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Ortho-Surgical Management of Open Bite
Skeletal Class III Malocclusions with
Periodontics Deficiency in Adult Patient:
Amal El Aouame1*, Lahcen Ousehal1 and Kadiri Fatmi2
1Department of Dentofacial Orthopedics, Dental University of Casablanca, Morocco
2Oral and maxillofacial surgery, Private Practice, Casablanca, Morocco
Submission: March 26, 2017; Published: May 29, 2018
*Corresponding author:Amal El Aouame, Department of Dentofacial Orthopedics, Dental University of Casablanca, Morocco,
How to cite this article:Amal El Aouame, Lahcen Ousehal, Kadiri Fatmi. Ortho-Surgical Management of Open Bite Skeletal Class III Malocclusions with
Periodontics Deficiency in Adult Patient: Case Report. Adv Dent & Oral Health. 2018; 9(2): 555757. DOI: 10.19080/ADOH.2018.09.555757
It is known that one of the most challenging problems that confront the practicing orthodontist is the treatment of skeletal Class III malocclusion in adult patients. The clinician is faced with the option of either orthodontic camouflage or orthognathic surgery. In severe cases, ortho-surgical treatment is the only guarantor of successful result both functionally and aesthetically. This case report presents the treatment of a Moroccan female patient with open bite skeletal Class III malocclusion and periodontic desease. After combined orthodontic-surgical treatment the result was complete with positive overbite and acceptable occlusion, using a combination of fixed orthodontic appliance treatment as well as the orthognathic surgical management. The patient was satisfied with her new appearance and function.
Keywords: Class III malocclusion; Open bite; Orthognathic Surgery; Bimaxillary osteotomy; Orthodontics
Ones of the most complex problems that orthodontics has to manage are skeletal class III malocclusions.
Prevalence of this type of malocclusion is different from a population to another, it goes in Caucasians ranges from 0.8 to 4.0%, to rises up to 12.13% in Japanese and Chinese populations, whatever in North Indian population, and it’s found in up to 3.4% of the population . Multi factorial causes are incremented in adult and include genetic and/or environmental factors. The characteristics of this malocclusion are mandibular prognathism, maxillary deficiency or both . Studies show that maxillary deficiency is more frequent, accounting for 60% to 63% of the causes of this malocclusion . It’s known that etiology of skeletal class III malocclusion is closely linked to heredity . According to Litton et al.  one third of a group of patients with severe class III malocclusion had a parent with the same problem and one-sixth had an affected sibling. Arnett shows that jaw bases attribute to malocclusion in all three dimensions; this is why the dento-alveolar and soft tissue components should be reviewed [5,6].
At first the skeletal disharmony is detected and confirmed, then clinician must make the differential clinical diagnosis of Class III malocclusion, by verifying occlusal pattern both at Centric Relation (CR) and Intercuspal Position (IP). This maneuver aims to assess the severity of the malocclusion, and define the nature
of causes of Class III malocclusion (skeletal, dental malocclusion or functional. Diagnosis is confirmed by lateral cephalograms at the aforementioned occlusal positions . The treatment decision is based on the clinical examination confronted to the cephalometric analysis by assessing the amount of sagittal and vertical discrepancy, dentoalveolar compensations and facial esthetic . To treat this type of malocclusions we can chose one of two options, orthodontic camouflage treatment witch calls on dentoalveolar compensations  and orthodontic-surgical treatment which involves correction of the skeletal disharmony .
The choice between these two treatment options is made on the basis of a clinical data face cephalometry. The final decision remains dependent on the practitioner’s clinical experience and personal preference . In adult Orthognathic surgery and Orthodontic therapy are compliment to each other to achieve the desired results . Accurate clinical examinations followed by the right diagnosis and treatment planning are essential . These complex cases require careful treatment planning, an integrated approach and patient cooperation .
The aim of this report is to describe and discuss the option of orthodontic-surgical treatment of Class III skeletal malocclusion in adult patient for reestablishment of a normal occlusion and an adequate facial esthetics.
Moroccan female patient aged 35 years reported
dissatisfaction with her facial and dental appearance associated
to functional problems. Facial examination disclosed facial
symmetry with malar deficiency, oral closure needed contracture
of perioral muscles. The facial profile was concave, with maxillary
hyperplasia, a protrusive nasomaxillary area and prominent
lower third of the face with a protruded lower lip relative to the
upper lip. Smile analyses showed a low smile line with a gingival
exposure and a well developed buccal corridors (Figure 1).
Intraoral examination objectified a narrow maxilla, class III
molar and canine relationship, anterior crossbite with lack of
overbite and bilateral posterior crossbite, accentuated negative
dentoalveolar discrepancy in the maxillary arch. The patient had
a pathological periodontal tissue, with bilaterals incisif’s diastema
and local recessions in the mandible. No other family members
were known to have similar abnormalities of the teeth and
craniofacial skeleton. Panoramic radiograph (Figure 2) showed
horizontal resorption of the bone crests both in the maxilla and
the mandible, missing mandibular third molars and retention
of the maxillary third one. The postero anterior cephalometric
radiograph of the face confirmed skeletal classe III malocclusion
with open bite sign’s.
Cephalometric analysis revealed a good antero posterior
maxillary relationship (SNA= 81°), with the mandible positioned
anteriorly to the cranial base (SNB=87°). The lag bone bases
was negative and estimated at 6°, it was accentuated by vertical
abnormality due to posterior mandibular rotation. Added to
this classical dento-alveolar compensations was observed and
expressed in sagittal plan with pro alveolar upper incisive (I/NA=
7mm) and retroalveolar lower incisive (i/NB=3mm) (Table 1).
No relevant family and medical history was to note. However, the
patient was greatly dissatisfied by her looks and highly positive
for the treatment.
The aim of our treatment was to attain a pleasing profile
by improving the relationships of jaw bases .We wanted also
to correct crossbite and open bite, individual tooth rotations,
make sure that an dequate torque for maxillary and mandibular
incisors is achieved and at the same time improve the smile line.
To reach these goals, was decided for an orthognathic approach,
this treatment included three phases. The first one is the presurgical
phase which consists of orthodontic preparation that was
essential to correct dental disharmonies with aligning the arches
and improving torque of maxillary and mandibular incisors. We
initiated with 022 preajusted edgewise appliance. The orthodontic
treatment was done without premolar exyarctions. Both maxillary
and mandibular arches were aligned using flexible wires NiTi
archs which were followed by progressive heavy arch. A quad helix
was bonded on the maxillary arch to obtain transversal alveolar
expansion (Figure 3). The second phase is jaw surgery. Bilateral
sagittal split osteotomy was performed to setback the mandible by
5 mm. LeFort I surgical procedure was carried out as decided and
the maxilla was repositioned 3 mm superiorly.
In the aim to stabilize the mandibular, a rigid fixation was
used. Finally, a post-surgical phase has been, it’s an orthodontic
phase to achieve final desired tooth interdigitation using wires
and settling elastics (Figure 4).
After combined orthodontic-surgical treatment, it was
observed functional occlusion, normal overjet and overbite,
adequate intercuspation with coincident midlines, and normal
lateral and protrusive excursions.
The post-treatment radiograph revealed no periodontal bone
loss, acceptable root parallelism of the newly positioned incisors
and canines (Figure 5). The cephalometric data showed that the
sagital skeletal relationship was corrected from Class III to Normal
and the mandiblular plane was maintained (Table 1). The overall
treatment duration was 6 months.
Skeletal class III malocclusion in adult is characterized by a
rich clinical table, which involves many esthetic and functional
prejudices,  a good comprehension of the components of this
malocclusion conditions the establishment of an accurate and
effective treatment plan . To treat this type of malocclusion, the
clinician can chose between two options, orthodontic camouflage
and orthognathic surgery. The use of the surgery requires that
the clinician after evaluating the patient’s face, deduce that facial
esthetics is deficient, which imply that orthodontic treatment
alone is insufficient to achieve a successful result.
Many authors agree on the fact that in adult patient who
present with ful fledgest class III malocclusion, combined orthosurgical
management remains the only option [4,16,17]. For limit
cases called “bordline, the choice of the appropriate option can
be difficult to make. Many studies have been destined to identify
criteria of distinguishing the mean value of indicators of treatment
choice, especially the cephalometric ones [15,18]. According to
Cassindy  borderline Class III can be treated by orthodontic or
surgical treatment, in the base of moderate skeletal discrepancies
they involves .
In our case, patient presented severe class III malocclusion,
with many esthetics and functional problems.
Skeletal parameters were sounded on the facial plane with
esthetic disgrace. The therapy of choice to correct the skeletal
discrepancy was ortho-surgical treatment through dental
decompensation. Orthodontically, it was easy to achieve negative
overjet by repositioning the maxillary anterior teeth and closing
spaces at the mandible. Patient was informed about aesthetic
prejudice than result of the lag aggravation before surgery; she
was also made aware of the need for combined surgery. Bilateral
sagittal split osteotomy was performed to setback the mandible by
5 mm, we associate le- Forte I surgical procedure, to reposition the
maxilla 3 mm superiorly and correct vertical prejudice.
Referring to Eckhardt & Cherackal [1,20] bimaxillary
osteotomy, comparing to one-jaw osteotomies, offers a greater
potential to modify anterior face height, what is heard on the soft
tissues. This is why it’s justified in patients, such as in this case, in
the aim to improve excessive vertical dimension of the lower face
[1,20]. Clinical success after orthognathic therapy can be defined
as a combination of following factors: patient (and patient’s
family) satisfaction, Correct static and functional occlusion,
patient comfort when chewing no pain in the temporomandibular
joint and stability of the result in long term .
In terms of stability, in 2-jaw surgery, there is better control
of ramus inclination and less relapse related to this, but upward
movement of the maxilla that allows the chin to rotate upward
and forward brings its total forward movement to about the same
level as with mandonly surgery . When upward and forward
movements of the maxilla are combined with lower border ramus
osteotomies, thus prevent excessive forward rotation of the
mandible and garant the excellent postsurgical stability [16,21].
Mobarak et al.  assessed long trem changes in soft tissue
profile following mandibular setback surgery and deduced
that mandibular setback surgery is a stable procedure and if
relapse occurs, it appears in first six months postoperatively
[22-25]. Bailey et al.  evaluated long term soft tissue changes
after orthodontic and surgical corrections of skeletal class III
malocclusions and concluded that class III patients are less
stable during first year after surgery but show fewer changes in
hard and soft tissue measurements beyond that point . In
their retrospective cephalometric study extended over a period
of 5 years, L’Tanya J et al.  show those skeletal Class III adult
patients treated by ortho-surgery show minimal change in soft
tissues in post-surgery .
High Class III certainly is a great challenge to orthodontist
and constitutes the greatest cause of facial deformity among
all types of malocclusions. Success in the management of such
malocclusion is conditioned by a proper diagnosis and treatment
planning. In adult with a severe discrepancy, combined orthosurgical
approaches is the only way to achieve successful results. It
demure a stable procedure, however relapse may be due to faculty
planning, faulty or postsurgical growth which is avoided in adult
patients. In our case the patient and her legal guardians were very
pleased with the final result, which considerably improved her
self-esteem. In contrast long term follow up demure essential.