nitin vm et al.: case report vm et al_.pdf · the arch wire sequence proceeded as ... fig 4:...

International Journal of Oral Health and Medical Research | ISSN 2395-7387 | SEPTEMBER-OCTOBER 2017 | VOL 4 | ISSUE 3 60

CASE REPORT Nitin VM et al.: Skeletal Class III Malocclusion with Anterior Open Bite

Correspondence to: Dr. Abhishek Ranjan, JSS Dental College and

Hospital JSS University, Mysore. Contact Us: www.ijohmr.com

Treatment of Skeletal Class III Malocclusion

with Anterior Open Bite using Ortho-Surgical approach: A Case Report Nitin VM1, Abhishek Ranjan2, Raghunath NM3

Class III malocclusion usually exhibit a great underlying skeletal discrepancy. These kinds of malocclusion are usually

inherited and have a strong genetic predisposition. The aggravated skeletal discrepancies have a strong impact on facial

esthetics and are often accompanied by facial asymmetries. The correction of skeletal class III malocclusion in adult

patients involves close conjugation of orthodontic and orthognathic treatment modality. This case report presents the

treatment of a 25-year male patient with Class III skeletal malocclusion, having narrow maxilla, anterior open bite, and

mandibular midline shift. Clinical examination also revealed maxillary hypoplasia, increased lower one-third of the

face, concave facial profile and facial asymmetry with mandibular deviation to the right side. The treatment was

performed in three phases: pre surgical orthodontics, orthognathic surgery, and post surgical orthodontics. The final

results obtained after the treatment correlated well with the predetermined objectives. KEYWORDS: Skeletal Class III Malocclusion, Open Bite

AASSSAAsasasss

Understanding class III malocclusion has always been a

challenge and various studies conducted to find the

etiology have shown that the deformity is not only

restricted to the jaw but involves the whole craniofacial

complex.1,2

Most subjects with Class III malocclusions

have combinations of skeletal and dentoalveolar

components.3 The prevalence of class III malocclusion

varies among different ethnicities based on their genetic

background and environmental factors. Because of the

structural complexity of the craniofacial region, the

factors work synergistically or antagonistically to

aggravate or cancel out the deformity.2 Treatment of the

class III malocclusion often involves dento-alveolar

decompensation or combined Orthognathic approach to

achieve normal occlusion and soft tissue harmony.4,6

Diagnosis and Clinical Etiology: A 25-year-old male

patient came with a chief complain of long and dished in

face and inability to chew (Fig: 1). He was quite

concerned with his appearance and desired orthodontic

treatment for the correction of his facial appearance. He

had a skeletal Class III malocclusion with angles class III

molar relation on right side, end-on canine relationship

with an anterior open bite of 10 mm, a concave facial

profile, midline shift to the right side and facial

asymmetry (Fig: 2). The absence of mandibular left first

molar aggravated his occlusal problem. The patient had a

severe retrognathic maxilla with a reverse overjet of -8

mm. He had a prognathic mandible with a steep

How to cite this article: Nitin VM, Ranjan A, Raghunath NM. Treatment of Skeletal Class III Malocclusion with Anterior Open Bite using Ortho-Surgical approach: A Case Report. Int J Oral Health Med Res 2017;4(3):60-64.

INTRODUCTION

ABSTRACT

CASE REPORT

Fig 1: Pre treatment extra oral photographs

Fig 2: Pre treatment intra oral photographs

1-Associate Professor Dept. of Orthodontics JSS Dental College and Hospital JSS University, Mysore. 2-Dept. of Orthodontics JSS Dental College and Hospital JSS University, Mysore. 3-Professor & HOD Dept. of Orthodontics JSS dental College and Hospital JSS University, Mysore.



mandibular plane angle (Fig: 3). And due to his

appearance, the patient had a low self-esteem and was

low on confidence when interacting with people.

Problem List (Table: 1)

Retrognathic maxilla.

Prognathic mandible.

Reverse overjet of -8 mm.

Anterior skeletal open bite of 10 mm

Midline deviation towards the right by 4 mm.

Acute Nasolabial angle.

Retrusive upper lip and protrusive lower lip.

Psychological trauma.

Measurement Norm Pretreatment Post-treatment

Maxillary components

SNA(°) 82 91 98

A-N perp (mm) 1 +2 +7

NA-TH(O) 90±3 87 97

Mandibular components

SNB (°) 80 96 93

P-NPrep (mm) -2-4 -10 -12

NP-TH 86±2.5 94 91

Maxillomandibular relationship

ANB (°) 2 -5 3

Convexity (NAP (°) 3 -6 +5

Facial growth pattern SN.GoGn(°)

32 34 32

GoGn-TH(o) 25±3 38 31

Maxillary dentoalveolar components

Mx1.Na(°) 22 43 25

Mx1.Na(mm) 4 12 10

Mx1.PP(mm) 30.3 24 25

Mx6.PP(mm) 25.5 25 25

Mandibular dentoalveolar components

Md1.NB(°) 25 35 35

Md1.NB(mm) 4 12 10

Md1.GoMe(mm) 44.5 45 45

Md5.GoMe(mm) - 33 32

IMPA 90 87 89

Overjet (mm) 2.09 -8 2

Overbite (mm) 2.87 -10 2

Soft tissue components

Nasolabial angle (°) 90-110 75 89

ST convexity (°) 12 4 12

Upper lip to E (mm) -6 -8 -3

Lower lip to E (mm) -4 +5 +1

Treatment objective:

Maxilla: To correct the anterior open bite and assist the

sagittal coordination of the mandible.

Mandible: To correct the mandibular prognathism,

dental malocclusion, and mandibular asymmetry.

Maxillary dentition: To position the teeth more ideally

into the alveolus and achieve ideal overjet and overbite

relationship.

Mandibular dentition: To remove the dental

compensation and place the dentition more ideally over

the basal bone. To level, align, correct the midline shift

and coordinate with the upper arch. By correcting the

vertical, transverse and sagittal discrepancy, both

functional and aesthetic problems would be solved,

resulting in a more harmonious facial appearance.

Therefore by correction the dental and skeletal jaw

relationship, we hoped to improve the patient’s self-

esteem, confidence and an improved oral health quality of

life (ORHQoL).

Treatment Plan:

To coordinate upper and lower jaw arches.

Level and align upper arch and de-rotate the

maxillary molar.

Alignment and leveling in the lower arch which

requires the tipping of lower anterior to resolve and

correct the dental compensation. As with the upper

dentition, proper placement of the lower dentition

would enhance aesthetics, function, and degree of

skeletal correction possible with surgery.

To correct the reverse overjet and anterior open bite.

Le Fort I advancement surgery to assist the sagittal

coordination with the mandible and bilateral sagittal

split ramus osteotomy to correct the mandibular

prognathism, sagittal maxillomandibular relation,

mandibular asymmetry and dental malocclusion.

Prosthetic replacement of the missing mandibular

molar.36

Treatment Progress: The pre adjusted edgewise

appliance plan included 0.022x0.028 inch MBT

prescription. The arch wire sequence proceeded as

follows: 0.016 inch NiTi, followed by 0.016 SS,

0.017x0.025 inch NiTi, 0.017x0.025 SS and 0.019x 0.025

SS wires (Fig: 4). Reverse Orthodontics was done to

decompensate the inclination of upper and lower incisors

and to upright the incisors on their basal bone. The

reverse overjet obtained before surgery was -10 mm (Fig:

4,5). Mock surgery was done on Hanau semi adjustable

articulator with condylar guidance adjusted at 30⃰. Mock

surgery was done by maxillary advancement and

mandibular setback and two acrylic splints were prepared

for the surgery, one to be used after mandibular setback

and the other after the maxillary advancement.

Le Fort I maxillary advancement surgery was done to

assist the sagittal coordination with the mandible and to

reduce the midface concavity. Asymmetrical bilateral

sagittal split ramus osteotomy was done to correct the

mandibular prognathism and asymmetry. The maxilla TABLE 1: List Of Cephalometric Variables

Fig 3: Pre treatment radiographs



was advanced by 6 mm and mandible was set back by 6

mm to coordinate the upper and lower arch. A 2mm of

overcorrection was planned to overcome the minor

relapse occurring post surgery. Asymmetric BSSO

involves cutting more of the bone on the normal side of

mandible so that minor mandibular asymmetry can be

corrected by the surgical technique.

Surgery was performed and rigid internal fixation was

used. Post surgical notations included rather a normal

ecchymosis and some transient paresthesia of the chin

and lower lip. Post surgical orthodontics was resumed

two months later. 0.016 SS was placed in upper and

lower arch to correct the minor midline shift (Fig: 6,7).

Occlusal settling was done by cutting the wire distal to

the canine and placement of settling elastics. The total

duration of the treatment was 23 months.

Treatment Results: At the end of treatment, functional

occlusion, normal overjet, and overbite, adequate

intercuspation, with angles Class I molar relationship on

right side, Class I canine relationship, Class I incisor

relationship, normal lateral and protrusive excursions was

achieved (Fig: 8). Mandibular prognathism was

eliminated and facial aesthetics was considerably

improved (Fig: 9). The cephalometric measurements

showed maxillary advancement, contributing to improve

the patient’s profile (Fig: 10). The upper incisors were

bodily moved ahead during maxillary advancement and

the pre-treatment midline deviation of the mandibular

dentition to the right was corrected fully with post-

surgical orthodontics. All the functional movements of

the mandible were without limitations and without

symptoms. The patient decided to opt for a prosthetic

Fig 4: Initial wire 0.016" HANT in upper and lower arch

Fig 5: Presurgical radiographs

Fig 6: Presurgical photographs

Fig 7: Post surgical orthodontics with 0.016 SS in upper and lower arch



implant to replace the missing lower left first molar at a

later date. Therefore a rigid wire of 1mm stainless steel

was bonded on the buccal surfaces of the 2nd molar to the

2nd premolar of the third quadrant to maintain the space

until the tooth was replaced.

In order to frame an accurate treatment plan, it is very

important to understand the concept of facial

asymmetry.7,10

The localization of the asymmetry can be

done with the help of posteroanterior cephalometric

radiographs. These analyses help us to determine the

asymmetry of the jaws in sagittal or transverse direction

and its association with dental compensation.

Most studies have proven the correlation that exists

between the transverse dental compensation and skeletal

asymmetry.8,10,12

The important characteristics that help

us to determine the presence and extension of the facial

asymmetry are the occlusal plane inclination and menton

position observed in the posteroanterior cephalo-

grams.13,14

The findings in this patient presented

significant facial asymmetry, increased occlusal plane

angle, and left menton deviation. Haraguchi et al14

and

Severt and Proffit15

have reported that the lateral

excursion to the left was present in over 85% of the

studied population with mandibulofacial deformities.

According to Haraguchi et al14

, the mandible is more

asymmetrical than the maxilla because of its

unpredictable growth potential. While the mandible is not

fixed, the maxilla is rigidly attached to the adjacent

skeletal structures by means of sutures and

synchondroses. The objectives of the pre surgical

orthodontic goals were achieved and minor occlusal

settling was required post surgery to obtain adequate

functional occlusion and pleasant facial aesthetics. The

severe orthodontic problem that cannot be treated

perfectly with growth modification or camouflage often

resort to Orthognathic approach. As the envelope of

discrepancy indicate the limitation in orthodontics, a

surgical treatment approach offers the best alternative

while treating a skeletal Class III malocclusion in

adults.18

At the end of the treatment, the psychological

aspects of the patient were successfully addressed as the

patient became more confident and had improved oral

health quality of life (OHRQoL). Studies done by Kiyak

H et al19

have concluded that malocclusion and

orthodontic treatment do appear to affect general or oral

health quality of life to a measurable degree. It can be

very well measured by subjective and objective evidences

for improved appearance, oral function, health, and social

well-being of the patient.

When the skeletal problem compromises the facial

aesthetics, the surgical orthodontic treatment is the viable

treatment alternative for patients with facial asymmetry,

who have surpassed their growth potential. A correct

diagnosis and treatment planning with an appropriate

Fig 8: Post treatment intra oral photographs

Fig 9: Post treatment extra oral photographs

Fig 10: Post treatment radiographs

DISCUSSION

CONCLUSION



execution are the significant determining factors for

successful result and stability. In this case report, the

orthodontic-surgical treatment was well indicated for

correction of the Class III skeletal malocclusion and the

patient’s facial asymmetry (Fig: 11,12), providing

adequate masticatory function, pleasant facial aesthetics

and hence improving the patient's self-esteem.

1. Guyer EC, Ellis EE 3rd, McNamara JA Jr, Behrents RG.

Components of Class III malocclusion in juveniles and

adolescents. Angle Orthod 1986; 56: 7-30.

2. Battagel JM. The aetiological factors in Class III

malocclusion. Eur J Orthod 1993; 15: 347-370.

3. Mackay F, Jones JA, Thompson R, Simpson W.

Craniofacial form in Class III cases. Br J Orthod 1992; 19:

15-20.

4. Arnett GW, Bergman RT. Facial keys to orthodontic

diagnosis and treatment planning. Part II. Am J Orthod

Dentofacial Orthop 1993; 103: 395-411.

5. Arnett GW, Bergman RT. Facial keys to orthodontic

diagnosis and treatment planning. Part I. Am J Orthod

Dentofacial Orthop 1993; 103: 299-312.

6. Arnett GW, Worley CM Jr. The treatment motivation

survey: defining patient motivation for treatment. Am J

Orthod Dentofacial Orthop 1999; 115: 233-238.

7. Decker, JD. Asymmetric mandibular prognathism: a 30-

year retrospective case report. Am J Orthod Dentofacial

Orthop 2006; 129: 436-443.

8. Hayashi K, Muguruma T. Morphologic characteristics of

the dentition and palate in cases of skeletal asymmetry.

Angle Orthod 2004; 74: 26-30.

9. Ko EW, Huang CS, Chen YR. Characteristics and

corrective outcome of face asymmetry by orthognathic

surgery. J Oral Maxillofac Surg 2009; 67: 2201-2209.

10. Sekiya T, Nakamura Y, Oikawa T, Ishii H, Hirashita A,

Seto K. Elimination of transverse dental compensation is

critical for treatment of patients with severe facial

asymmetry. Am J Orthod Dentofacial Orthop 2010; 137:

552-562.

11. Kusayama M, Motohashi N, Kuroda T. Relationship

between transverse dental anomalies and skeletal

asymmetry. Am J Orthod Dentofacial Orthop 2003; 123:

329-337.

12. Van Elslande DC, Russett SJ, Major PW, Flores-Mird C.

Mandibular asymmetry diagnosis with panoramic imaging.

Am J Orthod Dentofacial Orthop 2008; 134: 183-192.

13. Padwa BL, Kaiser MO, Kaban LB. Occlusal cant in the

frontal plane as a reflection of facial asymmetry. J Oral

Maxillofac Surg 1997; 55: 811-816.

14. Haraguchi S, Takada K, Yasuda Y. Facial asymmetry in

subjects with skeletal Class III deformity. Angle Orthod

2002; 72: 28-35.

15. Bell WH, Proffit WR, White R P (1980). Surgical

correction of entofacial deformities. Philadelphia, WB

Saunders.

16. Phillips C, and Proffit WR; Psychosocial aspects of

Dentofacial deformity and its treatment in the

contemporary treatment of Dentofacial deformity, ed WR

Proffit, RP White Jr, and DM Sarver, Mosby, StLouis,

2003, 69-117.

17. Decker J. Asymmetric mandibular prognathism: A 30-year

retrospective case report. Am J Orthod Dentofacial Orthop

2006; 129: 436-443.

18. Kiyak HA. Does orthodontic treatment affect the patients’

quality of life? J Dent Educ 2008 Aug; 72(8): 886-894.

Fig 12: Post treatment radiographs

Fig 11: Radiographic Superimposition

REFERENCES

Source of Support: Nil

Conflict of Interest: Nil

nitin vm et al.: case report vm et al_.pdf · the arch wire sequence proceeded as ... fig 4:...

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