DeMaio V a, Abdullah Fa, Sangsuwon Ca, Teixeira CCb, Alikhani Ma,c
Traditionally, treatment for non-growing patients with a skeletal Class III malocclusion includes orthognathic surgery or camouflage treatment requiring extraction of lower teeth. Considering the latest advances in Orthodontics and Dentofacial Orthopedics, here we report a non-surgical, non-extraction orthopedic treatment of a severe skeletal deformity. An adult patient with a skeletal Class III jaw relation, presented to our clinic with all permanent teeth in a negative overjet, generalized gingival recession, and thin alveolar bone architecture. The patient reported discomfort and pain in both left and right temporomandibular joint areas. It is considered that the main obstacle preventing orthopedic changes in adult patients is the closure of the sutures. However, recent animal research has rejected this belief. To address this patient’s maxillary deficiency, we targeted both the sutures for displacement of the maxilla, and the periosteum for cortical drifting, stimulating a significant biological response in the upper jaw. Treatment included an expander, facemask, bite plate, and orthodontic correction using fixed appliances (braces) to address the patient’s transverse and sagittal skeletal problem. The patient demonstrated excellent motivation and compliance with all treatment instructions. We were able to stimulate significant maxillary displacement and cortical drifting in both transverse and sagittal dimensions, which helped correct the relation between the upper and lower jaws. At the end of treatment, we established a skeletal Class I relation of the jaws with Class I canine and molar occlusion, resulting in a functional occlusion with improved esthetic results.
Keywords: Class III, Skeletal deformity, Non-surgical treatment, Suture, Cortical Drifting, Expander, Adult, Orthopedic, Orthodontic
Skeletal Class III malocclusion is a complex skeletal problem that affects nearly 8% of the world’s population [1]. In this condition, the coordination between the growth of the upper jaw and lower jaw has been interrupted so that, in the sagittal dimension, the upper jaw is located more backwards in comparison with the lower jaw position. This condition can be caused by a lack of growth of the maxilla (most common), excess mandible growth (less common), or a combination of both [2, 3]. In addition, this sagittal deformity can be associated with normal, increased, or decreased vertical dimensions of the jaws and face.
Class III skeletal problems can significantly affect the overall quality of life of the patient and need to be efficiently treated. Specifically, when combined with vertical discrepancies, Class III malocclusions have been shown to negatively impact the patient’s physical and social well-being, dental and facial esthetics, speech, temporomandibular joint (TMJ) health, nasomaxillary complex, oropharynx space, and head and neck muscles [4-8].
Treatment of adult patients who suffer from Class III conditions has been limited to either camouflage treatment in milder discrepancies, which involves different extraction patterns in the lower dental arch [9, 10], or orthognathic surgery alone or in combination with extraction for more severe forms of skeletal Class III problems.
Unfortunately, extractions are usually accompanied by many functional and esthetic compromises, such as severe retro-inclination of lower teeth, severe proclination of upper teeth, long-term opening of extraction spaces, and relapse in both sagittal and vertical dimensions. Orthognathic approaches not only have the same instability as orthodontics treatment but in addition are associated with a high risk of morbidity in both oral and nasal cavities. The cost associated with these procedures is another reason for patients to avoid surgeries [11]. In addition, some procedures, such as mandibular setback, can invade the airway and require additional surgery, such as rotation of the maxilla-mandibular complex and genioplasty, to compensate for these problems [12, 13]. Therefore, orthognathic surgeries are considered another form of camouflage treatment since instead of addressing the source of the deformity, they compensate by changing the relation of other bones.
Due to the limitations of mandibular setback surgeries and the research demonstrating that most Class III discrepancies are the result of maxillary deficiency and not mandibular excess, treatment of Class III deformities has been focused mainly on the advancement of the maxilla. However, the reason clinicians do not provide orthopedic treatment in adults is the misunderstanding that sutures surrounding the maxilla are closed and cannot be opened.
Our previous animal research demonstrated that sutures do not completely close and can respond to orthopedic forces by recruiting osteoclasts to the area [14, 15]. While the rate of suture “opening” in adults compared with children is slow, it can still provide enough biological response to correct a maxillary deficiency. If the sutural response is combined with proper stimulation of cortical drifting in the dentoalveolar area [16, 17], a broader spectrum of severe to mild Class III conditions can be corrected by non-surgical orthopedic treatment in adults.
Our previous case reports clearly show that adult patients with Class III skeletal jaw relation can benefit from a combination of maxillary advancement and cortical drifting [8] treatment. However, it was unclear if this advancement was enough to eliminate the need for extraction in these patients. Here, we report the orthopedic treatment of an adult patient with a Class III skeletal deformity with significant negative overjet. With the new knowledge that jaws can be remodeled orthopedically even in adults, we aim to promote orthopedic corrections of adults as a viable option for those who do not want to undergo surgical or extraction treatment.
A healthy male, 27 years and 1 month old, presented to our clinic with the chief concern of “underbite”. The patient stated he had multiple previous consultations with orthodontists, all recommending orthognathic surgery as his only treatment option. The patient did not wish to undergo surgery and has delayed treatment for several years, until he was finally referred to our center.
The patient presented with clicking on both temporomandibular joints. He reported occasional facial muscle tenderness and noted his jaw “locked open” several times, but he could reposition it, thus never seeking medical attention. His medical history was irrelevant, and the patient visits his general dentists regularly for cleanings. Additionally, he had no previous history of orthodontic treatment. Extraoral examination and photographs (Figure 1) show the patient has a balanced face with equal facial thirds (mesofacial), and no asymmetries. The relaxed frontal portrait (Figure 1) shows the patient has lip competence, and the smiling portrait shows a straight smile line and the presence of small buccal corridors. Upon smiling, the patient shows 75% of his maxillary incisors, with no gingiva displayed. No facial or occlusal cants were observed. The lateral portrait photograph (Figure 1) shows a straight profile, retrusive upper lip, and a protrusive lower lip relative to the E-line (-4.5 and 3.1, respectively). The lateral cephalometric analysis (Figure 3, Table 1) shows a Class III skeletal relationship (ANB = -1.2°) with a hypo-divergent mandibular relationship to the cranial base (SN-MP = 26.2°). Additionally, the patient has a decreased mandibular plane angle in relation to Frankfort Horizontal (FMA = 14.6°), and lower incisors are protruded in relation to NB line (L1-NB = 9.8 mm).
Intraoral photographs (Figure 1) show moderate generalized recession with normal buccal and lingual frenum positions. An anterior crossbite is present, spanning his upper central and lateral incisors and lower six anterior teeth. Intraoral examination shows a bilateral Class III molar and canine relationship. Clinically, the patient presents with 31 erupted teeth, with the upper right third molar unerupted (Figure 3).
Digital cast analysis (Figure 2) shows both a mild Curve of Spee and a Curve of Wilson. Space analysis demonstrates that the patient has mild crowding in the upper (-2.6 mm) and lower (-3.4 mm) arches, with -2.5 mm overjet and about 10% (2.1 mm) overbite. A Bolton discrepancy (1.8 mm) was noted suggesting an anterior maxillary dental size deficiency.
Figure 1: Pre-treatment portrait and intra-oral photographs. Frontal extraoral photograph shows lip competence at rest and facial symmetry. Frontal smiling portrait shows a straight smile line with buccal corridors within normal limits , and 75% upper incisor display. Intraoral photographs show an anterior crossbite spanning the maxillary central and lateral incisors and the six lower anterior teeth, and the lower midline is 0.5 mm to the right of the upper midline. The anterior gingival margins are not aligned, and the gingival heights of contour are not properly positioned. Intraoral photographs reveal no severe rotations.
Figure 2: Pre-treatment digital casts evaluation. Digital casts show a mild Curve of Spee and a mild Curve of Wilson. Crowding was measured on the maxillary (-2.6 mm) and mandibular (-3.4 mm) arches. A Bolton discrepancy was present due to a deficiency of 1.8 mm in the maxillary anterior region. Cast measurements show an overjet of -2.5 mm and an overbite of 2.1 mm.
Figure 3: Pre-treatment panoramic radiograph. The pre-treatment panoramic radiograph shows a complete dentition. No root resorption was present, and no significant findings were noted for the maxillary sinuses. Condyles shows some degree of remodeling and asymmetry.
Figure 4: Pre-treatment lateral cephalometric radiograph and analysis. The pre-treatment lateral cephalogram (A) and cephalometric analysis (B) reveal a prognathic mandible, proclined upper incisors and uprighted lower incisors, and lower mandibular plan angle among other findings
Table 1: Cephalometric Analysis of Pre- and Post-treatment lateral cephalograms. Angular and linear measurements were taken on craniofacial skeletal, dental, and soft tissue landmarks identified on pre- and post-treatment lateral cephalograms (° – degrees, mm – millimeters).
The main treatment objectives were to provide a functional and stable occlusion and improve dental and smile esthetics. The following were the planned objectives of treatment:
I. Facial Esthetics: Improve facial profile and upper and lower lip position relative to the E-plane while maintaining facial symmetry.
II. Skeletal Objectives: Reduce the upper arch’s transverse discrepancy while maintaining the lower transverse width, protract the maxilla to reduce the Class III skeletal relationship, and maintain the vertical dimension of the jaws.
III. Dental Objectives: Expand the maxillary arch, correct the anterior crossbite, improve the posterior transverse relationship, and correct crowding in upper and lower arches. Increase the inclination of the maxillary incisors and decrease the inclination of the mandibular incisors. Improve the canine relationship by protracting the maxillary canines and retracting the mandibular canines. Improve the molar relationship.
The patient was presented with various treatment options, having declined the orthognathic surgical option. To address his skeletal problems, we offered a non-surgical approach using both orthopedic and fixed appliances. This treatment plan included a palatal expander, facemask, and posterior biteplate in conjunction with periosteal stimulation and fixed appliances (braces). Following treatment, retention was implemented with upper and lower lingual fixed retainers and removable retainers.
Maxillary expansion served two primary purposes in this patient’s treatment plan. First, the expander was utilized to widen the upper arch, improve the transverse skeletal and dental relationship with the mandibular arch, and help alleviate crowding. Second, palatal expansion stimulates the recruitment of osteoclasts to other sutures in the maxillary-cranial complex, aiding in maxillary protraction and remodeling with the facemask. Concurrently with the expansion process, a mandibular posterior bite plate was utilized to control the eruption of the posterior teeth. While utilizing the facemask, the bite plate was replaced with bite blocks bonded to the lower second molars to open the bite, allowing advancement of the maxilla without restriction from the anterior crossbite.
Fixed appliances (braces) were bonded in the posterior mandibular dentition to begin retraction of the posterior teeth, while in the maxillary arch, a one-couple system was utilized to procline and extrude the anterior teeth using anterior v-bend in a free object design. This treatment was followed by the full set-up of fixed appliances bonded to the maxillary and mandibular teeth to protract the maxillary posterior teeth and retract and upright the mandibular anterior teeth. Once positive overjet was achieved, facemask therapy was discontinued, and finishing movements were completed to optimize occlusal contacts.
The total treatment time was 12 months and 6 days, and all dental and orthopedic objectives were achieved by a precise mechanotherapy plan complemented with meticulous patient compliance.
I. Facial and Soft Tissue analysis
The overall facial balance was improved, and the profile analysis showed a 1.4 mm improvement in the distance of the maxillary lip relative to the E-line and a 1.5 mm improvement in the distance of the mandibular lip relative to the E-line (Figure 5).
II. Smile analysis
Upon smiling, the patient showed a wider maxilla and decreased buccal corridor width. Correcting the incisal display significantly enhanced the smile aesthetics. The anterior crossbite was also corrected, resulting in an overjet of 3 mm. (Figure 5).
III. Intra-oral and Digital Cast analysis
Intra-oral photographs (Figure 5) and analysis of casts (Figure 6) at the end of treatment showed the following outcomes:
1) The maxillary and mandibular dentition were expanded and developed transversely.
2) The crowding in the maxillary and mandibular dental arches was eliminated.
3) The anterior crossbite was corrected, and proper overjet (3 mm) and overbite (3.2mm) were established.
4) Class I molar and canine relationships were achieved on both sides of the arch.
IV. Panoramic Radiograph Analysis
The panoramic radiograph taken after treatment (Figure 7) shows proper root positioning and no major changes in root structure.
V. Cephalometric Analysis
Pre-treatment and post-treatment comparisons of skeletal and dental cephalometric parameters showed significant improvement in the sagittal skeletal relationship between the maxilla and the mandible. The ANB angle increased from -1.2° to 2.6°. The skeletal vertical dimension slightly increased, with the FMA changing from 14.6° to 17.2° and SN-MP from 26.2° to 27.3° (Figures 8 and 9).
Figure 5: Post-treatment portrait and intra-oral photographs. Post-treatment lateral portrait photograph shows an improved facial profile and upper and lower lip positioning relative to the E-plane. The post-treatment frontal resting photo shows maintained facial symmetry, maintained lip competence, and maintained even facial thirds. Intraoral photographs show correction of the anterior crossbite and Class I canine and molar bilaterally.
Figure 6: Post-treatment digital casts. Post-treatment digital cast analysis showed a correction of the negative overjet (3.0 mm), overbite (2.8 mm), coincidental midlines, tooth alignment, and Class I canine and molar relation.
Figure 7: Post-treatment panoramic radiograph. The post-treatment panoramic radiograph shows good root parallelism and no additional condyle remodeling compared to the pre-treatment radiograph.
Figure 8: Post-treatment lateral cephalometric radiograph and analysis. Post-treatment lateral cephalometric radiograph (A) and cephalometric analysis (B) reveal a general enhancement in the relationship between the maxilla and mandible, an increase in mandibular plane angle, correction of the anterior crossbite, as well as an optimal overjet and overbite.
Figure 9: Superimposition of pre- and post-treatment cephalometric tracings. Superimposition of pre-treatment (black) and post-treatment (red) tracings using best fit on cranial base (A), best fit of the maxilla profile (B), and posterior contour of the symphysis and mandibular canal (C) reveal both dental and skeletal changes in response to treatment.
The orthopedic correction in this patient was accomplished by two basic movements: displacement of the maxilla due to sutural opening, and cortical drifting, especially in the premaxilla area. While displacement of the maxilla can be attributed to the application of a facemask and expander, cortical drifting is the result of applying a one-couple system in the anterior part of the maxilla and expander in the posterior part of the maxilla.
For the displacement of the maxilla to occur, sutures need to open gradually. Animal studies demonstrate that sutural widening is a biological reaction and not, as was previously thought, a purely physical phenomenon [15]. In other words, we should avoid the application of high-magnitude force in adults with the hope of opening the sutures by force and instead apply lighter forces over an extended period of time until the biological reaction opens the sutures. This is why, in this patient, expansion forces were applied every 3 days. Our research shows that in response to the application of force, an inflammatory reaction is started in the sutures, followed by the activation of osteoclasts, which gradually open the sutures. This activation occurs in all surrounding sutures and is not limited to the midpalatal sutures. Opening of these sutures allows a maxillary movement similar to a Le Fort II surgical result [14,15].
Expansion forces also stimulate the forward movement of the maxilla due to the slanted position of zygomaticomaxillary sutures. However, most of the sagittal correction of the maxilla should be attributed to the application of sagittal forces by the facemask, far away from the center of resistance of the maxilla, that produces a significant counterclockwise moment. This moment can quickly rotate the maxilla and occlusal plane counterclockwise and help correct anterior crossbite.
Both the expander and the one-couple systems can stimulate cortical drifting in the surrounding periosteum and allow the widening of the alveolar bone in the direction of movement, as seen in the maxilla’s superimposition. This is also important when we evaluate the health of periodontium. It has been assumed that the application of expanders in adults may push the teeth out of the alveolar bone and would be contra-indicated in this patient, who already presented with recession on multiple sites at the beginning of treatment. However, the patient’s periodontium status did not worsen after treatment, even in the presence of thin cortical bone. This suggests that, while in certain patients, application of TAD-supported expanders may be necessary, the majority of patients can benefit from a tooth-supported expander where the palatal bar of the expander extends from the second molars to canines with an additional spring behind the lateral and central. The static force produced by the expander can stimulate osteogenesis ahead of the dental movement.
A posterior bite plate was used in this patient for many purposes. First, it provided better support for the TMJ, which allowed the faster relief of discomfort that the patient felt in the TMJ area before starting the treatment. Second, it helped deprogram the muscular memory that kept the maxilla and mandible in a particular relation. Third, it reduced the obstacle produced by occlusion during the maxilla’s forward movement. However, as soon as fixed appliances and sectional wires were placed in the posterior segments of the lower arch, the posterior bite plate was discontinued and replaced with bite blocks on the lower second molars.
Another important aspect of the treatment in this patient was the presence of third molars, which, due to their healthy condition, we decided to keep and include in the treatment. Unfortunately, clinicians often rush to extract these teeth even when they are in a good position. Third molars, from a biomechanical point of view, significantly reduce the magnitude of forces applied to the TMJ, and if they can be maintained, we should include them in the treatment.
While the ramus and the condyle of the mandible demonstrate some magnitude of remodeling, the mandible was not repositioned posteriorly. In comparison, mandibular setback orthognathic surgery can force the distal segment of the mandible backward and invade the airway space. Fortunately, most Class III patients require maxillary advancement, not mandibular setback. Mandibular setback mostly has esthetic value and, from a functional point of view, does not contribute to the patient’s health.
As demonstrated by the pre-and post-treatment clinical and radiographic records, correction of severe skeletal Class III malocclusion is possible through precisely designed mechanotherapy plans, even in post-pubertal or non-growing individuals. This contradicts previous literature, which states that non-surgical skeletal correction is impossible in adults [18]. Recent studies have shown that bone remodeling machinery can be recruited to stimulate both sutural opening and cortical drifting, indicating that the form of the skeleton can change throughout the life of an individual [16,17]. Our results show that clinicians can take advantage of the highly adaptable nature of bone to correct complex malocclusions non-surgically, utilizing carefully planned biomechanics such as the one discussed in this case report.
Diligent retention is necessary in all cases and is especially imperative in complex malocclusions. While many blame genetics for the development of Class III conditions, recent understanding in the development of the craniofacial forms [19-21] considers Class III skeletal deformities, especially in non-syndromic patients, a developmental problem where the trajectory of the form has been changed due to interfering factors. The treatment results should be stable if we can eliminate the underlying etiological factors or at least control them during our retention phase. Although the factors that caused this patient’s Class III skeletal pattern are unknown, surgical or non-surgical treatment does not necessarily correct these underlying factors. Therefore, in combination with establishing a functional occlusion, it is essential to design an appropriate retention plan to mitigate the risk of relapse. The use of Essix retainers or Hawley retainers is contraindicated in these patients. These retention options interfere with the occlusion and cannot maintain the vertical position of posterior teeth or the horizontal relation of the dentition, possibly causing development of spaces for example, where the retention elements of these appliances cross the occlusion. In the retention plan for these patients we recommend lingual fixed retainers from premolar to premolar to maintain the correct occlusion signaling during function.
This patient presented to our clinic with a strong desire to find a treatment plan that did not include orthognathic surgery or extractions. Considering the patient already had three prior orthodontic consults and rejected all proposed treatment plans that involved orthognathic surgery and/or extractions, it is imperative that the clinicians widen their knowledge of biology and biomechanics to be able to provide alternative care for these patients. Furthermore, to achieve a good outcome, the patient must be informed of the compliance requirements, which are crucial for the successful result. Clinicians need to adequately inform their patients of the risks and benefits of surgical and non-surgical approaches, so patients can make an educated decision when choosing a treatment.v
In this article, we demonstrate that stimulating the proper biological response in combination with customized mechanotherapy can widen the treatment options for patients with skeletal deformities. By defining new targets, such as periosteum/endosteum in craniofacial orthopedics, we can offer alternative treatment options to our patients, expanding the spectrum of malocclusions that can be treated non-surgically.
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