Approaches to Correction of Class III Skeletal Malocclusion

Approaches to Correction of contour trinity Skeletal Malocclusionunite orthodontic and Surgical Approach in the Correction of phratry troika Skeletal MalocclusionDr. Abdulaziz AlShahraniAstracWhile growth modification and camouflage orthodontic intervention offers a limited solution in treating some in straitened circumstances(p) Class 3 malocclusion depending on the age of the diligent , Underlying skeletal severity, colligation of the teeth and the erect facial proportions, a combination of surgical and Orthodontic therapy is the intervention of choice in all dreaded skeletal Class III malocclusion. In this case give out I present a combination of surgical-orthodontic therapy for an adult female enduring with skeletal company III malocclusion which resulted in good skeletal, dental and haywire create from raw stuff family relationship, with marked proceeds in function and facial esthetics.KeywordsClass III malocclusion, Orthognathic Surgery, surgical dental orth opedicsIntroductionClass III malocclusion is considered to be one of the most toilsome and multifactorial orthodontic problems to treat. The prevalence of carve up III malocclusion has been reported to be as low as 3-5% in the Caucasian population, but is high in the Chinese and Japanese population (4-13%) (Often associated with upper jawbone retrusion)i,ii,iii.The etiology of class III is complex and multifactorial. However, in that location is usually a strong patrimonial contribution. Genetic factor is one of the etiological factors where one third of children with severe Class III had a parent with the same problem and one-sixth had an affected siblingiv. Racial tendency may solve a purpose as the blacks have video displayn higher incidence than whitesv.Environmental factors appear to play an adaptiverole in the etiology of Class III malocclusionvi.Class III malocclusion domiciliate be associated with other factors such as c left palatevii.Individuals with class III m alocclusion show combinations of skeletal and dentoalveolar components. Class III malocclusion may occur as a result of protrusive mandible, retrusive upper jawbonery, combination of bothviii. While the most commonly pitch Class III malocclusion (30%) showed a combination of mandibular project and maxillary retrusion, Maxillary retrusion alone was found in 19.5% of the sample and Mandibular protrusion alone was found in 19.1% of the sampleix.These complex nature of class III requirea careful planning, amultidisciplinary approach and patient cooperationx.CaseReportA 17-year-old caucasian girl presented for orthodontic treatment because of referral from her dentist with primary complaint of un-esthetic facial and dental appearance. She has a hyper-divergent Class III skeletal and dental relationship. This is characterized by retrognathic maxilla, retroclined inflict preceding teeth, with maximum active opening of 47mm with 5mm negative overjet and lateral excursions of 7 mm to b oth right and left sides.The patient has an ovoid, relatively asymmetrical facial expression with chin some deviated to the left. The lip line at rest displayed approximately 2 mm of upper incisor. At full animation there was 7mm of upper incisal display and 2 mm of set about incisal edge. She has a slightly concave profile, and competent lipsFigure1.Pretreatment extra oral photosIntraorally, the oral mucosa was healthy. there were no periodontal pockets present. The gingival tissues were inflamed especially around the prosthetic crowns. There was no bleeding tendency except sometimes with brushing. gratis(p) gingival margins were near to the CEJ and attached gingiva was of normal width passim the mouth. The frenal attachments in both kinkes were normal. The tongue was normal in size, function and appearance. odontiasis 26, 36 and 46 have been crowned. There was a lingual arc placed one year ago to maintain lower incisors position. diaphragm analysis, she was in the perman ent dentition and the 3rd molars were un-erupted. She has good oral hygiene. facade view Shows a dental midline discrepancy. The lower dental midline is coincident with the facial midline while the upper midline is not coincident with the facial midline its off to the left by 2.5mm, the occlusal planewas slightly canted to the left. A negative overjet of 5 mm reported.Right and left Lateral Views Shows the canines and molars in Class III relationships. The upper occlusal view shows a U-shaped arch with well aligned anterior segment. The lower occlusal view reveals a U-shaped arch with crowding of 3.9mmFigure 2.TREATMENT OBJECTIVESOur objective is to guide compensated lower incisors by proclining them to the ideal position and inclination followed by increasing the plane projection of the maxilla to correct upper jaw retrognathism, concave profile, class III dental relationshipand negative overiet. Increased lower facial top and hyper-divergence will be corrected byautorotation o f the mandible after the advancement of the maxilla and vertical reduction genioplasty.Mandibular asymmetry will be corrected by BSSO while maintaining lower incisor position.TREATMENT PROGRESSWe started Pre-surgical dental orthopaedics using self-ligation square bracket system (Roth prescription, 022slot). Leveling and alignment of maxillary and mandibular arches began with round 0.016 niti arch wires progressing to 0.0170.025 niti arch wires. Patient was referred to extract all 3rd molars at this stage. interrelated 0.0190.025 Stainless brace then used for arch coordination before direct the patient for surgical procedureFigures 67.All the movement and prediction were planned on pre-surgical lateral cephalometric x-ray using Moorres mesh as a guide. A sheet of tracing paper over the original tracing and the dodging of the mandible was drawn and trimmed making a templet, another template for the maxilla was produced and placed in the post-surgical position. The mandibular auto rotation then simulated accordingly. The soft tissue contours then drawn using the guidelines in literaturesxi,xii,xiiiFigure8.Centric relationship of Upper and lower jaws was recorded and Face bow transfer and juncture of pretendings on a semi-adjustable articulator was done. Model surgery then performed using Erickson model blockandacrylic inter occlusal wafer splint was produced.Le fort I osteotomywas performed to advance the maxilla for 7.1 mm and Bilateral sagittal burst out osteotomy was carried out to correct mandibular asymmetry while maintaining the A-P position of the mandible. Vertical reduction and advancement (4mm each) genioplastythen performed to address the increased lower facial height and achieve esthetically congenial facial profile. Rigid type of fixations were used in both arches.The patient was followed closely and the post-surgical Orthodontic was resumed 3 weeks after surgery. 0.0190.025 stainless steel changed to 0.021 0.025stainless steel to express th e torque. Finishing was performed with settling elasticsfigures9-12.Six months later, fixed appliances were removed and lower fixed retainer 3-3 was cemented along with upper and lower Hawleys retainers figures 13 14.Cephalometric finding shows a good skeletal, dental and soft tissue relationship and improvement in the function and facial estheticsTable 2, Figures15-17.pre- and post-treatment cephalometrictracingsDiscussionThis case report presents a combination of surgical and orthodontic therapy for an adult female patient with skeletal and dental class III malocclusion. The magnitude of the problem was so severe and lies outside the envelope of possible correction by orthodontics alonexiv. In growing patients, early treatment with maxillary expansion and good continuation can result in straightening of profile after 6 monthsxv. It can also promote more favorable psychosocial development and greater compliancexvi. Delaying treatment can lead to development of posterior cross bite and the consequent development of facial asymmetryxvii.During adulthood, correction of the Class III malocclusion usually requires complex surgical procedures to achieve a good skeletal, dental and soft tissue relationship and improve the function and facial estheticsxviii.In this case, our objective were achieved. correct lower incisors were address by proclining them to the ideal position and inclination in pre-surgical orthodontic treatmentwhile in post-surgical orthodontic treatment teeth were brought into settledocclusion.Normal skeletal relationship was achieved byLe fort I osteotomyto advance the maxilla, Bilateral sagittal split osteotomy to correct mandibular asymmetry while maintaining the A-P position of the mandible and vertical reduction and advancementgenioplastyiiiiiiivvviviiviiiixxxi.xii.xiiixivxvxvixviixviii