Skeletal Class III Malocclusion in an Adult Patient – Orthodontics versus Orthognathic Surgery: Is there Another Alternative?

© 2018 APOS T ends in O hodon ics | Published by Wol e s Kluwe - Medknow 161 Add ess o co espondence: D . Juan Ca los Pé ez Va ela, C/Dou o Teixei o N 12 1, 15701, San iago De Compos ela, A Co uña, Spain. E‑mail: jcpe [email p o ec ed], clinicadelno [email p o ec ed] Access his a icle online Websi e: www.apospublica ions.com DOI: 10.4103/apos.apos_63_18 Quick Response Code: Abs ac Class III malocclusions a e conside ed o be one o he mos di icul p oblems o ea . Due o he signi ican numbe o pa ien s wi h Class III malocclusion who canno unde go o hogna hic su ge y o di e en easons, we ha e p oposed an al e na i e ea men ha we ha e called su gically assis ed apid pala al expansion (SARPE) + empo a y ancho age de ices (TADs) which allows sol ing mild and mode a e Class III malocclusion combined wi h maxilla y comp ession, ob aining accep able es he ic and unc ional esul s. We p esen a case epo o an adul emale wi h skele al Class III malocclusion wi h comp ession in he maxilla y and mandibula asymme y, who was ea ed wi h SARPE + TADs. The esul is accep able in e ms o occlusion unc ion, es he ic o he smile, and acial es he ics. Keywo ds: Case epo , Class III malocclusion, maxilla y comp ession, o hodon ics, su gically assis ed apid pala al expansion + empo a y ancho age de ices Skele al Class III Malocclusion in an Adul Pa ien – O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e? Case Repo Juan Ca los Pé ez Va ela, Bea iz Iglesias Sánchez, Mi iam López Vila Depa men o O hodon ics, Uni e si y o San iago de Compos ela, Galicia, Spain How o ci e his a icle: Pé ez Va ela JC, Sánchez BI, Vila ML. Skele al class III malocclusion in an adul pa ien – o hodon ics e sus o hogna hic su ge y: Is he e ano he al e na i e? APOS T ends O hod 2018;8:161-7. This is an open access jou nal, and a icles a e dis ibu ed unde he e ms o he C ea i e Commons A ibu ion‑NonComme cial‑Sha eAlike 4.0 License, which allows o he s o emix, weak, and build upon he wo k non‑comme cially, as long as app op ia e c edi is gi en and he new c ea ions a e licensed unde he iden ical e ms. Fo ep in s con ac : ep in [email protected] In oduc ion Acco ding o he classi ica ion o D . Angle, Class III is he malocclusion in which he es ibula g oo e o he lowe i s mola is loca ed mesial o he mesiobuccal cusp o he uppe i s mola .[1] I is necessa y o dis inguish a den al Class III malocclusion om skele al one because in he second, he malocclusion is due o a disp opo ion in he bony bases, which may be due o a e ogna hism o he uppe jaw, a mandibula p ogna hism, o a combina ion o bo h.[2,3] The highes p e alence o Class III malocclusions is ound in Asia (12%) and Eu ope, alues anging be ween 1.5% and 5.3% and in Caucasians in No h Ame ica be ween 1% and 4%.[4,5] The skele al de o mi ies a e he esul o he p esence o anomalies in he posi ion o he maxilla and mandible. In malocclusions in which a single bone is in ol ed, maxilla y e usion is mo e common (19.5%) han a mandibula p o usion (19.2%), al hough he p esence o hese wo ea u es in a combined o m is mo e common (30.2%).[6,7] In he ea men o skele al Class III malocclusion in adul s, he e a e basically wo ea men al e na i es: o hodon ic ea men and su gical ea men combined wi h o hodon ics. The choice o one o he o he will depend on se e al ac o s; one o he main ones will be he deg ee o bone disc epancy, since o hodon ic camou lage can only be done when Class III malocclusion is mild. On he o he hand, no all pa ien s a e willing o unde go su gical ea men , due o i s cos , in asi e na u e, o heal h condi ions, despi e being he ideal op ion om he o hodon ic poin o iew.[8‑10] In cases in which, in addi ion o he sagi al p oblem, he e is a ans e sal p oblem due o maxilla y comp ession, i is possible o pe o m a segmen ed Le Fo (combining Le Fo I wi h os eo omies ha allow disjunc ion). Ano he op ion is he p e ious execu ion o a su gically assis ed apid pala al expansion (SARPE).[11‑13] Fede ico He nández Al a o desc ibes he SARPE pe o med on 257 pa ien s, unde local anes hesia and seda ion, making a comple e Le Fo I wi hou mobiliza ion, which achie es a o al elease and bipa i ion o he maxilla ha gua an ees skele al dis ac ion and p e en s a damaging load a he den al le el.[14] Due o he numbe o pa ien s wi h Class III malocclusion wi h maxilla y Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e? 162 APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 Figu e 1: Ini ial ex ao al pho og aphs Figu e 2: Ini ial in ao al pho og aphs Figu e 3: Ini ial ele adiog aph and o hopan omog aphy Figu e 4: Cone beam compu ed omog aphy be o e su gically assis ed apid pala al expansion comp ession who e use ea men wi h o hogna hic su ge y, we ha e p oposed a less in asi e solu ion o he pa ien , mo e economically a o dable, and ha ob ains e y good esul s, bo h es he ically and unc ionally. This al e na i e consis s in he pe o mance o a SARPE unde local anes hesia and seda ion, and he placemen o minipla es, wo supe io s a he le el o he p e ygoid and wo in e io s in he symphysis, be ween he la e al inciso s and he canines. The case p esen ed is a Class III malocclusion wi h maxilla y comp ession, mandibula asymme y, and de ia ion o he lowe line o he igh . Al hough he ideal op ion o co ec all he p oblems was o hogna hic su ge y, he pa ien decided o unde go ea men o SARPE + empo a y ancho age de ices (TADs), assuming ha he mandibula asymme y would no be co ec ed. Diagnosis and e iology The pa ien is an adul o 28 yea s old p esen ing wi h ans e sal and sagi al hypoplasia o he maxilla, skele al asymme y, de ia ion o he lowe line o he igh , and c owding. Clinical on al examina ion e ealed an asymme ical ace. The p o ile assessmen e ealed conca e p o ile, wi h an e io acial di e gence, la cheekbone con ou , and pu e es he ics o he smile in he on al and la e al iews [Figu e 1]. When we analyzed he smile in de ail, we obse ed c owding, poo coo dina ion o he den al midlines, and he uppe ee h a e wo n [Figu e 1]. In ao al examina ion e ealed Class III mola and canine ela ion on bo h sides. The mandibula midline was de ia ed 4.5 mm o he igh . The pa ien had uppe and lowe c owding and comp ession in he maxilla [Figu e 2]. Tempo omandibula join (TMJ) examina ion e ealed a li le disc epancy be ween cen ic ela ion and cen ic occlusion, and he pa ien complained o pain in he join . Cephalome ic examina ion e ealed e ogna hic maxilla (SNA 73º) and Class III malocclusion (Wi s ‑10mm and ANB ‑4º) [Figu e 3 and Table 1]. T ea men p og ess Due o he la ge numbe o adul pa ien s who p esen Class III malocclusion bu decide no o unde go o hogna hic su ge y, despi e being he ideal op ion, o di e en easons explained abo e, we decided o de ise an in e media e op ion be ween camou lage and o hogna hic su ge y. When a SARPE is pe o med o sol e maxilla y comp ession, he pala ine and p e ygoid su u es a e eleased. I we also add some minipla es a he le el o he Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e? APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 163 p e ygoids each side by es ibula and o he s be ween he lowe la e al inciso s and he lowe canines by es ibula , we can pull o wa d he maxilla, bene i ing om he elease o he p e ygoid su u es made in he SARPE. We ha e de ined his echnique as SARPE + TADs. O hodon ic ea men combined wi h SARPE + TADs consis s o h ee phases: p esu gical o hodon ic ea men , su gical ea men , and pos su gical o hodon ic ea men . Table 1: Cephalome ic alues Value Mean Ini ial T ea men p e‑SARPE Final SNA (º) 82±3.5 73 73 76.5 SNPg (º) 80±3.5 77 77 77 SNB (º) 80±2 77.5 77.5 77.5 ANPg (º) 2±1.5 −4.5 −4.5 −1 ANB (º) 2±1 −4 −4 −0.5 SN/ANS‑PNS (º) 8±3.0 14.5 14.5 14.5 SN/GoGn (º) 33±2.5 38 38 38 ANS‑PNS/GoGn (º) 25±6.0 20 20 20 +1/ANS‑PNS (º) 110±6.0 108 108 119.5 −1/GoGn (º) 94±7.0 83 91 82 O e je (mm) 3.5±2.5 −0.3 −2 0.3 O e bi e (mm) 2±2.5 1.7 1.5 2 In e incisal (º) 132±6.0 147 142 137 Wi s 0±1 −10 −10 −4 SARPE: Su gically assis ed apid pala al expansion Figu e 5: Tele adiog aph be o e su gically assis ed apid pala al expansion Figu e 7: In ao al pho og aphs be o e su gically assis ed apid pala al expansion Figu e 8: Ex ao al pho og aphs a e su gically assis ed apid pala al expansion Figu e 6: Ex ao al pho og aphs be o e su gically assis ed apid pala al expansion Figu e 9: In ao al pho og aphs a e su gically assis ed apid pala al expansion Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e? 164 APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 Figu e 10: Cone-beam compu ed omog aphy a e maxilla y expansion Figu e 11: In ao al pho og aphs du ing he ea men Figu e 12: Final ex ao al pho og aphs Figu e 13: Final in ao al pho og aphs Figu e 14: Final in ao al scan (CBCT) o measu e he ans e sal p oblem [Figu es 4 and 5]. The pa ien i s needed a su ge y o expand he maxilla y by SARPE echnique be o e he placemen o b acke s in he uppe a ch. In ou p o ocol, his su ge y is conside ed ambula o y because i is pe o med unde local anes hesia and seda ion on an ou pa ien basis in 30 min [Figu es 6‑9]. Nex , he pa ien unde wen he ope a ion o SARPE + TADs. The ac i a ion was 3 u ns pe day, and an in e maxilla y elas ic was placed om he igh uppe minipla e o he lowe igh one and ano he om he uppe le minipla e o he lowe le one, wi h o ces o 200–400 g pe side o app oxima ely 24 h a day ( he pa ien can only emo e hem o ea and b ush he ee h) [Figu e 8]. Once he desi ed expansion was ob ained, we made a CBCT o con i m ha he expansion was comple ely co ec ed and o measu e he sagi al ad ance o he maxilla [Figu e 10]. One mon h la e o he las u n o he sc ew, we bonded he b acke s in he uppe a ch and we closed he dias ema and coo dina ed he den al a ches o achie e an In pa ien s wi h skele al p oblems and TMJ pain, we p opose o use a spli in uppe a ch, and we decompensa e he lowe a ch o make su e which is he eal ans e sal and sagi al p oblem o 4 mon hs. A e his i s phase, we did a ele adiog aph [Figu e 4 and Table 1] and a cone‑beam compu ed omog aphy Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e? APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 165 Figu e 15: Final cone-beam compu ed omog aphy Figu e 16: Final ele adiog aph Figu e 17: Supe posi ion o he acings be o e su gically assis ed apid pala al expansion (blue) and inal ( ed) on he an e io c anial base adequa e occlusion and es he ics o he smile ( o cen e he midlines, ob ain mola and canine in Class I, achie e o e bi e wi h in e maxilla y elas ics, and ge a co ec smile a ch) [Figu e 11]. The elas ics o he minipla es con inued o be placed un il he pa ien ’s sagi al p oblem was esol ed. Du ing he ea men , we used he ollowing a ches: • Alignmen : 0.014 NiTi and 0.016 NiTi • Le eling: 0.017 × 0.025 NiTi. • To que and space closu e: 0.019 × 0.025 s eel wi e • Finishing: 0.018 s eel wi e wi h bindings. T ea men esul s A e he ea men , he b acke s and TADs we e emo ed and inal adiog aphs we e aken. The esul a e he ea men is accep able. We ob ained a signi ican imp o emen in alignmen , occlusion unc ion, coo dina ion o he midlines, and es he ics o he smile in on al and la e al iews and acial es he ics. The mandibula asymme y was no co ec ed since o hogna hic su ge y would ha e been necessa y o his pu pose [Figu es 12 and 13]. The lingual occlusion is accep able, and we can see i wi h he den al scan [Figu e 14]. In he CBCT, we can obse e ha he oo s a e in he middle o he al eola bone, and he e is no oo eso p ion [Figu e 15]. Cephalome ic examina ion showed an ad ance o he maxilla (SNA 76.5º), a Class I malocclusion (Wi s ‑4 and ANB ‑0.5º) and a co ec in e incisal angle (137º) [Figu e 16 and Table 1]. The main changes ob ained in he ea men o SARPE + TADs in he pa ien a e as ollows [Table 1]: • The e ha e been no o a ions o he maxilla y o mandibula plane • The Class III malocclusion has been comple ely co ec ed (ANB om −4º o −0.5º, Wi s om −10 o −4 mm) • P ope ad ancemen o maxilla has been achie ed (SNA om 73º o 76.5º) • The inclina ion o he uppe inciso (119.5º) and he lowe (92º) is co ec ed • The in e incisal angle is co ec ed (137º) • The o e je dec eased om ‑2 o 0mm. In o de o isualize he changes p oduced a e he ea men o he pa ien wi h SARPE + TADs, he supe posi ion o he acings a e SARPE and inal, on he an e io c anial base, was made, showing all he Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e? 166 APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 Figu e 19: Compa ison be ween ini ial and inal in ao al pho og aphs Figu e 18: Compa ison be ween ini ial and inal ex ao al pho og aphs Figu e 20: Re en ion ex ao al pho og aphs changes p e iously exposed [Figu e 17], and a compa ison be ween in ao al and ex ao al pho og aphs was made [Figu es 18 and 19]. Two yea s la e , he occlusion unc ion is s able. The es he ic o he smile is accep able. The pa ien does no ha e TMJ p oblems [Figu es 20 and 21]. Conclusion In cases whe e he e a e a maxilla y comp ession and a mild o mode a e Class III malocclusion, and/o when he pa ien ejec s he op ion o o hogna hic su ge y due o i s economic cos , heal h condi ions, o in asi e na u e, he ea men o SARPE + TADs is an op ion ha ob ains e y Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e? APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 167 Figu e 21: Re en ion in ao al pho og aphs accep able esul s, bo h unc ionally and es he ically, and allows pa ien s o sol e skele al p oblems ha un il now could only be co ec ed wi h o hogna hic su ge y. Decla a ion o pa ien consen The au ho s ce i y ha hey ha e ob ained all app op ia e pa ien consen o ms. In he o m, he pa ien has gi en his consen o he images and o he clinical in o ma ion o be epo ed in he jou nal. The pa ien unde s ands ha he names and ini ials will no be published and due e o s will be made o conceal he iden i y, bu anonymi y canno be gua an eed. Financial suppo and sponso ship Nil. Con lic s o in e es The e a e no con lic s o in e es . Re e ences 1. P o i WR. The de elopmen o den o acial de o mi y: In luence and e iological ac o . In: P o i WR, Whi e RP J ., Sa e DM. Con empo a y T ea men o Den o acial De o mi y. S . Louis: CV Mosby; 2003. 2. Ngan P, Moon W. E olu ion o Class III ea men in o hodon ics. Am J O hod Den o acial O hop 2015;148:22‑36. 3. Benyahia H, Aza oual MF, Ga cia C, Hamou E, Abouqal R, Zaoui F. T ea men o skele al Class III malocclusions: O hogna hic su ge y o o hodon ic camou lage? How o decide. In O hod 2011;9:196‑209. 4. Ca los Pé ez Va ela J, Sánchez BI. O hodon ic ea men o an asymme ic case wi h Class III malocclusion, c owding, and an impac ed canine. APOS T ends O hod 2016;6:306‑11. 5. Va ela JC, Sanchez BI. 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