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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 26-31

Tackling mandibular prognathism with evidence-based surgical orthodontics: A paradigm shift


Department of Orthodontics and Dento-Facial Orthopedics, Dr. D.Y. Patil University School of Dentistry, Navi Mumbai, Maharashtra, India

Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Vivek P Soni
Dr D.Y. Patil University Deemed to be School of Dentistry, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_10_19

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  Abstract 


The esthetic outcome of orthognathic surgery has always been of utmost importance to patient as well as the surgeon. With innovations in orthognathic surgical procedures, the addition of soft tissue prediction is a boon to orthodontists and oral surgeons together. The evolution in treatment planning from mere radiographic–cephalometric tracings to simulated surgeries has been a tremendous and path-breaking journey for the field. Three-dimensional printing, soft tissue analysis, splint fabrication, stereolithographic models, rapid prototyping, and various such adjuncts have thereon revolutionized surgical procedures and treatment predictions.

Keywords: Evidence, orthognathic, rapid prototyping, surgical orthodontics, three-dimensional printing, traditional


How to cite this article:
Soni VP, Patil AA, Shetty MK, Bhatia VR. Tackling mandibular prognathism with evidence-based surgical orthodontics: A paradigm shift. Indian J Oral Health Res 2019;5:26-31

How to cite this URL:
Soni VP, Patil AA, Shetty MK, Bhatia VR. Tackling mandibular prognathism with evidence-based surgical orthodontics: A paradigm shift. Indian J Oral Health Res [serial online] 2019 [cited 2019 Sep 23];5:26-31. Available from: http://www.ijohr.org/text.asp?2019/5/1/26/261148




  Introduction Top


Orthognathic surgery has toddled and cemented its steps with orthodontists and oral surgeons in its own way and form. Over the past few decades, treatment planning and esthetic outcome prediction have painted its own journey in easing out expectations of the patients undergoing surgical procedures. Be it Le-fort, bilateral sagittal split osteotomies (BSSOs), genioplasty, or facial asymmetry corrections, there are now no surprises awaiting the patient. As for the surgeon, cone beam computed tomography (CBCT) analysis, myography studies, stereolithographic models, and three-dimensional (3D) printing aid in treatment planning and its outcome, prognosis, and relapse tendencies. The prototype models help in performing mock surgeries along with aid in the formation of guide templates for the incisions, setbacks, advancement, and repositioning of the maxilla and mandible. In the olden days, all that was used were cephalometric and standardized photographs to document and predict the favorable position and the final outcome of dental, skeletal, and esthetic positioning of any particular case.

With advancement in technology, conventional techniques should be bid adieu, and this evolving paradigm shift of latest techniques and trends must be accepted for better diagnosis and ideal treatment planning.

Orthognathic surgery is far more than just a series of surgical procedures used to move the jaws, or segments thereof. Diagnosis, including a four-dimensional analysis of a growing and aging craniofacial complex, covered by a manifestly variable soft tissue envelope and treatment planning with its intricacies and complexities are the cornerstones of successful treatment.

A better example to elucidate this would be the transition in the way surgeries are implemented; the routine surgical procedure in excessive mandible cases: the BSSO – operation to reduce mandibular prognathism was not undertaken again for almost 50 years. The first known surgical procedure that may be described as “orthognathic” appears to have been by the American surgeon Hullihen in 1849.[1],[2],[3],[4]

In 1897, Blair (1871–1955) performed the first “double resection of the mandible;” which was essentially a bilateral osteotomy of the mandibular body via an extraoral approach, with parallel cuts in the premolar regions and removal of the osteotomized blocks. Copper wire interosseous ligatures secured the bony segments. In this respect, Ottolengui appears to have been ahead of his time, as modern surgical wafer splints are a modification.[5],[6],[7]


  Case Reports Top


Case presentation 1

A 20-year-old male patient came to the department with a chief complaint of forwardly placed jaw. He presented with a concave profile with skeletal Class III base [Figure 1]. The patient had a Class III molar relation on the right and Class I molar relation on the left with lower midline shifted to the left by 11 mm. The patient showed a reverse overjet on the left side and a negative overbite on the right side. Cephalometric Grummon's analysis confirmed the skeletal asymmetry.
Figure 1: Pretreatment photographs and X-rays

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Treatment objectives

  • Correction of the facial asymmetry
  • Correction of profile
  • To give a stable occlusion
  • To improve the functional efficiency of the patient.


Treatment plan

  • Presurgical orthodontics


  • 1. Incisor decompensation

    2. Intra-arch coordination

    3. Interarch coordination

  • Mock surgery
  • Orthognathic surgery
  • Postsurgical orthodontics.


  • 4. Finishing and detailing

    5. Retention.


Treatment progress

Before active treatment began, the patient was referred to specialists for extraction of 4 third molars. After that, 0.022” × 0.028” preadjusted edgewise appliances with MBT prescription were placed in both arches. Bands were placed in upper first and second molars and in lower first and second molars. The patient underwent presurgical orthodontics up to 0.019” × 0.025” SS straight archwires on both upper and lower arches.

A face bow transfer of the patient was done, and the casts were mounted onto a Hanau articulator for the mock surgery to be carried out. A splint was fabricated on the final position post the mock surgery. This splint would help to stabilize the jaw during the intraoperative procedure and help to stabilize the position [Figure 2].
Figure 2: (a) Mock surgery. (b) Surgical splint

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The final BSSO surgery was carried out according to the planning, and the jaw was stabilized using the manually prepared splint.

Conventional surgery in the early periods was difficult to plan as there was only two-dimensional techniques available for planning of the surgery [Figure 3].
Figure 3: (a) Presurgical. (b) Postsurgical

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Case presentation 2

A 24-year-old male patient came to the department with a chief complaint of forwardly placed jaw. He presented a concave profile with a Class III skeletal base [Figure 4]. The patient had a Class III molar occlusion with the lower midline shifted to the left. The patient showed a reverse overjet of − 4 mm.
Figure 4: Preoperative

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Treatment options

1. Orthognathic surgery

2. Camouflage.

Keeping in mind the age and the reverse overjet of the patient and the inferences of various surgical cephalometric analysis, orthognathic surgery was chosen. The patient also accepted this treatment option.

Treatment plan

  1. Presurgical orthodontics
    • Leveling and aligning
    • Correction of dental malocclusion and achievement of decompensation
    • Closure of all spaces.
  2. Surgical phase
    • BSSO setback of mandible.
  3. Postsurgical orthodontics
    • Finishing and Detailing
    • Retention.


Treatment progress

Before active treatment began, the patient was referred to specialists for extraction of 4 third molars. After that, 0.022” × 0.028” preadjusted edgewise appliances with MBT prescription were placed in both arches. Bands with the same prescription were placed in upper first and second molars and in lower first molars. Presurgical orthodontics ended with 0.019” × 0.025” SS straight archwires on both upper and lower arches.

With an advance in technology creating a buzz everywhere, new advanced ways were used to diagnose this case.

The plaster casts of both preoperative occlusions were scanned with a high-resolution optical scanner [Figure 5]. Digital Imaging and Communications in Medicine images of both skull and occlusion were then imported to develop a virtual 3D model of the hard and soft tissue of the head. A 3D cephalometric analysis was done by Simplant OMS.
Figure 5: Treatment - hard tissue planning

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Recent advances in intraoral digital scanning technology have given orthodontists the ability to eliminate unpleasant impressions while providing patients with more accurate appliances and reduced treatment times.[1] The next paradigm shift in orthodontics is the development of 3D printers, working in conjunction with intraoral scanners [Figure 6].
Figure 6: Preoperative versus postoperative

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Case presentation 3

A 26-year-old male patient came to the department with a chief complaint of forwardly placed lower jaw. He presented a concave profile with a Class III skeletal base. The patient had a Class III molar occlusion with the lower midline shifted to the left. The patient showed a reverse overjet of − 11 mm [Figure 7].
Figure 7: Presurgical

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Treatment objectives

  • To improve profile of the patient
  • To give stable occlusion
  • To improve the functional efficiency of the patient.


Treatment plan

  • BSSO setback of mandible
  • Postsurgical orthodontics
  • Finishing and Detailing
  • Retention.


Treatment progress

Like the previous case, everything was digitized to avoid any man-made errors with the diagnosis and treatment plan. Hard tissue and soft tissue simulation was done. CBCT played a vital role in formulation of the treatment plan and also with the comparison of the before and after treatment changes. All cephalometric analysis was carried out by Dolphin software [Figure 8].
Figure 8: Three-dimensional printed models

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A surgery first approach was chosen for the patient. Extraction of all the third molars was done. The patient underwent all the necessary medical tests to be declared physically and mentally fit. BSSO was carried out on the patient under general anesthesia with a setback of 11 mm. After 24 days of surgery, the patient was bonded with 0.022” × 0.028” preadjusted edgewise appliances with MBT prescription in both arches. Bands with the same prescription were placed in upper first and second molars and in lower first molars. Presurgical orthodontics ended with 0.019” × 0.025” SS straight archwires on both upper and lower arches.

Making use of advanced technology for diagnosing and formulating a thorough treatment plan helped in avoiding of errors. The patient was 100% satisfied with treatment outcome [Figure 9].
Figure 9: Pretreatment versus posttreatment

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Latest trends in surgical orthodontics

With the advances in technology and time, the 3d printing universe can be applied to a more wider platform which would help in ease of surgery along with the planning as well as the procedure itself [Figure 10].
Figure 10: 3D printed surgical models

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Some new trends and advances that might already be in use are[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] as follows:

  1. 3D printed splint
  2. 3D printed surgical guide
  3. 3D printed spacers
  4. 3D printed fixation plates/implants.



  Discussion Top


Orthodontics and orthognathic surgery have come a long way with varying ways to diagnosis and devise a steady treatment plan. With the steady enhancement of its processes and materials, the distribution of 3D printing technology has widely increased in various fields of medicine. Recent advances in 3D imaging, virtual surgical planning coalesced with CAD/CAM software as well as further developments of 3D printers opened up new probabilities to fabricate more precise patient-specific devices based on patient's 3D digital models for orthognathic surgery.[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31]

Subsequently, numerous studies have demonstrated that 3D printing technologies help the clinician to condense operative time, upsurge surgical safety, and improve the predictability of surgical outcomes. One must bid goodbye to conventional orthodontic surgery techniques and be ready to welcome the new era in treatment planning. A paradigm shift? Yes of course![32],[33],[34],[35],[36],[37],[38],[39],[40],[41] [Table 1].
Table 1: Comparision of 2D and 3D cephalometrics

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

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