Combined orthodontic-orthognathic surgical treatment

of a Class II, Division 1 malocclusion

Kevin P. Harris, DDS, a Michael Weinberg, DMD, b and Cyril Sadowsky, BDS, MS c
Chicago, Ill.

This case report shows the need to extract four first premolars in addition to orthognathic surgery,
even though the initial treatment plan involved a nonextraction strategy. The extractions were
necessary to reduce maxillary dental protrusion and proclination and also to recover from the
mandibular incisor proclination that occurred as a consequence of leveling the mandibular arch.
(Am J Orthod Dentofac Orthop 1997;111:640-5.)

When orthognathic surgery is needed in HISTORY AND CLINICAL EXAMINATION

combination with orthodontics for the treatment of
a Class II, Division 1 malocclusion, it is advanta-
geous to attempt to avoid extractions if at all
possible. A nonextraction strategy would shorten the
orthodontic phase substantially and also avoid ex-
cessive incisor retraction and the often associated
flattening of the lips. However, even in the absence
of crowding, it is important to eliminate dental
compensations that may be present before treat-
ment. Also, in leveling a lower curve of Spee, the
lower incisors are often advanced, which makes the
mandibular incisor proclination worse. The follow-
ing case report shows an example of the need to
extract four premolars in addition to orthognathic
surgery, even though the presenting problem ini-
tially led us to a nonextraction strategy.
From the Department of Orthodontics, University of Illinois at Chicago,
College of Dentistry.
aln private practice in Baton Rouge, La.
bin private practice in Chicago, I11.
cProfessor.
Reprint requests to: Dr. Cyril Sadowsky, Department of Orthodontics,
University of Illinois at Chicago, 801 S. Paulina, Chicago, IL 60612.
Copyright © 1997 by the American Association of Orthodontists.
0889-5406/97/$5.00 + 0 8/4/67852
This Hispanic female patient, aged 12 years 9 months,
was concerned with the protrusion of her upper anterior
teeth. Her medical history was noncontributory. She re-
ported infrequent asymtomatic clicking in both temporo-
mandibular joints.
Functional movements were normal, including nega-
tive findings on temporomandibular joint (TMJ) exami-
nation. A tongue thrust habit was present on swallowing.
Her profile was severely convex and retrognathic, with
protrusion of the upper lip and eversion of the lower lip.
A large interlabial gap was present, with strain on closure,
due to the severe overjet. There was generalized marginal
gingivitis and some carious lesions were present. She
presented with a severe Class II, Division 1 malocclusion
with spacing of the maxillary incisors.
DIAGNOSIS
Photographic Analysis
The profile was convex and retrognathic, with lips in
poor balance and harmony (Fig. 1). The upper lip was
severely protrusive and the lower lip everted. The lips
were apart at rest and strained on closure. The smile line
was acceptable.

Fig. 1. Pretreatment facial photographs.

640
American Journal of Orthodontics and Dentofacial Orthopedics Harris, Weinberg, and SadowsLy 641
Volume Ill, No. 6

Fig. 2. Pretreatment panoramic radiograph,

Fig. 3. Pretreatment study models.

Radiographic Analysis
All third molars were developing normally. Root
development was normal (Fig. 2).

Study Model Analysis

The molar and canine relationships were Class II, with
a 16 mm overjet, 9 mm overbite, and impingement of the
lower incisors into the palatal mucosa (Fig. 3). The
midlines were correct and coincident. The maxillary arch
form was tapered and the mandibular arch form ovoid to
square. The curve of Spee was excessive and the compen-
sating curve was flat. There was 9 mm of spacing in the
maxillary arch anteriorly. The mandibular arch had ade-
quate arch length, with some premolar and canine rota-
tions present.

Cephalometric Analysis
There was a severe Class II brachyfacial skeletal pattern,
due mainly to a protrusive maxilla (Fig. 4, Table I). There
was a severe Class II denture base discrepancy. The man-
dibular plane was decreased and the Y-axis indicated an
average growth direction. The decreased interincisal angle
was due to proclination of the maxillary incisors. The max-
illary incisors were protrusive, whereas the m~mdibular inci- Fig. 4. Pretreatment cephalometric tracing.
642 Harris, Weinberg, and Sadowsky American Journal of Orthodontics and Dentofacial Orthopedics
June 1997

Fig. 5. Presurgical facial photographs.

Fig. 6. Presurgical intra-oral photographs.

Table I. Cephalometric summary overbite, a n d 9 m m of spacing in the maxillary arch. T h e

lips were a p a r t at rest a n d strained o n closure, with p o o r
Measurements
b a l a n c e a n d h a r m o n y . T h e r e was a severe Class II d e n t u r e
Facial angle 88.3 87.2 91.0 91.0 base discrepancy, due mainly to maxillary skeletal protru-
Angle of convexity 3.4 19.3 21.0 12.8 sion; also severe maxillary dental protrusion.
SNA 84.3 89.7 93.0 90.7
SNB 81.9 79.4 81.3 83.8
ANB 2.3 10.3 11.6 7.0 TREATMENT OBJECTIVES
Mandibular plane 23.7 19.2 16.0 21.7
Y-axis 59.3 57.4 56.6 55.8
1. C r e a t e a m o r e acceptable facial profile a n d an
A-N vertical 0.4 7.0 11.0 9.0
Po-N vertical 0.0 -3.4 0.0 4.1 i m p r o v e m e n t in lip balance.
Anterior face height 112.8 116.5 119.3 123.5 2. C o r r e c t the overbite by leveling the curve of Spee.
Lower anterior face height 62.1 62.0 67.3 70.1
3. C o r r e c t the overjet by m a n d i b u l a r a d v a n c e m e n t
Interincisal angle 138.3 1 1 1 . 6 126.0 125.7
Lower incisor-occlusal plane 16.8 25.4 29.6 29.5 a n d retraction of the maxillary incisors while clos-
Lower incisor-mandibular plane 1.0 8.7 15.9 13.7 ing t h e maxillary a n t e r i o r spacing.
Upper incisor-SN 101.8 122.0 103.5 101.3
Upper incisor-APo 4.4 15.4 8.7 5.6
Lower incisor-APo 0.5 -3.2 -4.3 1.4 GENERAL PLAN OF TREATMENT
Facial contour angle -11.0 -28.9 -25.7 -19.0
Upper lip-E line -3.0 1.6 -2.0 -6.1 1. Level a n d align the m a n d i b u l a r arch.
Lower lip-E line -1.5 -4.3 -0.8 -4.4 2. R e t r a c t t h e maxillary a n t e r i o r t e e t h while main-
taining m a x i m u m a n c h o r a g e with cervical h e a d -
A = pretreatment, P = progress presurgical, B = posttreatment.
*Standards used: White, female, age 16 years. gear.
3. C o o r d i n a t e the arches in p r e p a r a t i o n for m a n d i b -
ular a d v a n c e m e n t surgery.
sors were slightly retruded and proclined. The upper lip was 4. Surgical m a n d i b u l a r a d v a n c e m e n t .
severely protruded and lower lip slightly retruded. 5. O r t h o d o n t i c detailing of the occlusion after sur-
gery.
DIAGNOSTIC SUMMARY 6. R e t e n t i o n with a maxillary Hawley r e t a i n e r to
A Class lI, Division 1 malocclusion was p r e s e n t in the m a i n t a i n incisor space closure a n d a m a n d i b u l a r
early p e r m a n e n t dentition, with 16 m m overjet, severe fixed lingual p r e m o l a r - t o - p r e m o l a r r e t a i n e r to
American Journal of Orthodontics and Dentofacial Orthopedics Harris, Weinberg, and Sadowsky 643
Volume 111, No. 6

Fig. 7. Posttreatment facial photographs.

maintain correction of the curve of Spee and

incisor alignment.

PROGRESS OF TREATMENT
1. A full-fixed preadjusted edgewise appliance was
placed, including maxillary cervical headgear for an-
chorage. Compliance with headgear wear was poor.
2. A nonextraction strategy was initially used. How-
ever, after 11 months, the decision was made to
extract the maxillary second premolars and man-
dibular first premolars to permit the incisors to be
retroclined within their respective arches. Mini-
mum to moderate anchorage was planned without
auxiliary appliances.
3. The patient did not return for 9 months. At that time,
space closure was initiated with sliding mechanics and
intra-arch elastics on 0.016-inch arch wires.
4. After numerous failed appointments for m a w
months at a time, 57 months into treatment ideal
0.016 × 0.022-inch arch wires were placed. Small
spaces were maintained mesial to the maxillary ca-
nines in preparation for mandibular surgery (Figs. 5
and 6).
5. A mandibular sagittal split osteotomy was per-
Fig. 8. Posttreatment cephalometric tracing.
formed with 10 mm advancement. The four third
molars were extracted at the time of surgery.
6. Class II intermaxillary elastics were used for a short maxillary first molars were constricted 5 mm, and
period before appliance removal after 69 months. the canines were constricted 3 mm. T h e mandibular
7. There were 34 appointments, with 17 missed ap- first molars were constricted 6 m m and the canines
pointments often for many months at a time. were constricted 4 ram.
Cranial base s u p e r i m p o s i t i o n i n g , b e f o r e sur-
RESULTS ACHIEVED gery, s h o w e d significant m a n d i b u l a r g r o w t h ir~ a
A t the time of appliance removal, the lips were h o r i z o n t a l direction over a 5-year, 8 - m o n t h p e r i o d
well balanced, with pleasing facial esthetics (Figs. 7 b e t w e e n r a d i o g r a p h s (Fig. 10, T a b l e I). T h e re-
and 8), Functional m o v e m e n t s were n o r m a l and no gional s u p e r i m p o s i t i o n s s h o w e d that the maxillary
signs or s y m p t o m s of t e m p o r o m a n d i b u l a r joint dys- incisors w e r e r e t r o c l i n e d and retracted, and the
function were evident. m o l a r s m o v e d mesially a similar a m o u n t with
T h e occlusion was almost ideal (Fig. 9). T h e s o m e extrusion or eruption. T h e m a n d i b u l a r inci-
644 Harris, Weinberg, and Sadowsky American Journal of Orthodontics and Dentofacial Orthopedics
June 1997

Fig. 9. Posttreatment intra-oral photographs.

Fig, 10. Pretreatment to presurgical cephalometric superimposition.

sors were maintained in anteroposterior position,
as the extraction spaces were closed with minimal
anchorage.
At appliance removal, cranial base superimposi-
tioning demonstrated the 10 mm surgical mandibu-
lar advancement (Fig. 11, Table I). The Y-axis
decreased, while the mandibular plane was slightly
increased. Maxillary incisor inclination was ideal but
the mandibular incisor was slightly proclined with a
close to ideal interincisal angle.
The panoramic radiograph after treatment re-
vealed slight maxillary incisor root resorption (Fig.
12).
RETENTION
Thirteen months into retention, the occlusion
has remained stable. The maxillary Hawley retainer
is being worn at nights and the mandibular fixed
lingual retainer is still in place; it may be changed to
a removable retainer in the near future for night-
time wear.
Despite the extremely poor cooperation and the
very lengthy time that the patient was in appliances
because of the many missed appointments for pro-
tracted lengths of time, treatment outcome was very
favorable with minimal iatrogenic damage. Even
though the initial treatment plan involved a nonex-
American Journal of Orthodontics and Dentofacial Orthopedics Harris, Weinberg, and Sadowsky 645
Volume 111, No. 6

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Fig. 11. Pretreatment to posttreatment cephalometric superimposition.

traction strategy with no crowding in the mandib-

Fig. 12. Posttreatment panoramic radiograph.
ular arch and spacing in the maxillary arch, it
became necessary to extract four premolars to
reduce maxillary dental protrusion and proclina-
tion and also to recover from the mandibular
incisor proclination that occurred as a conse-
quence of leveling the mandibular arch. The
surgical mandibular advancement was very effec-
tive in producing a pleasing facial esthetic result,
even though the presurgical cephalometric analy-
sis suggested primarily maxillary protrusion. The
posttreatment result shows a tendency toward
bimaxillary protrusion, which in this patient, is
most pleasing.