Surgical Orthodontic Treatment for a Skeletal Class III Severe Vertical Patient with a Different Initial Treatment Plan in an Orthodontic Residency Program: Case Report

• This article describes the treatment of a skeletal Class III severe vertical and asymmetric patient. The patient was treated in a university orthodontics program in two stages that represent the guidance of two different faculty members as the first instructor to start the treatment moved residency to another state. In the First Stage of treatment a Hyrax appliance and a reverse facemask with vertical control was used. In the second stage of treatment (change of faculty member guidance) two treatment alternatives were explained: conventional orthodontics to camouflage the skeletal anomaly and traditional orthodontics/orthognathic surgery approach; the surgical option was selected. Pre-surgical orthodontics was applied for leveling, aligning, and relieving dental compensations. A bilateral sagittal split osteotomy was performed for mandibular setback and a Le Fort I for maxilla advancement. Post-surgical orthodontics was applied for finishing and detailing occlusion. The second stage total treatment time was 24 months. Facial balance and harmony were enhanced, and a functional dental occlusion was achieved.

Many patients seek orthodontic treatment in orthodontic programs around the world. These programs depend on the continuing education, research, expertise, and teaching skills of their faculty members. Dentistry has evolved and different approaches are available for the practitioner and patient to solve a specific problem or clinical situation; in orthodontics different philosophies and mechanics can accomplish same treatment goals. In an orthodontic program residents learn and apply different ways to achieve contemporary orthodontic objectives; faculty members may share the timing or the way to treat a specific orthodontic problem or not, treatment planning in orthodontics includes an ideal orthodontic plan and in some cases treatment alternatives. 

One faculty member started the case but moved to another state, so the patient was reassigned to another instructor. The case is described in two stages that represent the different instructor’s supervision and approach to the case.

Table 1: Cephalometric measurements.

Figure 3: Pretreatment facial and intraoral photographs.

Figure 4: Pretreatment study models.

Class III maloclussion treatment is a difficult challenge in everyday orthodontic practice. Early treatment is successful in some patients avoiding a surgical intervention but others don´t, although good patient compliance and treatment planning; some of them will require a surgical intervention or extractions to camouflage the skeletal discrepancy. Timing of orthodontic intervention can be controversial in respect of the success of treatment response and outcome [1]. The inability to predict mandibular growth is one reason why clinicians are reluctant to render early orthopedic treatment [2]. Protraction facemask therapy has been advocated in early of Class III malocclusion with maxillary deficiency [3-5].

Optimal treatment timing for facemask therapy is in the deciduous or early mixed dentition [2]. In this case the initial approach for treatment of class III malocclusion was a reverse facemask therapy. But the patient was in permanent dentition; some clinicians prefer to explode all remaining growth, but evidence shows a better outcome in an early stage. Patients receiving early orthodontic or orthopedic treatment might need surgical treatment at the end of the growth period [6]. This is the reason why an overall assessment was made, and a different treatment approach established.

An orthodontic surgical approach was chosen, and the next decision was to select a “Surgery First” or “Orthodontics First” approach. “Surgery First” provides immediate improvement of facial appearance, rather than worsening it as it happens when eliminating dental compensations in an “Orthodontics First” approach [7-10]. 

Figure 5:  Le Fort I osteotomy for maxilla advancement and bilateral sagittal split osteotomy (BSSO) for mandibular setback.

Figure 6: Posttreatment facial and intraoral photographs.

Figure 7: Posttreatment study models.

Figure 8: Posttreatment radiographs.

Orthodontic therapy has evolved significantly with new treatment protocols, technology innovation, and new scientific data; the contemporary orthodontic quest is to achieve Function, Esthetics, Stability and Periodontal tissue integrity in every patient. There are different protocols or approaches to treat an orthodontic problem; treatment planning depends on the orthodontist training, philosophy, and experience. As in many health related sciences controversies in orthodontics may arise from different points of view or treatment preferences between specialists but as far as treatment objectives are achieved by healthcare professionals, they may choose a particular way to solve orthodontic problems based on evidence based scientific data.

The authors declare that the patient was treated with all ethical approval; the informed consent was explained to the patient and patient´s family who signed. The authors declare no conflict of interest

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