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Rawan Oueis, Peter D. Waite, Jue Wang, Chung H. Kau: Keywords
Rawan Oueis, Peter D. Waite, Jue Wang, Chung H. Kau: Keywords
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
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.
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
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.
Case Report
Figure 1
Initial photos and radiographs
3
Figure 3
Virtual surgical planning (VSP): 2 options of treatment simulation (Le Fort I surgery/Le Fort I and bilateral sagittal split osteotomy)
4
Case Report
Lateral cephalometric analysis revealed a normal maxillary rela- complaint was the gummy smile, VME and lip incompetence.
tion to the cranial base but a retrognathic mandibular relation- Her family discouraged her from mandibular advancement and
ship (72.98). Skeletal and Class II were evident (ANB 9.38, WITS genioplasty due to the more extensive procedure and risk of
7.0 mm) upper and lower incisors were upright (figure 2). nerve damage. A Le Fort I to impact the posterior maxilla
followed by orthodontics to correct any postsurgical occlusal
Treatment plan discrepancies was decided on. The preoperative virtual surgical
The patient was diagnosed with a mild right maxillary canting of planning was conducted and empower brackets would be used
the occlusal plane, skeletal class II, vertical maxillary excess, to accomplish inter-arch settling (figure 3).
moderate maxillary crowding, and mild mandibular crowding.
After evaluating all the diagnostic records, the following treat- Treatment Progress
ment plan was developed: The treatment started with presurgical orthodontic treatment
alignment and levelling of the dentition in the upper and using clear American Orthodontics Empower brackets bonded on
lower arches; the upper arch followed by the lower arch after two months.
correction of the open bite and over jet; The first and the second molars were banded. Initial levelling
correction of the dental midline deviation; was begun with the use of 0.016-inch NiTi and progressed
bimaxillary surgery; to 0.01 0.016-inch NiTi, 0.018 0.018-inch NiTi to
treatment of the malocclusion post-surgically. 0.017 0.025-inch NiTi before surgery. The maxillary arch
After through consultation and careful consideration of all the was expanded which relieved the crowding, and the teeth in
treatment options with the patient, a non-extraction, single jaw the mandibular arch were realigned. Five months after bonding,
surgery approach was selected by the patient, against the initial alignment was complete and presurgical CBCT, records,
advice of the orthodontist and the surgeon. The patient's main 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.
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
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 planning, however, the soft tissue results proved unpredictable.
removed from the lateral wall of the maxilla and the maxilla was Synching of the muscles of the alar of the nose increased the
impacted by 4.5 mm (table I). The maxilla was then fixated with patient's soft tissue protrusion in the maxillary area and overall
four KLS Martin 1.5 plates and the mandible was articulated facial convexity causing an anaesthetic facial imbalance. Poor
nicely into its predetermined position. A small amount of the chin projection and a shorter vertical facial dimension did not
nasal septum was removed to account for the impaction. This improve the convex profile (figure 4). The patient was dissatisfied
procedure resulted in a two-degree rotation of the occlusal plane. with the outcome and was psychologically depressed by the
The patient was discharged without any complications. The resulting profile. Extensive counselling and re-treatment plan-
postsurgical follow up took place four weeks after the procedure ning according to the Orthodontist (CHK)/Oral Maxillofacial Sur-
and post-surgical records and CBCT images were taken. The hard geon (PDW) were carried out. Five months following the first
tissues demonstrated the expected results of the virtual surgical surgical procedure, a second VSP guided surgical procedure to
6
Case Report
Figure 5
VSP workflow showing Retreatment surgery plan of Le Fort I, BSSO and genioplasty
7
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.
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
correct the facial balance and improve the bite was performed Treatment Results
(figure 5, table II). It took 5 months for the patient to make the Post-treatment records show a successfully well-balanced and
decision to proceed with the second procedure and it required harmonious facial profile and occlusion. Intraorally, the VME was
extensive counselling and treatment planning. A bilateral sagittal corrected after the first Le Fort I surgical procedure, while the
split and a secondary maxillary procedure were performed. The extraoral profile and aesthetics were improved after the second
new incision was made through the existing scar line and old surgical procedure with the posterior movement of the maxilla,
hardware was removed. The maxilla was moved backwards by BSSO and genioplasty. The final records reveal a pleasing profile
5 mm and impacted by an additional 2 mm. The maxilla and with competent lips, and an aesthetic smile arc with upright
mandible were then placed in intermaxillary fixation. A horizon- incisors and limited gingival display (figure 6). Posttreatment
tal genioplasty was performed that advanced the chin point by cephalometric findings show that the soft tissue convexity signi-
8.5 mm and moved laterally to the right by 2.5 mm. After ficantly decreased while skeletally, the SNB improved from
symmetry was verified and the chin point was fixated with 72.48 to 80.98 and the ANB angle had decreased from 98 to
six 7 mm KLS Martin screws. Post-surgery, the teeth were aligned 2.28 (figure 7, table III). Debonding of the case took place eleven
and finished with the progressive use of 0.016-NiTI, months after the initiation of orthodontic treatment.
0.016 0.022-inch NiTi and 0.018-NiTi. Orthodontic treatment The treatment was successful in addressing the patient's chief
was concluded 5 months after surgery. A retainer was delivered complaint, as it addressed both the aesthetic and functional
at the last appointment and orthodontic records were done. needs. The goals of the patient's treatment were accomplished.
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Case Report
Figure 6
Post second surgery cephalometric radiograph with tracing and superimposition of initial (black) and final (red) cephalometric
tracings
Figure 7
Final intra-oral and extra-oral photographs
TABLE III
Cephalometric measurements.
Case Report
Surgical preparation was done using virtual surgical planning, expectations to prevent the physical dangers that may accom-
allowing the surgeon and orthodontist to accurately visualize pany an impacted psychology and lowered self-esteem that
the hard and soft tissue changes that would occur with the result from the unsatisfactory treatment results [25]. The second
surgery. The facial areas of the nose, lip and chin are the most surgical procedure to compensate for the unfavourable outcome
critical regions that affect facial aesthetics. However, despite was critical to relive the patient's distress, and lower the high
hard tissue predictions being accurate, soft tissue changes stakes of this unplanned complication in the treatment. The goal
remain an unpredictable factor on the outcome of treatment, of virtual planning was to increase balance and decrease the
especially in the previously mentioned facial areas [11,20–23]. patient's dissatisfaction with the surgical outcome [23]. The
This can be due to the algorithms of the predicative software establishment of the E-line (Rickett's) was absolutely para-
being population specific resulting in an outcome that does not mount in the success of the final outcome.
correspond with different ethnicities [24]. In many instances, the goal of orthognathic surgery is to correct
This autonomous decision led to an overall unfavourable out- occlusal discrepancies, but more importantly for the patient, to
come for the patient and orthodontic and orthognathic teams, correct facial imbalances and significantly enhance the facial
and negatively affected the patient's psychology and self- profile. 89–95% of patients that undergo orthognathic surgery
esteem. Bonanthaya et al. have stated the benefit of refusing report satisfying outcomes. However, this leaves approximately
to provide treatment to patients that demonstrate unrealistic 5–11% that may be dissatisfied or seeking more. According to
Figure 8
Initial, intermediate, final soft tissue profile and frontal smile
11
Schendel and Mason, unsatisfactory results of orthognathic procedure is recommended, with the mandible being adjusted
surgery are the result of either skeletal deviations that occur first and the maxilla being readjusted accordingly [31].
or unforeseen soft tissue changes [26]. Postoperative defects Our patient, with the resulted increase in jaw prominence and
include bone defects of the maxilla or the mandible, asymmetry, convexity, underwent a secondary bimaxillary surgery to bal-
soft tissue defects of the nasal base, chin, and lips or a combi- ance her facial profile (figure 8).
nation [27].
Re-operation of orthognathic surgery proves more of a chal-
Conclusion
lenge than primary surgery due to factors that include: repeti-
tion of planning, the need to remove existing plates and Facial aesthetics is the key reason for patients seeking orthog-
hardware, the concern for extensive scarring, further fixation, nathic treatment. It is important to recognize that the goal of
and additional financial burden or costs to the patient [28]. combined orthodontic and orthognathic treatment lies not only
However due to the increase of importance of aesthetics in in the correction of the occlusion, but even more so in the
our time, patients have been found to be generally accepting of improvement of the soft tissue profile. Although the best surgi-
repeat surgeries. cal results are those that we see after primary surgery, some
Due to the intensity of reoperation, patients undergoing a results may be diminished due to unanticipated soft tissue
second surgery should be screened to ensure their psychological response. This case report highlights the need for clear commu-
and mental state is suitable to grasp/understand outcome nication of the treatment plan and also the unpredictability of
expectations as seen fit by the orthodontic and orthognathic certain treatment outcomes especially when the literature does
doctors. If a patient is diagnosed with body dysmorphia [29], a not provide for definitive conclusions. In addition, it sheds light
"red flag'' to treatment expectations should be raised warrant- on the challenge of unpredictable response of soft tissue after
ing careful treatment planning and extensive counselling [30]. surgical treatment and the importance of patient expectations
Raffaini et al. proposed different approaches of secondary sur- of outcomes. It is hoped that the paper provides a platform for
gery for the corresponding defects that resulted from the pri- future discussions of difficult malocclusions.
mary surgery. For excessive maxillary jaw prominence with good
occlusion, as in the case of our patient, a bimaxillary surgical Disclosure of interest: the authors declare that they have no competing
interest.
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