Surgical correction of vertical maxillary excess: a re-evaluation

Surgical-orthodontic approach for correcting Vertical Maxillary Excess: Case report

This report describes a patient with Vertical Maxillary Excess without open bite in whom surgical orthodontic treatment to reduce lower facial height remarkably improved function and facial esthetics. The patient was a 22-year-old male whose main concern was crowding and temporomandibular joint clicking sounds. The clinical and radiological findings led to the diagnosis of Vertical Maxillary Excess with a mild skeletal class II malocclusion. The proposed treatment plan comprised a bimaxillary surgery without premolar extractions. LeFort I osteotomy was planned to reposition the maxilla superiorly by 7-8 mm. This surgery was combined with a bilateral sagittal split osteotomy for mandibular anterior derotation to adjust the mandible to the occlusal and anteroposterior change. Postoperatively, the mandibular plane angle (GoGn-SN) was decreased by 4° and skeletal class I was achieved (ANB, 4°). In addition, lip incompetence was corrected and the excessive gingiva exposure upon smiling was significantly improved. The patient was satisfied with the treatment result and reported the temporomandibular joint clicking sounds disappearing after surgery.

A Combined Orthodontic and Surgical Treatment Approach to Treat Vertically Diverse Skeletal Class II Malocclusions: A Case Series

Malocclusions in the vertical plane are more difficult to treat as compared to the malocclusions in the sagittal plane as they often require multidisciplinary (surgical) approach. Skeletal vertical deficiency and excess causes jaw discrepancies in the sagittal vector too due to rotation of the mandible, thus presenting a complex situation which requires astute treatment planning and implementation. In this article, two cases treated with combined orthodontics and orthognathic surgery to treat skeletal class II malocclusion with vertical deficiency and excess are shown and all details of treatment planning are discussed.

Impact of orthognathic surgery on the treatment of gummy smile: an integrative review

The gingival smile is considered unpleasant and can be treated in different ways according to its etiological factor. When caused by maxillary vertical growth excess, orthognathic surgery may be indicated to correct the vertical excess. The aim of this integrative review was to evaluate the impact of orthognathic surgery on the treatment of gingival smile. An electronic search was performed of the PubMed/Medline, Cochrane Library, Scopus, and Google Scholar databases. The selection of studies was performed by two blinded reviewers. Firstly, studies were selected by reading the titles and the abstracts of articles. The references from each study selected were then searched to find articles that were not found in the electronic search. After reading the full-text articles, studies that met the inclusion criteria were selected. A total of 667 studies were identified, but only 19 were selected for the integrative review after applying the inclusion and exclusion criteria. The selected articles reported maxillary impaction from 2 to 10 mm, but this amount of superior repositioning of maxilla does not appear to be related to the initial gingival exposure described. Orthognathic surgery is not the first choice of treatment for gingival smile, but it appears to be a suitable therapy for other conditions in the same patient for improving a gummy smile by correction of gingival exposure.

Posterior maxillary segmental osteotomy for prosthodontic rehabilitation of vertically excess maxilla -a review

PURPOSE

The purpose of this systematic review was to analyze the literature of the various surgical options available for the correction posterior maxillary alveolar ridge excess without going for radical approaches. It also analyzed the effectiveness of posterior maxillary segmental osteotomy in prosthetic rehabilitation in terms of stability, success rates, function, occlusion, aesthetics and long term postoperative complications.

STUDY SELECTION

A systematic search of Medline/Pubmed and Web of Science databases of English articles published till December 2017 for the treatment of vertical excess in the posterior maxilla for prosthetic reasons was performed. A total of 37 articles met the inclusion criteria.

RESULTS

Posterior maxillary segmental osteotomy (PMSO) was performed as a single stage procedure in 23 cases with minimal post- operative discomfort in all cases. The amount of superior positioning of the osteotomised maxilla ranged between 4 mm to 9 mm which provides sufficient space for prosthodontic rehabilitation.

CONCLUSIONS

PMSO is fairly competent in treating vertical ridge excess of posterior maxilla, makes space for prosthesis and is associated with fewer postoperative problems when a multidisciplinary team approach is put into service.

Maxillary single-jaw surgery combining Le Fort I and modified horseshoe osteotomies for the correction of maxillary excess

A modified technique of horseshoe osteotomy combined with Le Fort I osteotomy for superior and posterior repositioning of the maxilla is presented. Eight patients with maxillary excess associated with retrogenia or microgenia were treated with this technique in combination with genioplasty. The maxillary segment was repositioned a maximum of 5.0mm posteriorly and 7.0mm superiorly at point A. The mandible autorotated anterosuperiorly to achieve sound occlusion. Point B moved 2.0-10.0mm anteriorly and 5.0-10.0mm superiorly. The pogonion moved 7.0-17.0mm anteriorly in combination with genioplasty. All patients obtained sound occlusion and a good profile after the operation. Almost no skeletal relapse was observed during 1 year of postoperative follow-up. Patients with long faces with maxillary excess and retrogenia often have small, unstable condyles. In these cases, because surgical intervention to the ramus can result in postoperative progressive condylar resorption, maxillary single-jaw surgery with a horseshoe osteotomy, thereby avoiding ramus intervention, is a less invasive option.

Comparative evaluation of cephalometric occlusal characteristics between the long face pattern and pattern I

OBJECTIVE

To compare the cephalometric and intraoral characteristics between Long Face pattern and Pattern I patients, besides evaluating associations between subjective facial patterns, cephalometric facial patterns and the intraoral characteristics.

METHODS

Through evaluation of frontal and right side extraoral photographs, three previously calibrated and experienced examiners selected 30 Long Face patients (Group 1) and 30 Pattern I patients (Group 2), aged between 9 and 19 years, of both genders. The cephalometric characteristics were assessed by the following variables: SN.GoGn, NS.Gn, AIFH, SNA, SNB, ANB, 1.1, 1.NA,1-NA, 1.NB, 1-NB, NA.Po, nasolabial angle and H-Nose. Clinical evaluations were also performed to determine the presence of posterior crossbite, anterior open bite and type of Angle's malocclusion. The cephalometric data were compared by independent t test. The chi-square test was used to evaluate the association between qualitative variables.

RESULTS

Significant differences were observed between groups regarding the variables SN.GoGn, NS.Gn, AIFH, ANB, NA.Pog, 1-NA, 1.NB and 1-NB, with an increase of these measures in Group 1. There were also significant differences between groups on variable 1.1, being lower in Group 1 than in Group 2.

CONCLUSIONS

The Long Face was associated to Angle Class II malocclusion, to the presence of posterior crossbite and to anterior open bite. The Long Face subjective facial pattern was associated to dolichofacial cephalometric pattern.

Padrão facial na dentadura decídua: estudo epidemiológico

INTRODUÇÃO: é possível definir a morfologia facial e o padrão de crescimento em idade precoce, a partir da dentadura decídua completa. OBJETIVOS: frente à escassez de trabalhos na literatura pertinente ao assunto, a presente pesquisa explora o diagnóstico epidemiológico da face no estágio de dentadura decídua. METODOLOGIA: a amostra foi composta por 2.009 crianças de etnia brasileira, de ambos os gêneros, entre 3 e 6 anos de idade, no período de dentadura decídua completa, de 20 pré-escolas do município de Bauru/SP. RESULTADOS E CONCLUSÕES: baseando-se nos resultados obtidos no levantamento epidemiológico, foi encontrado - na análise em norma lateral - predomínio de crianças Padrão I (63,22%) em relação ao Padrão II (33,10%) e Padrão III (3,68%), não havendo diferenças estatisticamente significativas quanto ao gênero. Na análise em norma frontal, houve predomínio do tipo mesofacial (64,56%) em relação ao dolicofacial (21,90%) e braquifacial (13,54%), sendo que a proporção do tipo braquifacial nas meninas foi significativamente superior em relação aos meninos. Na distribuição dos tipos faciais frontais dentro dos padrões faciais sagitais ficou evidenciada uma manifestação mais freqüente do tipo dolicofacial dentro dos Padrões II e III, sendo encontrado dimorfismo quanto ao gênero, notadamente no Padrão I, onde houve maior manifestação do tipo braquifacial e menor manifestação do dolicofacial no gênero feminino.

Características cefalométricas do Padrão Face Longa: considerando o dimorfismo sexual

OBJETIVO: o presente estudo avaliou a hipótese de variação das características cefalométricas de acordo com o gênero para portadores de Padrão Face Longa. METODOLOGIA: foi analisado um total de 73 telerradiografias em norma lateral, sendo 34 Padrão Face Longa e 39 Padrão I (grupo controle), selecionadas com base na morfologia facial, sem considerar as relações oclusais. Foram avaliados: padrão de crescimento facial, alturas faciais anteriores e posterior, relação maxilomandibular, além das relações dentárias com suas bases apicais. RESULTADOS: o grupo controle (Padrão I) apresentou dimorfismo (p<0,001) no comprimento efetivo da maxila e da mandíbula, além das alturas faciais avaliadas. Foram significantes também (p<0,05) as proporções entre as alturas faciais e as distâncias entre os incisivos e molares em relação aos planos palatino e mandibular. Para os portadores de Padrão Face Longa, as mesmas variáveis cefalométricas não mostraram diferenças significantes entre os gêneros (p>0,05), exceto os comprimentos efetivos da maxila e da mandíbula, além da altura facial anterior inferior e posterior (p<0,05). CONCLUSÕES: concluiu-se que enquanto ocorreu dimorfismo nos indivíduos Padrão I, para as estruturas influenciadas pela diferença no tamanho esquelético entre os gêneros, isso não aconteceu nos portadores de Padrão Face Longa. Essa maior similaridade entre os gêneros provavelmente ocorreu porque a deformidade, mais grave no gênero feminino, foi suficiente para anular o menor tamanho esquelético esperado para estes indivíduos.

Proposta para classificação, segundo a severidade, dos indivíduos portadores de más oclusões do Padrão Face Longa

OBJETIVO: o presente estudo teve como objetivo propor um método para classificação, segundo a severidade, dos indivíduos Padrão Face Longa, avaliando sua confiabilidade e reprodutibilidade. METODOLOGIA: foram utilizadas fotografias faciais (frontal, perfil e frontal sorrindo) de 125 crianças Padrão Face Longa (54 do gênero feminino e 71 do gênero masculino), selecionadas apenas considerando-se a morfologia facial, com idades entre 10 anos e 6 meses e 15 anos e 2 meses. As fotografias foram avaliadas, separadamente, por três examinadores, sendo reavaliadas após três semanas, em uma nova disposição aleatória. Os indivíduos foram graduados em três subtipos, de acordo com a severidade: moderado, médio e severo. Para avaliar as concordâncias intra e interexaminadores, foi utilizada a estatística Kappa (k). RESULTADOS: na avaliação intra-examinador, todos os examinadores obtiveram concordâncias substanciais, com o valor de Kappa variando de 0,64 a 0,66, havendo em todos os examinadores 80% ou mais de concordância. Quando comparadas as avaliações interexaminadores, as freqüências de concordância diminuíram, variando de 67,2% a 70,4%. A partir dos valores de Kappa, que variaram de 0,41 a 0,46, a interpretação foi considerada moderada. CONCLUSÕES: com base nesses resultados, o método foi considerado aplicável, com necessidade de complemento de informações provenientes de outros exames rotineiramente aplicados em Ortodontia. A aplicação clínica será demonstrada com intuito de evidenciar os níveis diferentes de severidade das más oclusões do Padrão Face Longa e as características do protocolo de tratamento recomendado.

Características cefalométricas do padrão face longa

Este estudo determinou as características cefalométricas dos indivíduos portadores de Padrão Face Longa em comparação com indivíduos Padrão I. Um total de 73 telerradiografias em norma lateral, sendo 34 Padrão Face Longa e 39 Padrão I, foram selecionadas com base na morfologia facial, não considerando as relações oclusais e sagitais. Foram avaliados: padrão de crescimento facial, alturas faciais anteriores e posterior, relação maxilo-mandibular, além das relações dentárias com suas bases apicais. De uma forma geral, os indivíduos Padrão Face Longa apresentaram grandes desvios em relação aos indivíduos Padrão I, sendo a doença decorrente de um desequilíbrio entre os componentes verticais. Pôde-se observar que os valores das grandezas AFAT, AFAI, AFATperp, AFAIperp, 1-PP, 6-PP, 1-PM, SNB, ANB, ângulo goníaco, ângulo plano mandibular, além das proporções AFAI/AFAT e AFAIperp/AFATperp, estavam significantemente alterados para os indivíduos Padrão Face Longa. Com base nos resultados obtidos neste estudo, verificou-se que esses indivíduos caracterizavam-se pelo padrão de crescimento vertical e por um aumento da altura facial anterior inferior - conseqüentemente, da altura facial anterior total - estando a deformidade localizada abaixo do plano palatino. Foram observados ainda um retrognatismo maxilar e mandibular, além da presença de extrusão dentária anterior (superior e inferior) e póstero-superior, com os incisivos superiores bem posicionados em suas bases e os inferiores lingualizados.

Skeletal stability following maxillary impaction and mandibular advancement

The purpose of this study was to retrospectively evaluate the stability of combined Le Fort I maxillary impaction and mandibular advancement performed for the correction of skeletal Class II malocclusion. Twenty-nine patients, mean age 22.6 years, underwent bimaxillary surgery with rigid internal fixation. Standardised cephalometric analyses were performed using serial lateral cephalometric radiographs. The post-surgical follow-up was a minimum of 12 months, with a mean of 25.2 months. The maxilla was impacted by a mean of 4.3 +/- 3.3 mm, and horizontally advanced by a mean of 2.6 +/- 2.3 mm. The results demonstrated that the maxilla tended to move anteriorly and inferiorly but this was not significant in either horizontal or vertical planes (P > 0.05). The mean advancement of the mandible, at menton, was 10.7 +/- 5.6 mm, and in 14 cases (48.2%) menton was advanced greater than 10 mm. In 34.7% of the patients the mandible underwent posterior movement between 2 and 4 mm. In the vertical plane, gonion moved superiorly by a mean of 2.7 +/- 3.6 mm which was significant. Significant mandibular relapse was found to have occurred in five female patients, with high mandibular plane angles who had undergone large advancements of greater than 10 mm. In conclusion, the majority of patients undergoing bimaxillary surgery for the correction of skeletal Class II malocclusions maintained a stable result. However, a small number of patients, exhibiting similar characteristics, suffered significant skeletal relapse in the mandible secondary to condylar remodelling and/or resorption.

Stability of the Le Fort I maxillary osteotomy after rigid internal fixation

PURPOSE

The purpose of this study was to evaluate the postsurgical stability of the Le Fort I osteotomy with impaction in which rigid internal fixation was used for stabilization.

MATERIALS AND METHODS

Lateral cephalograms of 19 patients were evaluated. Descriptive statistics were compiled that included absolute linear and angular measurements as well as absolute changes in measurements for successive cephalometric radiographs. Comparisons were made from 1) presurgery to immediate postsurgery, 2) immediate postsurgery to splint removal, 3) splint removal to longest follow-up, and 4) immediate postsurgery to longest follow-up. Repeated measures analysis of variance were used to describe significant differences for absolute changes in measurements.

RESULTS

All surgical movements were significant except for horizontal position of dental structures, horizontal position of the posterior mandible, and posterior vertical facial height. All significant movement from immediate postsurgery to splint removal was secondary to removal of the occlusal splint. Changes were minimal from splint removal to longest follow-up, with only 3 of 24 measurements showing statistically significant differences. These measurements related to tooth position and were affected by postsurgical orthodontics. The data derived from this study were also compared with those found in similar studies in which fixation was by wire osteosynthesis.

CONCLUSIONS

The magnitude of postoperative movement was considerably less with rigid internal fixation than that reported with the use of wire fixation. This is attributed to the increased stabilizing effect of rigid internal fixation.

The stability of facial osteotomies. Part 5. Maxillary advancement with miniplate and screw fixation

Surgical repositioning of the dento-skeletal components of the middle-third of the face, combined with appropriate orthodontic treatment, can be used to improve function and aesthetics. However, the attainment of three-dimensional stability following corrective jaw surgery continues to be a major problem in the postsurgical period. This paper examines the short-term (six weeks postoperative) and long-term (12 months postoperative) horizontal skeletal stability of Le Fort I maxillary advancement in 15 patients. The mean horizontal advancement of the maxilla was 8.76 +/- 0.99 mm. Six weeks later, a mean relapse of 0.22 +/- 0.19 mm was identified. The mean relapse at long-term follow-up was 0.61 +/- 0.26 mm (6.96%). These results indicate that rigid miniplate and screw fixation of Le Fort I osteotomy undertaken to correct horizontal mid-dentofacial deficiency is both statistically and surgically predictable and stable when reviewed up to twelve months after surgery.

Planning and control of vertical dimension in Le Fort I osteotomies

Depending on the different anatomy of the soft and hard tissues, concavity or convexity of the face, measurements of inferior or superior repositioning of the maxilla may be less predictable when using only the osteotomy site for this calculation. A more reliable method would be to measure the distance from a bone mark in the forehead to the incisor edges. This method has been practiced by our clinic during the past five years. The method is thought to offer a more accurate estimation of the position of the upper anterior teeth in relation to the lip, although one must anticipate a certain degree of postoperative relapse especially concerning inferior repositioning. In order to evaluate the accuracy of our method, a comparison has been made of the calculated vertical repositioning and the surgical results in two groups. In group I (12 individuals) conventional estimation of maxillary repositioning in the osteotomy line was made; in group II (12 individuals) measurements were made from a bone mark on the forehead to the incisor edges. A satisfying correlation was found between calculated and achieved results in both groups. In comparison between calculated and immediate postoperative measurements the results showed no statistically significant difference between the two methods.

Maxillary osteotomies without postoperative intermaxillary fixation (anterior, superior and inferior repositioning of entire maxilla). A clinical and cephalometric study

Surgical correction of maxillary anomalies with anterior-superior or anterior-inferior repositioning of the segment was performed in 50 patients. The maxillary segment was stabilized by means of steel wires as horizontal mattress sutures, which, in all cases, gave very good primary stability. In case of insufficient bone contact miniplates were used. Postoperatively no rigid intermaxillary fixation (IMF) was applied. There are several advantages to not using intermaxillary fixation: 1) It is possible to carry out immediate postoperative inspection of the location of the condyles and thereby confirm that the segments are in the expected position. 2) Segment fixation is not disturbed by mandibular movements during recovery from general anaesthesia. 3) Manipulations by the anaesthesiologist immediately after surgery are not interfered with. 4) For the patient there is better postoperative comfort with no breathing, talking or feeding problems. 5) Minor corrections of intercuspation by means of orthodontic elastics are possible. These can act in the required direction and will not disturb the masticatory function. Masticatory function was resumed immediately after surgery and was usually normalized within 2-3 weeks. Cephalometric analysis revealed no significant relapse subsequent to surgery. Thus we conclude that omitting IMF, among other advantages, enhances patient comfort and has no negative effect on the postoperative stability of the maxilla.

Stability of simultaneous maxillary intrusion and mandibular advancement: a comparison of rigid and nonrigid fixation techniques

This study examines the short-term stability of bimaxillary surgery following Le Fort I impaction with simultaneous bilateral sagittal split osteotomies and mandibular advancement using two standard techniques of postsurgical fixation. Fifteen adults had skeletal plus dental maxillomandibular fixation, and fifteen adults had rigid internal fixation using bone plates in the maxilla and bicortical bone screws between the proximal and distal segments in the mandible. The group with rigid internal fixation did not undergo maxillomandibular fixation. Radiographic cephalograms were analyzed during the postsurgical period to evaluate skeletal and dental stability. There was no statistical difference in postsurgical stability with rigid internal fixation or skeletal plus dental maxillomandibular fixation other than the vertical position of the maxillary molar; the skeletal plus dental maxillomandibular fixation group had a significant amount of postsurgical intrusion of the maxillary molar when compared with the rigid internal fixation group. Although the other measures showed no statistically significant difference between the experimental groups, the amount of variability in postsurgical stability in the group with skeletal plus dental maxillomandibular fixation was greater than that found in the group with rigid internal fixation.

Refined intraoperative repositioning of the osteotomized maxilla in relation to the skull and TMJ

In dysgnathic patients, who have to be treated by surgical repositioning of the jaws, the necessary bone movements are predicted preoperatively with the help of sophisticated analysis. A high degree of accuracy, could not however be transferred to the patient, because of lack of an operative procedure as accurate as the preplanning. In this paper a face-bow is described, provided with an interocclusal splint that has been adjusted beforehand on an articulator, in a model operation taking into account the skull and TMJ relationship. Using this face-bow-splint combination the possibility of greater accuracy in transferring the preplanned movements to the patient is facilitated. The computerized preplanning, the model operation and the technical procedure as well as the operation itself are described, step by step.

The stability of Le Fort I advancement osteotomies using bone plates without bone grafts

The stability of Le Fort I advancement osteotomies using 4 "Champy" stainless steel mini plates without bone grafts was studied. Eleven consecutive patients, 3 of whom had cleft lips and palates were evaluated retrospectively. Seven patients had bimaxillary procedures. Cephalometric radiographs were taken preoperatively, immediately after operation and at least six months later. The mean maxillary advancement in the horizontal direction was 3.7 mm. The radiographs were traced and the results were subjected to a statistical analysis. No significant relapse was found.

Rigid fixation of maxillary osteotomies: a preliminary report and technique article

The authors review their experiences with seventy cases of maxillary osteotomy rigidly stabilized with bone plates and minimal or no maxillomandibular fixation. The surgical technique, which allows consistent placement of plates in dense bone without endangering root apices, is described in detail. Orthodontic management has been started as early as 3 weeks postoperatively. A disadvantage of small plates is the possible need for their removal, which requires a second surgical procedure. Plates have been removed or replaced in five patients in this series.

Morphologic analysis of upper lip area following maxillary osteotomy via the tunneling approach

Preservation of favorable upper lip morphology is a critical factor in assessing the success of maxillary osteotomy surgery. Unesthetic postsurgical lips often appear thin and tight, with the vermilion border shortened and rolled inward. Clinical observation of patients who had undergone total maxillary alveolar process osteotomies by means of vertical buccal incisions and a tunneling approach suggests that presurgical lip morphology is minimally changed. This study investigates the presence and degree of change in upper lip morphology following this technique. Pre- and postoperative cephalometric radiographs of ten patients were compared by superimposition of acetate tracings on cranial base landmarks. Cross-sectional lip area was calculated by compensating polar planimetry presurgically and at four intervals following intervention: 1 to 3 days, 1 to 3.5 months, 6 to 9 months, and more than 10 months. Analysis showed the cross-sectional upper lip area, compared to the presurgical baseline, to be as follows: Immediately following surgery, the area increased by a mean of 27.8% (range, 15.0% to 36.9%; SE = 4.72). At 1 to 3.5 months postsurgery, the increase was reduced to 3.3% (range, 0 to 7.7%; SE = 0.82). At 6 to 9 months, lip area remained minimally increased, at + 0.78% (range, -5.0% to 7.6%; SE = 1.68). At 10 months or longer, the mean increase from preoperative values was 0.61% (range, -6% to 6.4%; SE = 1.38). The results of this study indicate that the upper lip cross-sectional area returns to its presurgical value at 6 months following surgery and remains constant at subsequent measurements. The performance of maxillary surgery with this flap design appears to preserve presurgical lip morphology.