Abdullah Fa, Sangsuwon Ca, Alansari Sa, Alikhani Ma, Giovanetti Ma, Nervina JMa, Teixeira CCb, Alikhani Ma,c
Figure 1: Pre-treatment portrait and intra-oral photographs. Adult male patient who was receiving orthodontic treatment (with fixed appliances shown in photos) in another clinic in preparation for orthognathic surgery. Patient was referred to CTOR clinics for possibility of non-surgical treatment. Lateral profile photograph showed a brachyfacial concave profile, a decrease in the mandibular facial third, a protrusive chin, and deficient maxillary lip and acceptable mandibular lip position. Frontal portrait photographs show dark buccal corridors, asymmetric incisal display upon smiling, maxillary dental midline deviated 3 mm to the right in relation to the facial midline, mandibular midline deviated 1.5 mm to the left with respect the maxillary dental midline. Measurements indicated a cant of the incisal plane elevated on the right side. Facial asymmetry noted as the mandible deviated to the right. Intraoral photographs reveal a constricted maxilla, spacing in area of maxillary first premolars and mandibular second premolars as they were previously extracted. A crossbite observed extending from the maxillary right premolar to left first premolar, and a Class III canine and molar relationship.
Figure 2: Pre-treatment panoramic radiograph. Panoramic radiograph shows a complete dentition except for maxillary first premolars and mandibular second premolars. Roots on all teeth were fully developed and showed mild to moderate root resorption on the anterior teeth and the maxillary premolars. Bone loss is clear around the mandibular anterior teeth and the maxillary canines. Asymmetric condyles showed some degree of remodeling and flattening on their anterior surface. Mandibular morphology shows prominent and asymmetric gonial angles with some degree of remodeling on the left side. Nasal polyp is visible along the medial wall of the left nasal cavity
Figure 3: Pre-treatment lateral view of cephalometric radiograph. Cephalometric analysis showed a Class III tendency (ANB= -3.9°), hypo-divergent profile and protruded mandible (FMA= 14°, SN-MP= 23.3°, SNB= 86.1°), severely proclined maxillary incisors (U1°-SN= 112°), proclined mandibular incisors (IMPA= 101.2°) and an anterior crossbite with -2.1 mm of overjet.
Figure 4: Pre-treatment frontal view of cone-beam computed tomography (CBCT) scan. A) Pre-treatment frontal view of CBCT scan shows a nasal septal deviation towards the left side (vertical dotted line positioned slightly to the right of the septum to show bone deviation), and an asymmetric mandibular position canted upwards towards the right side (horizontal red lines). B) Coronal section localizing the nasal polyp (arrow in B and C) to the left nasal cavity. Cant of the nasal cavity floor up to the right is clearly visible. C)
Table I: Cephalometric Analysis Pre- and Post- Treatment. Angular and linear measurements were measured using craniofacial skeletal, dental and soft tissue landmarks identified on pre- and post-treatment lateral cephalograms (° – degrees, mm – millimeters).
Figure 5: Post-treatment portrait and intra-oral photographs. Post-treatment portrait photographs demonstrate an improvement in the facial profile, with an increase in the lower facial height, and improved smile esthetics. Intra-oral photographs show maxillary arch development, aligned maxillary and mandibular dentition, full correction of the crossbite, an ideal overjet and overbite relation, Class I molar and canine occlusal relationship, correction of the incisal/occlusal plane cant and closure of the extraction spaces. Both maxillary and mandibular dental midlines are aligned with the facial midline. Gingival margins and heights of contour improved around the anterior teeth. Lingual fixed retainers are shown extending from canine to canine in both arches.
Figure 6: Post-treatment panoramic radiograph. Panoramic radiograph at the end of treatment shows good root alignment, no additional bone loss and bone remodeling on the anterior surface of the condyle. Noticeable reduction in the size of the nasal polyp is also noted.
Figure 7: Post-treatment lateral cephalometric radiograph and analysis. Post-treatment cephalometric analysis showed overall improvement in maxillary and mandibular relationship (ANB= -1.6°), improved mandibular plane angle (FMA= 17.9°, SN-MP= 27.4°), correction of anterior crossbite into ideal overjet, ideal overbite, improvement in the maxillary incisor inclination (U1°-SN= 107.8°) and mandibular incisor uprighting (IMPA= 79.5°).
Figure 8: Superimposition of pre- and post-treatment cephalometric tracings. Cephalometric superimposition of pre-treatment (black tracing) and post-treatment (red tracing) on the anterior cranial base shows clockwise rotation of the mandible, extrusion of the maxillary and mandibular molars, extrusion, retraction and retroclination of the maxillary anterior teeth, and retraction and retroclination of the mandibular anterior teeth (A). Superimposition on the body of the maxilla shows maxillary molar extrusion, uprighting, and mesialization, and incisor retroclination (B). Superimposition based on the inferior-alveolar nerve and inner profile of the mandibular symphysis reveals mandibular molar extrusion and uprighting, and incisor retroclination (C).
Figure 9: Post-treatment frontal view of cone-beam computed tomography (CBCT) scan. A) Post-treatment lateral view of CBCT scan showed an overall improvement of the NSD (vertical dotted line) and a correction of mandibular cant (horizontal red lines). Note the leveling of the nasal cavity floor. B) Correction of the NSD and absence of the nasal polyp (white arrows on B and C)
Figure 10: Maximum nasal cavity width in the anterior, middle, and posterior areas. Linear measurements of the width of the nasal cavity were completed on pre- and post-treatment CBCT images (mm – millimeters). A) Measurements were taken from the widest points of the nasal cavity by drawing vertical lines (vertical dashed lines) perpendicular to the horizontal line joining the center of the right and left orbit (horizontal dashed line). The measurement was taken where the vertical line touched the curvature of the nasal cavity at the anterior, middle and posterior sections of the nasal cavity. B) The regions of the nasal cavity were established by joining ANS to PNS (red horizontal line in B) and dividing the length of that line into 4 equal sections. Vertical lines at the intersection of those 4 segments (vertical lines in B) mark the anterior, middle, and posterior sections where measurement of the with were completed.
Table II: Maximum width in different sections of the nasal cavity. Linear measurements of the width of the nasal cavity in the anterior, middle, and posterior sections, were completed on pre- and post-treatment CBCT images (mm – millimeters) as illustrated in figure 10.