Class III Surgical










Atlas ofOrthodontic Case Reviews, First Edition. MarjanAskari andStanley A.Alexander.
© 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.
Chapter No.: 1 Title Name: <TITLENAME> c15.indd
Comp. by: <USER> Date: 21 Jun 2017 Time: 08:12:32 AM Stage: <STAGE> WorkFlow:
<WORKFLOW> Page Number: 241
241
Interview Data
The patient was in orthodontic care prior to this initial
appointment. The previous orthodontist retired because
of health reasons. The patient’s chief complaint was “to
continue with care and get ready for surgery.
Development: 19‐year‐old post‐pubertal male
Motivation: excellent
Medical history: mild aortic stenosis with no need for
medication
Dental history: a history of temporomandibular joint
discomfort
Family history: twin sister does not require orthodontic
care; father’s occlusion is edge to edge
Habits: none
Facial form: long, ovoid leptoprosopic facial form with
asymmetry for the chin deviating to the right
Facial proportions: long, lower facial height
Clinical Examination
Incisor‐stomion (Figures15.1 and 15.2):
At rest: 2 mm
Smiling: 10 mm
15
Class III Surgical
LEARNING OBJECTIVES
When to determine that orthognathic surgery is required
The removal of dental compensations prior to surgery
The timing of orthognathic surgery
Figure15.1 Full‐face view displaying an asymmetric,
leptoprosopic form with mandibular deviation to the right.
Figure15.2 Full‐face view with smile displaying 6 mm
ofgingiva.

Atlas of Orthodontic Case Reviews
242
Breathing: nasal
Lips: together at rest
Appliances are in place from the previous orthodontist
Soft tissue profile: concave with prognathic mandible
(Figure15.3)
Nasolabial angle: slightly obtuse
High mandibular plane angle
Dentition (Figure 15.4)
Teeth clinically present:
7654321 1234567
7654321 1234567
Overjet: –4 mm
Overbite: 2 mm in anterior crossbite
Midlines: maxillary midline is shifted 1 mm to left of
facial midline; mandibular midline is 3.5 mm shifted to
right of maxillary midline
Right Buccal View (Figure 15.5)
Molar: Class III by 10 mm
Canine: Class III
Curve of Spee: flat
Crossbite: posterior and anterior crossbite
Caries: none
Left Buccal View (Figure15.6)
Molar: Class III by 12 mm
Canine: Class III
Curve of Spee: flat
Figure15.4 Anterior view of the dentition with prior appliances
in place. The maxillary midline is shifted 1 mm to the left and the
mandibular midline is shifted 3.5 mm to the right of the maxillary
midline. An anterior crossbite is present.
Figure15.5 Right buccal view of the dentiton displaying a Class III
molar and canine relationship, a flat curve of Spee, and anterior
and posterior crossbites.
Figure15.6 Left buccal view of the dentiton displaying a Class III
molar and canine relationship, a flat curve of Spee, and anterior
and posterior crossbites.
Figure15.3 Right lateral view of profile displaying a concave
pattern, obtuse nasolabial angle, and normal mandibular plane.

Class III Surgical 243
Crossbite: anterior and posterior crossbite to first
premolar
Caries: none
Maxillary Arch (Figure15.7)
Symmetric, U‐shaped arch form with appliances in
place
Slight rotation of right first premolar and left second
premolar
Mandibular Arch (Figure15.8)
Tapered, U‐shaped symmetric arch form
Function
Centric relation‐centric occlusion: coincident with
appliance in place
Maximum opening = 57 mm with clicking at 47 mm
bilaterally; lateral excursions = 7 mm bilaterally; protru-
sive = 13 mm. There is a loud click on the right joint with
no associated pain; there is no pain upon palpation
Adult dentition with orthodontic appliances in place;
third molars not present
Root length and periodontium appear normal
Condyles appear normal (Figure15.9)
Figure15.7 Occlusal view of the maxillary arch displaying
asymmetric, U‐shaped arch form.
Figure15.8 Occlusal view of the mandibular arch dispalying
atapered, U‐shaped arch form.
Figure15.9 Panoramic radiograph exhibiting a full adult dentition with missing third molars and orthodontic appliances in place.
Theperiodontium and condyles appear normal.

Atlas of Orthodontic Case Reviews
244
Diagnosis andTreatment Plan
The patient is currently wearing an orthodontic appliance
for the treatment of a Class III skeletal and dental maloc-
clusion, mid‐face deficiency, mandibular prognathia,
mandibular asymmetry, posterior crossbite, and anterior
crossbite (Tables 15.1 and 15.2). The treatment plan
consists of pre‐surgical orthodontics followed by orthog-
nathic surgery which will consist of a maxillary advance-
ment and an asymmetric mandibular setback.
Table15.1 Significant cephalometric values
Norm Patient pre‐treatment
SNA 80° 76.9°
SNB 78° 83.6°
ANB –6.6°
WITS appraisal –1 to +1 mm –10.6 mm
FMA 21° 18.2°
SN‐GoGn 32° 29.5°
Maxillary incisor to SN 105° 106.5°
Mandibular incisor to GoGn 95° 83.3°
Soft tissue
Lower lip to E‐plane –2 mm –2.4 mm
Upper lip to E‐plane –1.6 mm –10.0 mm
SNA, sella‐nasion‐A point; SNB, sella‐nasion‐B point; ANB, A point‐nasion‐B point; WITS appraisal, Witwatersrand
appraisal; FMA, Frankfort horizontal‐mandibular plane; SN‐GoGn, sella nasion‐gonion gnathion.
Table15.2 The patient’s problem list inthree dimensions
Transverse Sagittal Vertical
Soft tissue Asymmetric with mandibular
shift to the right
Concave profile; slightly obtuse
nasolabial angle; prognathic mandible
Appears hyperdivergent facially, but
normal cephalometrically
Dental Anterior and posterior
crossbite
Adult dentition; Class III molar and
canines and reverse overjet
2 mm overbite
Skeletal Asymmetric with anterior
and posterior crossbite
Class III Normodivergent, yet appears vertically
sensitive and hyperdivergent facially
Treatment Objectives
The patients problem is predominantly skeletal in
nature, and will require orthognathic surgery for cor-
rection of the mid‐face deficiency and mandibular
prognathia (Figures 15.10 and 15.11). The postero‐
anterior (PA) cephalogram in Figure 15.11 indicates
the facial asymmetry due to the mandibular shift to the
right. Pre‐surgical orthodontics will be required and
growth completed before the surgical correction is
performed. Surgical movements of the maxilla and
mandible were explained to the patient via Aquarium
software (Dolphin Imaging and Management Solutions,
Chatsworth, CA, USA).

Class III Surgical 245
Treatment Options
1) No treatment.
2) Pre‐surgical orthodontics followed by orthognathic
surgery.
3) The option for camouflage was not discussed due to
the severe skeletal deformity.
Option 2 was chosen as the patient was in prior
orthodontic treatment with a surgical correction as
part of the treatment plan (Figures15.12 and 15.13).
For proper band and bracket placement, it was
decided to debond the existing appliance and place a
bi‐dimensional appliance for the pre‐surgical phase
of treatment.
Figure15.10 Digitized
cephalogram exhibiting a
severe Class III skeletal
malocclusion. Normal
mandibular plane angle, and
normal incisal relationships
with orthodontic appliances in
place.
Figure15.11 Postero‐anterior (PA) cephalogram with gridlines
demonstrating skeletal asymmetry.

You're Reading a Preview

Become a DentistryKey membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Was this article helpful?

Atlas ofOrthodontic Case Reviews, First Edition. MarjanAskari andStanley A.Alexander. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.Chapter No.: 1 Title Name: <TITLENAME> c15.inddComp. by: <USER> Date: 21 Jun 2017 Time: 08:12:32 AM Stage: <STAGE> WorkFlow:<WORKFLOW> Page Number: 241241 Interview DataThe patient was in orthodontic care prior to this initial appointment. The previous orthodontist retired because of health reasons. The patient’s chief complaint was “to continue with care and get ready for surgery.” ● Development: 19‐year‐old post‐pubertal male ● Motivation: excellent ● Medical history: mild aortic stenosis with no need for medication ● Dental history: a history of temporomandibular joint discomfort ● Family history: twin sister does not require orthodontic care; father’s occlusion is edge to edge ● Habits: none ● Facial form: long, ovoid leptoprosopic facial form with asymmetry for the chin deviating to the right ● Facial proportions: long, lower facial height Clinical Examination ● Incisor‐stomion (Figures15.1 and 15.2): – At rest: 2 mm – Smiling: 10 mm15Class III SurgicalLEARNING OBJECTIVES ● When to determine that orthognathic surgery is required ● The removal of dental compensations prior to surgery ● The timing of orthognathic surgeryFigure15.1 Full‐face view displaying an asymmetric, leptoprosopic form with mandibular deviation to the right.Figure15.2 Full‐face view with smile displaying 6 mm ofgingiva. Atlas of Orthodontic Case Reviews242 ● Breathing: nasal ● Lips: together at rest ● Appliances are in place from the previous orthodontist ● Soft tissue profile: concave with prognathic mandible (Figure15.3) ● Nasolabial angle: slightly obtuse ● High mandibular plane angleDentition (Figure 15.4) ● Teeth clinically present:7654321 12345677654321 1234567 ● Overjet: –4 mm ● Overbite: 2 mm in anterior crossbite ● Midlines: maxillary midline is shifted 1 mm to left of facial midline; mandibular midline is 3.5 mm shifted to right of maxillary midlineRight Buccal View (Figure 15.5) ● Molar: Class III by 10 mm ● Canine: Class III ● Curve of Spee: flat ● Crossbite: posterior and anterior crossbite ● Caries: noneLeft Buccal View (Figure15.6) ● Molar: Class III by 12 mm ● Canine: Class III ● Curve of Spee: flatFigure15.4 Anterior view of the dentition with prior appliances in place. The maxillary midline is shifted 1 mm to the left and the mandibular midline is shifted 3.5 mm to the right of the maxillary midline. An anterior crossbite is present.Figure15.5 Right buccal view of the dentiton displaying a Class III molar and canine relationship, a flat curve of Spee, and anterior and posterior crossbites.Figure15.6 Left buccal view of the dentiton displaying a Class III molar and canine relationship, a flat curve of Spee, and anterior and posterior crossbites.Figure15.3 Right lateral view of profile displaying a concave pattern, obtuse nasolabial angle, and normal mandibular plane. Class III Surgical 243 ● Crossbite: anterior and posterior crossbite to first premolar ● Caries: noneMaxillary Arch (Figure15.7) ● Symmetric, U‐shaped arch form with appliances in place ● Slight rotation of right first premolar and left second premolarMandibular Arch (Figure15.8) ● Tapered, U‐shaped symmetric arch form Function ● Centric relation‐centric occlusion: coincident with appliance in place ● Maximum opening = 57 mm with clicking at 47 mm bilaterally; lateral excursions = 7 mm bilaterally; protru-sive = 13 mm. There is a loud click on the right joint with no associated pain; there is no pain upon palpation ● Adult dentition with orthodontic appliances in place; third molars not present ● Root length and periodontium appear normal ● Condyles appear normal (Figure15.9)Figure15.7 Occlusal view of the maxillary arch displaying asymmetric, U‐shaped arch form.Figure15.8 Occlusal view of the mandibular arch dispalying atapered, U‐shaped arch form.Figure15.9 Panoramic radiograph exhibiting a full adult dentition with missing third molars and orthodontic appliances in place. Theperiodontium and condyles appear normal. Atlas of Orthodontic Case Reviews244 Diagnosis andTreatment PlanThe patient is currently wearing an orthodontic appliance for the treatment of a Class III skeletal and dental maloc-clusion, mid‐face deficiency, mandibular prognathia, mandibular asymmetry, posterior crossbite, and anterior crossbite (Tables 15.1 and 15.2). The treatment plan consists of pre‐surgical orthodontics followed by orthog-nathic surgery which will consist of a maxillary advance-ment and an asymmetric mandibular setback.Table15.1 Significant cephalometric valuesNorm Patient pre‐treatmentSNA 80° 76.9°SNB 78° 83.6°ANB 2° –6.6°WITS appraisal –1 to +1 mm –10.6 mmFMA 21° 18.2°SN‐GoGn 32° 29.5°Maxillary incisor to SN 105° 106.5°Mandibular incisor to GoGn 95° 83.3°Soft tissue Lower lip to E‐plane –2 mm –2.4 mm Upper lip to E‐plane –1.6 mm –10.0 mmSNA, sella‐nasion‐A point; SNB, sella‐nasion‐B point; ANB, A point‐nasion‐B point; WITS appraisal, Witwatersrand appraisal; FMA, Frankfort horizontal‐mandibular plane; SN‐GoGn, sella nasion‐gonion gnathion.Table15.2 The patient’s problem list inthree dimensionsTransverse Sagittal VerticalSoft tissue Asymmetric with mandibular shift to the rightConcave profile; slightly obtuse nasolabial angle; prognathic mandibleAppears hyperdivergent facially, but normal cephalometricallyDental Anterior and posterior crossbiteAdult dentition; Class III molar and canines and reverse overjet2 mm overbiteSkeletal Asymmetric with anterior and posterior crossbiteClass III Normodivergent, yet appears vertically sensitive and hyperdivergent facially Treatment ObjectivesThe patient’s problem is predominantly skeletal in nature, and will require orthognathic surgery for cor-rection of the mid‐face deficiency and mandibular prognathia (Figures 15.10 and 15.11). The postero‐anterior (PA) cephalogram in Figure 15.11 indicates the facial asymmetry due to the mandibular shift to the right. Pre‐surgical orthodontics will be required and growth completed before the surgical correction is performed. Surgical movements of the maxilla and mandible were explained to the patient via Aquarium software (Dolphin Imaging and Management Solutions, Chatsworth, CA, USA). Class III Surgical 245 Treatment Options1) No treatment.2) Pre‐surgical orthodontics followed by orthognathic surgery.3) The option for camouflage was not discussed due to the severe skeletal deformity.Option 2 was chosen as the patient was in prior orthodontic treatment with a surgical correction as part of the treatment plan (Figures15.12 and 15.13). For proper band and bracket placement, it was decided to debond the existing appliance and place a bi‐dimensional appliance for the pre‐surgical phase of treatment.Figure15.10 Digitized cephalogram exhibiting a severe Class III skeletal malocclusion. Normal mandibular plane angle, and normal incisal relationships with orthodontic appliances in place.Figure15.11 Postero‐anterior (PA) cephalogram with gridlines demonstrating skeletal asymmetry. Chapter No.: 1 Title Name: <TITLENAME> c15.inddComp. by: <USER> Date: 21 Jun 2017 Time: 08:12:32 AM Stage: <STAGE> WorkFlow:<WORKFLOW> Page Number: 246Figure15.13 Post‐treatment extraoral and intraoral composite photograph.Figure15.12 Pre‐treatment extraoral and intraoral composite photograph with prior appliances in place. Class III Surgical 247 First Active AppointmentThe patient’s current appliance was completely debonded. Maxillary and mandibular first and second molars bands were fitted and cemented with glass ionomer. The remaining teeth were bonded with a bi‐dimensional orthodontic appliance. Maxillary and mandibular .016 nickel‐titanium wires were ligated (Figures15.14–15.18).Figure15.14 Anterior view of the dentition after new appliances were placed. Maxillary and mandibular .016 nickel‐titanium arch wires were placed.Figure15.15 Right buccal view of the dentition after new bi‑dimensional appliances were placed.Figure15.16 Left buccal view of the dentition after new bi‑dimensional appliances were placed.Figure15.17 Occlusal view of the maxillary arch after new bi‑dimensional appliances were placed.Figure15.18 Occlusal view of the mandibular arch after new bi‑dimensional appliances were placed. Atlas of Orthodontic Case Reviews248 Fifth andSixth Active AppointmentsFor the next 8 weeks, space closure was continued with elastomeric chain extending from the maxillary first molar to first molar and from maxillary right canine to maxillary first molar (Figures 15.22–15.26). Progress models, a progress lateral cephalogram to evaluate theremoval of dental compensations, and a panoramic radiograph were taken to evaluate root morphology (Figures15.27–15.29). Second andThird Active AppointmentsFour weeks later, the maxillary and mandibular arch wires were changed to .016 × .022 nickel‐titanium. During this month the patient consulted with the oral and maxil-lofacial surgeon, who indicated that the surgical proce-dure would require two‐jaw surgery and a genioplasty. Five weeks later the arch wires were changed to .017 × .025 nickel‐titanium. Fourth Active AppointmentFour weeks after the third appointment, both arch wires were changed to .017 × .025 stainless steel and cinched. The remaining maxillary space was closed with elastomeric chain extending from first molar to first molar and from the right first premolar to the right canine for greater space closure in the maxillary right quadrant (Figures15.19–15.21).Figure15.20 Right buccal view of the dentition at the fourth active appointment. In addition to the elastomeric chain extending from the maxillary right first molar to the left first molar, an addition chain was placed from the maxillary right canine to the right first molar.Figure15.21 Left buccal view of the dentition at the fourth active appointment.Figure15.22 Anterior view of the dentition 8 weeks later. Space closure was continued in the maxillary arch as previously discussed.Figure15.19 Anterior view of the dentition at the fourth active appointment 13 weeks later. Both maxillary and mandibular arch wires were changed to .017 × .025 stainless steel. Elastomeric chain was placed from the maxillary right first molar to the left first molar and from the maxillary right canine to the right first molar for space consolidation. Prior to this appointment, the arch wire sequence went from .016 × .022 nickel‐titanium to .017 × .025 nickel‐titanium. Class III Surgical 249Figure15.23 Right buccal view of the dentition 8 weeks later. Figure15.24 Left buccal view of the dentition 8 weeks later.Figure15.25 Occlusal view of the maxillary arch 8 weeks later.Figure15.26 Occlusal view of the mandibular arch 8 weeks later.Figure15.27 Progress cephalogram taken at the fourth active appointment toindicate the removal of dental compensations and root positions. Atlas of Orthodontic Case Reviews250 Seventh Active AppointmentTwelve weeks later an iTero scan (Align Technology, Inc, San Jose, CA, USA) was taken to evaluate arch coordina-tion and to determine whether the patient was ready forsurgery (Figure15.29). The patient saw the oral and maxillofacial surgeon 1 month later, where the surgeon indicated that the patient was ready for the procedure. Eighth Active AppointmentTwo months later, surgical hooks were placed on the .017 × .025 stainless steel wires and all teeth were tied with stainless steel ligatures (Figures15.30–15.34). The surgery was scheduled in two weeks.Figure15.29 An iTero scan taken at the seventh active appointment, 12 weeks later, to evaluate arch coordination prior to surgery.Figure15.30 Anterior view of the dentition 2 months later at the eighth active appointment. Surgical hooks were placed on the maxillary and mandibular .017 × .025 stainless steel arch wires.Figure15.31 Right buccal view of the dentition 2 months later atthe eighth active appointment.Figure15.32 Left buccal view of the dentition 2 months later atthe eighth active appointment.Figure15.28 Panoramic radiograph taken at the fourth active appointment to evaluate root morphology and positions. Class III Surgical 251 First Post‐Surgical AppointmentPrior to this visit, the surgeon had seen the patient due to bleeding complications. Because of the distance from the hospital, the patient went to the emergency room of a local hospital where clots were removed from the maxillary sinus. The surgeon of record had seen the patient a short time thereafter when it was determined that a slight shifting of the mandible had taken place. As a result, the surgeon placed the patient on Class III elastics. Jaw exercises were continued, and the patient was now referred back to complete the post‐surgical phase of treatment. The Class III elastics were discon-tinued. Both the parents and patient were happy with the surgical result.The maxillary arch wire was changed to .017 × .025 nickel‐titanium and the mandibular arch wire was changed to .016 × .022 nickel‐titanium. Elastomeric chain was used for space consolidation between the maxillary canines and mandibular canines. A Class III triangular elastic (3/16”, 4.5 oz.) from the maxillary left first molar to the mandibular left canine, and a short Class II elastic (3/16”, 4.5 oz.) from the maxillary right canine to the mandibular right first and second premolars were to be placed until the next appointment (Figures15.35–15.37). A post‐surgical panoramic radiograph and cephalogram were taken (Figures 15.38 and 15.39). The patient was to return to the surgeon in 5 weeks for progress evaluation.Figure15.33 Occlusal view of the maxillary arch 2 months later at the eighth active appointment.Figure15.34 Occlusal view of the mandibular arch 2 months later at the eighth active appointment.Figure15.35 Anterior view of the dentition at the first post‐surgical appointment. The maxillary arch wire was changed to .017 × .025 nickel‐titanium and the mandibular arch wire was changed to .016 × .022 nickel‐titanium. Elastomeric chain was used to consolidate space between the maxillary canines and mandibular canines. A Class III triangular elastic was placed from the maxillary left first molar to the mandibular left canine and a short Class II elastic was placed from the maxillary right canine to the mandibular first and second premolars. These elastics were used to correct the midline and to settle the occlusion. Atlas of Orthodontic Case Reviews252Figure15.38 Panoramic radiograph taken at the first post‐surgical appointment exhibiting the rigid fixation used to stabilize the maxillary, mandibular, and chin surgery.Figure15.39 Digitized cephalogram taken at the first post‐surgical appointment exhibiting the maxillary advancement, mandibular setback, and genioplasty.Figure15.36 Right buccal view of the dentition at the first post‐surgical appointment. A short Class II elastic was used to settle the occlusion and coordinate the midlines.Figure15.37 Left buccal view of the dentition at the first post‐surgical appointment. A Class III triangular elastic was used to settle the occlusion and coordinate the midlines. Class III Surgical 253 Second Post‐Surgical AppointmentThree weeks later, the patient returned and the mandib-ular arch wire was changed to .017 × .025 nickel‐titanium. Elastomeric chain was used to consolidate space between the maxillary first molars. The patient was instructed to wear settling elastics (3/8”, 4.5 oz.) and to return in 4 weeks for possible debonding of the appliances (Figures15.40–15.42).Figure15.40 Anterior view of the dentition 3 weeks later at the second post‐surgical appointment. The mandibular arch wire was changed to .017 × .025 nickel‐titanium and settling elastics were used to improve intercuspation.Figure15.41 Right buccal view of the dentition at the second post‐surgical appointment. Settling elastics were used to improve intercuspation.Figure15.42 Left buccal view of the dentition at the second post‐surgical appointment. Settling elastics were used to improve intercuspation. Third Post‐Surgical AppointmentThe appliances were removed and photographs (Figures15.43–15.50) and impressions were taken for immediate Essix retainers (DENTSPLY Raintree Essix, Sarasota, FL, USA). An iTero scan of the occlusion was done. The patient was instructed to wear the retainers at night and while sleeping. The patient‘s extraoral fea-tures improved. The smile is esthetic and the profile is straight with a strong chin button as a result of the geni-oplasty. The molar and canine occlusion is Class I and the arch forms are broad and U‐shaped. There is a slight mandibular dental midline deviation to the right which does not affect the esthetics or function. The patient will be seen in 1 month and then every 3 months if retainer adjustments are required. During the course of treatment, no temporomandibular dysfunction was apparent; therefore no referral to a proper specialist became necessary. The total treatment time was 14 months.Upon measurement, both the sella‐nasion‐A point (SNA) and sella‐nasion‐B point (SNB) improved due to surgical repositioning of the maxilla and mandible. The WITS appraisal also improved. Dental positions of the maxillary and mandibular incisors are acceptable for soft tissue support.Overall superimposition of the pre‐treatment (black), pre‐surgical (green), and post‐surgical (red) phases indi-cate that the dental compensations were removed prior to surgery, the maxilla was brought forward and the mandible was set back for a proper overjet appearance. The genioplasty maintained the strong chin position, but was masked by the mandibular surgery (Figure 15.51; Table15.3). Atlas of Orthodontic Case Reviews254Figure15.48 Left buccal view of the dentition at the third post‐surgical appointment after appliance removal.Figure15.43 Full‐face view at the third post‐surgical appointment after appliance removal.Figure15.44 Full‐face view with smile at the third post‐surgical appointment after appliance removal.Figure15.46 Anterior view of the dentition at the third post‑surgical appointment after appliance removal.Figure15.47 Right buccal view of the dentition at the third post‑surgical appointment after appliance removal.Figure15.45 Right lateral view of the profile at the third post‑surgical appointment after appliance removal. Class III Surgical 255Figure15.49 Occlusal view of the maxillary arch at the third post‐surgical appointment after appliance removal.Figure15.50 Occlusal view of the mandibular arch at the third post‐surgical appointment after appliance removal.Table15.3 Significant pre‐treatment andpost‐treatment cephalometric valuesNorm Pre‐treatment Post‐treatmentSNA 82° 76.9° 81.3°SNB 80° 83.6° 81.8°ANB 2° –6.6° –0.5°WITS appraisal –1 to + 1 mm –10.6 mm –0.8 mmFMA 21° 18.2° 17.1°SN‐GoGn 32° 29.1° 27.0°Maxillary incisor To SN 105° 106.5° 113.9°Mandibular incisor to GoGn 95° 83.3° 86.9°Soft tissue Lower lip to E‐plane –2.0 mm –2.4 mm –5.6 mm Upper lip to E‐plane –1.6 mm –10.0 mm –9.3 mmSNA, sella‐nasion‐A point; SNB, sella‐nasion‐B point; ANB, A point‐nasion‐B point; WITS appraisal, Witwatersrand appraisal; FMA, Frankfort horizontal‐mandibular plane; SN‐GoGn, sella nasion‐gonion gnathion.Figure15.51 Overall and regional superimpositions of pre‐treatment (black), pre‐surgical (green), and post‐surgical (red) phases. The skeletal relationships were improved due to the maxillary advancement and mandibular setback. Dental compensations were removed priorto surgery. The genioplasty waspartially masked by the mandibular setback. Atlas of Orthodontic Case Reviews256 CommentaryThe orthodontic treatment of a true skeletal problem of the maxilla and mandible that affects daily function and the psyche of the patient due to the deformity requires the clinical skills of both the orthodontist and the oral and maxillofacial surgeon. Selective extraction and/or an attempt to camouflage the defect, and thus to avoid the necessary surgery, very often result in failure for both the patient and the clinician.Review Questions1 Are dental compensations removed or enhanced prior to orthognathic surgery?2 What are the possible causes of a skeletal Class III malocclusion: maxillary deficiency or mandibular excess, or both anomalies?3 Stainless steel arch wires are placed prior to surgery due to their stiffness as compared with nickel‐titanium . True or false?4 In most orthognathic surgical cases, growth should be completed prior to surgery. True or false? Suggested ReferencesJoondeph DR. Stability of orthognathic surgery. In: Huang GJ, Richmond S, Vig KWL, eds. Evidence Based Orthodontics. Ames, IA: Wiley Blackwell, 2011; 217–231.McNamara JA Jr. Maxillary deficiency syndrome. In: NandaR, Kapila S, eds. Current Therapy in Orthodontics. StLouis, MO: Mosby Elsevier, 2010; pp. 137–142.Musich DR, Chemello PD. Orthodontic aspects of orthognathic surgery. In: Graber LW, Vanarsdall RL, VigKWL, eds. Orthodontics Current Principles and Techniques, 5th edn. Philadelphia, PA: Elsevier Mosby, 2012; pp. 897–963.Ngan P, He H. Effective maxillary protraction for Class III Patients. In: Nanda R, Kapila S, eds. Current Therapy in Orthodontics. St Louis, MO: Mosby Elsevier, 2010; pp. 143–158.Stellzig‐Eisenhauer A, Lux CJ, Schuster G. Treatment decision in adult patients with Class III malocclusion: orthodontic therapy or orthognathic surgery. Am J Orthod Dentofacial Orthop 122: 27–28, 2002. Atlas ofOrthodontic Case Reviews, First Edition. Marjan Askari and Stanley A. Alexander. © 2017 John Wiley & Sons, Inc. Published 2017 by John Wiley & Sons, Inc.Chapter No.: 1 Title Name: <TITLENAME> bindex.inddComp. by: <USER> Date: 21 Jun 2017 Time: 08:13:26 AM Stage: <STAGE> WorkFlow:<WORKFLOW> Page Number: 257257aanterior crossbite 24, 186, 220, 242–244correction 23–39, 174, 176dental compensation 189maxillary canine crossbite 208, 210–211rapid palatal expander use 25–36lateral incisor crossbite 24anterior space closure see diastema; space closure; space consolidationasymmetric mandibular setback 244–245asymmetry 75–90, 93, 129, 244masking of 79–90see also midline discrepanciesbbite opening 48, 59, 71, 121–122, 142–143, 212, 236blocked‐out canines 57creation of space for 47–53, 61–64mandibular 57maxillary 41–53, 93–94buccal crossbite 35, 64, 102correction 36, 64–66, 102–104button 114–115, 226palatal irritation 227–229ccaninesblocked‐out 57creation of space for 47–53, 61–64mandibular 57maxillary 41–53, 93–94eruption 68–69, 98–100, 135, 137forced eruption 100indication for extraction of primary teeth 9maxillary canine crossbite correction 208, 210–211retraction 132–134, 137–138, 154–157, 224–227cervical headgear 109, 113–114non‐compliance 116Class I dental pattern 3–4, 14, 44asymmetry 75–90blocked‐out canines 41–53, 57–58deep bite 55–74malocclusion 26, 57molar 24, 42, 56posterior and anterior crossbites 23–39Class I skeletal pattern 3–4, 14–15asymmetry 75–90blocked out canine 41–53deep bite 55–74Class II dental pattern 203–216malocclusion 206mixed dentition 2non‐compliant patient 109–126premolar extractions 91–108, 127–146Class II elastics 84–85, 117–118, 121, 138–139, 162, 211–213, 230–235, 251–252Class II skeletal patternnon‐compliant patient 109–126premolar extractions 91–108, 127–146class III dental pattern 169–183, 185–201, 241–256camouflage through dental compensation 188–201Class III elastics 82–85, 173, 176–179, 191–194, 251–252Class III skeletal pattern 152, 169–183, 185–201, 203–216, 219–238, 241–256malocclusion 78, 188, 206, 244–245dental compensation 189–201posterior and anterior crossbites 26–27, 39coil springclosed 61, 114–115, 132–135, 156–157open 46–47, 61–63, 97, 134–135, 225–227compliance issues 109–126cervical headgear 116elastics wear 139–140, 143protraction face mask 32–33, 36see also oral hygiene problemscondylesasymmetric 77, 86flattened 129cross elastics 64–65crossbite correction see anterior crossbite; buccal crossbite; posterior crossbitecrowding 43, 57, 78, 94–96, 108, 171blocked‐out canines 41–53, 57, 93–94, 128–130creation of space for 47–53, 61–64severe 128–131, 152–153, 221–222curve of Speeaccentuated 142, 161deep 56, 110, 128, 170, 186, 220flat 2, 12, 24, 42, 150, 242moderate 76, 92severe 204Index Index258ddeep bite 55–74, 112, 128, 130correction 59–74dental hygiene problems see oral hygiene problemsdiagonal elastic 105diastema 2closure 29–30, 32see also space closure; space consolidationrapid palatal expander as cause 9–10, 32eelasticsClass II elastics 84–85, 117–118, 121, 138–139, 162, 211–213, 230–235, 251–252Class III elastics 82–85, 173, 176–179, 191–194, 251–252cross elastics 64–65diagonal elastics 105settling elastics 70, 104–105, 122,143, 179–180, 196–198, 235, 253triangle elasticsClass I skeletal and Class I dental 47–48, 62–63, 66–69, 80–85Class II skeletal and Class II dental 100–104, 119–121, 142–143Class III skeletal and Class I dental 159–162, 230–235Class III skeletal and Class II dental 211–212Class III skeletal and Class III dental 176–179, 192–193, 195–196Class III surgical 251–252elastomeric chaincanine retraction 132–134, 137–138, 154–157, 224–227incisor labialization 226–227midline shift 229–230molar alignment 138–139rotation correction 114–116premolar rotation correction 114–116, 174–177, 224–225space closure 19, 29, 32–38, 69–70, 101–104, 160–163, 177–179, 248space consolidation 81–85, 116–122, 134–143, 156–158, 160, 176, 179–180, 190–197, 211–212, 225, 230, 251–253eruptioncanines 68–69, 98–100, 135, 137forced 100indication for extraction of primary teeth 9premolar 117–118Essix retainers 49, 71, 86, 105, 122, 143, 163, 180, 198, 213, 236,253extractionsextraction sites 97, 155healed 156premolars 127–146, 219–223first premolars 91–108, 149–167primary teeth 9fflaring of the incisors 38, 45, 59, 71,212avoidance of 154forced canine eruption 100Forsus spring 118–119, 140–141Frankel III retainer 39ggenioplasty 252–253, 255glass ionomer build‐up 68–69, 137–138, 190–194, 208–210hHawley retainer 36headgear, cervical 109, 113–114non‐compliance 116hygiene problems see oral hygiene problemsHyrax appliance 153–155iincisorsalignment 156–158angulation improvement 134, 223anterior crossbite 24diastema 2closure 29–30, 32flaring of 38, 45, 59, 71, 212avoidance 154intrusion 134–139labialization 226–227non‐ligation 154–155rotation 13severely flared 206see also anterior crossbite; space closure; space consolidationinterceptive treatmentanterior space closure 18–21posterior crossbite 5–10, 14–21interproximal reduction (IPR) 173llingual holding arch 2–3, 6–7, 33, 36–38, 109, 111–115, 151, 153–154maximum anchorage attainment 223–225mmalocclusionClass I 26, 57class II 206class III 78, 188, 206, 244–245mandibular archovoid 3U‐shaped 13, 43, 77, 111, 129, 187, 221broad 25, 205tapered 57, 93, 151, 171, 243mandibular prognathia 244mandibular setback 252mandibular shift see asymmetry; midline discrepanciesmaxillary advancement 244, 252maxillary archasymmetric 77, 93, 129catenary 3, 129levelling 18ovoid 13, 171U‐shaped 77, 93, 151, 243broad 20, 38, 43, 111, 187, 205,221narrow 25tapered 57maxillary constriction 1, 14maxillary intrusion 135–139maxillary shift see asymmetry; midline discrepanciesmaximum anchorage attainment 223–224mid‐face deficiency 244midline discrepanciesleft mandibular shift 2, 56, 61, 110, 186, 204left maxillary shift 42, 76, 110, 204, 242right mandibular shift 11, 12, 17, 24, 75–90, 135, 220, 225, 229–231, 241–244right maxillary shift 220see also asymmetry Index 259mixed dentition 1–10, 150–152, 187, 221blocked‐out canines 57, 93posterior crossbite correction 1–10, 11–21, 23–39supernumerary teeth 221–223, 232molarsalignment 138–139Class I pattern 24, 42, 56Class II pattern 2rotation 3, 7, 13–14elastomeric chain use 114–116quad‐helix appliance use 5, 15, 17nNance appliance 96–97, 132–136, 151maximum anchorage attainment 223–225nasolabial angleacute 170, 186normal 76, 204obtuse 2, 12, 24, 92, 110, 150, 242non‐compliance see compliance issuesoopen coil spring 46–47, 61–63, 97, 134–135, 225–227opening space see space creationoral hygiene problems 53, 85, 98–103, 206, 227orthognathic surgery 244, 251–252over‐expansion correction 64–66overbiteimprovement 56–74, 83, 87, 120, 136–138, 162–164palatal impingement 56–58, 128–130overjetimprovement 32, 83, 87, 102, 106, 138–141overcorrection 119, 142positive overjet creation 175–178severe 128, 130, 206overlay wire 47–48, 66, 134, 226–228pPA radiograph 5palatal expansionover‐expansion correction 64–66radiograph 5rapid palatal expander (RPE) 26–36diastema risk 9–10, 32slow‐expansion device 9quad‐helix appliance 3, 5–7, 14–18, 60–65space closure following 32–37, 69surgically assisted rapid palatal expansion (SARPE) 10palatal impingement 56–58, 128–130quad‐helix appliance 17rapid palatal expander 35palatal irritation by button 227–229piggyback wire 134, 137, 228posterior crossbite 2, 12, 24, 242–244interceptive correction 5–10, 14–21over‐correction 7–9, 17–18quad‐helix appliance 3, 5–7, 14–18rapid palatal expander 26–36mixed dentition 1–10, 11–21, 23–39premolarseruption 117–118extractions 127–146, 219–223extraction sites 97, 155–156first premolars 91–108, 149–167rotation 114–116, 159, 174–177, 224–225protraction face mask 31–33, 36compliance issues 32–33, 36qquad‐helix appliancecrowding correction 60–64molar rotation 5, 15, 17palatal expansion 3, 5–7, 14–18, 60–65posterior crossbite correction 3, 5–7, 14–18rrapid palatal expander (RPE)crossbite correction 26–36diastema risk 9–10, 32surgically assisted rapid palatal expansion (SARPE) 10retainersEssix 49, 71, 86, 105, 122, 143, 163, 180, 198, 213, 236, 253Frankell III 39Hawley 36retraction, canines 132–134, 137–138, 154–157, 224–227roller‐coaster effect 205rotationincisors 13molars 3, 7, 13–14elastomeric chain use 114–116quad‐helix appliance use 15, 17premolars 114–116, 159, 174–177, 224–225ssettling elastics 70, 104–105, 122,143, 179–180, 196–198, 235, 253see also triangle elasticsshim 141slow‐expansion device 9see also quad‐helix appliancespace closure 18–21, 29, 32–38, 69–70, 101–104, 160–163, 177–179, 248following palatal expansion 32–37, 69space consolidation 81–85, 116–122, 134–143, 156–157, 160, 176, 179–180, 190–197, 211–212, 225, 230, 251–253space creation 97, 225–226for blocked‐out canines 47–53, 61–64supernumerary teeth 221–223, 232–233surgical hooks 250surgically assisted rapid palatal expansion (SARPE) 10ttooth extractions see extractionstriangle elasticsClass I skeletal and Class I dental 47–48, 62–63, 66–69, 80–85Class II skeletal and Class II dental 100–104, 119–121, 142–143Class III skeletal and Class I dental 159–162, 230–235Class III skeletal and Class II dental 211–212Class III skeletal and Class III dental 176–179, 192–193, 195–196Class III surgical 251–252

Related Articles

Leave A Comment?

You must be logged in to post a comment.