proffit WR. A comparison of current predic-
tion imaging programs. Am J Orthod Dentofacial Orthop 2004;
125:527-36.
35. Kiyak HA, Bell R. Psychosocial considerations in surgery and ortho-
dontics. In: Proffit WR, White RP, editors. Surgical orthodontic
treatment. St Louis: Mosby Year Book; 1991. p. 71-95.
36. Allgayer S, Mezzomo FS, Polido WD, Rosenbach G, Tavares CA. Or-
thodontic-surgical treatment of skeletal facial asymmetry: case
report. Dental Press J Orthod 2011;16:100-10.
37. Han JJ, Yang HJ, Lee SJ, Hwang SJ. Relapse after SSRO for
mandibular setback movement in relation to the amount of
mandibular setback and intraoperative clockwise rotation of the
proximal segment. J Craniomaxillofac Surg 2014;42:811-5.
€
38. Aydil B, Ozer N, Marşan G. Bimaxillary surgery in Class III maloc-
clusion: soft and hard tissue changes. J Craniomaxillofac Surg
2013;41:254-7.
39. Hoffman GR, Brennan PA. The skeletal stability of one-piece Le
Fort 1 osteotomy to advance the maxilla: part 1. Stability resulting
from non-bone grafted rigid fixation. Br J Oral Maxillofac Surg
2004;42:221-5.
40. Aldelayme R, AlKen M, Hamdoon Z, Jerjis W. Skeletal and dental
relapses following skeletal Class III deformity correction surgery:
single-jaw versus double-jaw procedures [abstract]. J Oral Maxil-
lofac Surg 2013;42:1324.
41. Martis CS. Complications after mandibular sagittal split osteot-
omy. J Oral Maxillofac Surg 1984;42:101-7.
42. Luther F, Morris DO, Karnezi K. Orthodontic treatment following
orthognathic surgery: how long does it take and why? a retrospec-
tive study. J Oral Maxillofac Surg 2007;65:1969-76.
July 2018  Vol 154  Issue 1