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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.
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | SEPTEMBER-OCTOBER 2017 | VOL 4 | ISSUE 3 61
CASE REPORT Nitin VM et al.: Skeletal Class III Malocclusion with Anterior Open Bite
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
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | SEPTEMBER-OCTOBER 2017 | VOL 4 | ISSUE 3 62
CASE REPORT Nitin VM et al.: Skeletal Class III Malocclusion with Anterior Open Bite
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
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | SEPTEMBER-OCTOBER 2017 | VOL 4 | ISSUE 3 63
CASE REPORT Nitin VM et al.: Skeletal Class III Malocclusion with Anterior Open Bite
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
International Journal of Oral Health and Medical Research | ISSN 2395-7387 | SEPTEMBER-OCTOBER 2017 | VOL 4 | ISSUE 3 64
CASE REPORT Nitin VM et al.: Skeletal Class III Malocclusion with Anterior Open Bite
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.
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Fig 12: Post treatment radiographs
Fig 11: Radiographic Superimposition
REFERENCES
Source of Support: Nil
Conflict of Interest: Nil