CLINICAL Management of Vertical Maxillary Excess In An
Adult Patient By Combined Orthodontics and
Orthognathic Surgery - A Case Report
Author's Name
Dr. K. S. Senthil Kumar, MDS,
Associa te Professor, Departm ent of Orthodontics
Dr, Deepika MDS,
Lecturer, Department of Orthodontics.
Dr. Triveni, MDS, DIBO
Associate Professor, Departm ent of Orthodontics
Dr. P. Jayakumar MDS,
Principal and HO D, D epartm ent of Orthodontics.
M ee nakshi Ammal Dental College
Chennai
Diagnosis and treatm ent planning has been criti ca l for a the results are sa ti sfactory o nly if th e facial esth etics and
vertica l problem . The transition is now what is ca lled teeth relationship are acceptable' . Today th e concept of
parad igm shift in whi ch th e primary goa l is th e best correcting th e occlu sal relationships of th e teeth alone is
possible adaptation and proporti onality of soft ti ssue of not an adequate descripti on of successfu l treatment.
th e face and mouth ', Today th ere sho uld be no regard Occlu sion is important but comparable facial esthetics
for a camouOage treatment protocol for a skeletal accompanying the fun cti onal goa ls is equally significant.
problem especially in cases of long face syndromes. In
th is si tu ation orth ognathi c surge ries are required to
complete th e treatment goals and accomplish th e Case report
trea tment outcome desired by the pati ent. Though
awa re of th e consequences, we do end up trea ting Here we present a case trea ted fo r the dental pro blem
compromised based on ca mouflage options for skeletal and not happy with the treatment outcome. M S aged
cases and the cost is pati ent dissa tisfaction. 23years reported to th e departm ent w ith the chief
complai nt of gummy smile and impaired function on
In an ad ult pati ent w ith no growth remaining w ith a jaw chewing. Patient had undergone orthodontic trea tm ent
discrepancy, th e only possibility of o rth odontic seven years back invol ving th e extracti on of four fi rst
trea tment alone is camou fl age by displacement of teeth premolars. Her 36 wa s extracted same tim e due to gross
relati ve to jaw bases. The resulting dental compensa ti on decay. Pati ent was very conscious about th e gummy
may produce reasonably norm al dental occlusion but smile and unhappy w ith th e orth odontic results.
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Extra oral examination Intra oral examination
Good oral hygiene with norm al soft tissue featu res.
Dolicocephalic head pattern and leptoprosopic facial
fo rm . f rontal exa mination displayed a symmetri cal face
wi th lip incompetence and th e interl abial gap was 8 7 65 - 321 1 23- 56 7 8
measured to be 6mm . The fronta l extraoral photographs
have been taken with lips cl osed forcibly. The actu al
extent of gummy smile is very evident in th e mid 8 7 65 -3 21 1 2 3 -5-78
treatm ent photographs. Ca re is to be taken such th at th e
pa tient is in rest posi tion w hile th e frontal photograph is
taken. The lower facial height was increased. Profil e
Generalized nuorosis of the teeth was observed.
read ing showed a convex profil e w ith posteri or
M axillary and mandibular arch were U shaped and
divergence, deep mentolabial sulcus, and inadequate
symmetri cal, distopalatal rotati on of 12, 13 and
chin and increased cl inica l fMA. At rest about 6mm of
extru sion of 26. Mild spacing in the lower anterior area
the incisors are exposed and on smi le, complete incisors
w ith distolingual rotation of 43 and mesially ti pped 37.
w ith 7mm of gingival exposure were record ed.
The lower midline is shifted to the left by 2mm . the
overbite. Overj et is 4mm with Class II incisor
relationship. O n th e ri ght bucca l aspect, canine is class II
by 3mm and molar is cl ass II by 3mm . left side, lower first
molar is missing and second molar is tipped mesially,
canines shown an end on relati onship and there is
overh anging of palata l cusp of upper first molar.
Composite Cephalometric analysis
Elucidates a class II skeletal base w ith orthognathic maxilla, retrognathic mandible, increased mandibu lar plane angle and
associated vertical maxillary excess and increased lower facial height. Dentoa lveolar analysis indicates retrocli ned upper
incisors and norm al lower incisor incl inati on. Soft ti ssue analysis indica tes lip strain and protrusive lower lip.
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Diagnosis Rationale for the devised treatment plan
Dentoalveolar Class lion a Class II skeletal base wi th Since th e patient had undergone previous extraction,
orthognathic maxilla, retrognathic mandible, vertical there was no scope and need for furth er therapeutiC
maxillary excess with increased mandibular plane angle. extra ction. The chief complaint of the patient wa s lip
competence, gummy smile and difficulty in chewing
due to occlusal derangement. The patient was treated
Problem li st by extraction of al l first premolars, a camouflage
treatment plan for a skeletal probl em. Su rgi cal
Gummy smile, increased overjet, class II molar and Treatment Objective (STO) was drawn for the patient.
canine relationship, deviated midlines, mesially tipped Various probabilities for th e patient were drawn and the
37, occl usa l mutilation on the left side and increased best treatm ent opti on was selected. Lefort I impaction
lower anteri orfa cial height. of Smm and set back of 3mm with advancement
genioplasty showed best results and therefore were
considered with high priority for the final trea tment
Treatment objectives plan . Prosth eti c repl acement of 36 was considered to
achieve cla ss I molar relationship on the left side.
Correction of overjet, uprighting of 37, correction of
rotated teeth, achieve class I molar and ca nine
relationship, correcti on of midlines, achieve functional
occlusion and improvement of the soft ti ssue profi le and
improvement in the smile line.
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fabl e I Cephalometric composite analysis
VARIABLE PRETREATMENT NORMAL
Sagittal Skeletal Relationship:
SNA 80° 82°
SNB 72° 80°
ANB 8° 2°
Wits appraisal AO ahead of 80 by 4mm . O mm
Dental Base Relationship:
Upper incisor to NA ( mm/deg) 18°; 3.5 mm 22°; 4 mm
Lower Incisor to NB (mm/deg) 35°; 10 mm 25°; 4mm
Upper Incisor to SN Plane 9r 102°
Lower incisor to mandibular plane angle (lMPA) 92° 90°
Dental Relationship:
Inter- incisal angle 121° 13 1°
Lower incisor to APo line 5 mm 0-2 mm
Over bite 3 mm 2-4 mm
Overjet 4 mm 2-4 mm
Vertical Skeletal Relationships:
Maxillary - mandibular planes angle 40° 25°
SN Plane - Mand Plane 41 ° 32°
Upper anterior face height 55 mm 47.6 -52.4mm
Lower anterior face height 72 mm 57.6-65.0 mm
Face height ratio 42 : 58 % 45: 55 %
Jarabak Ratio 55 .73% 62 - 65 %
Maxillary Length 90mm 93.6 ±3.2 mm
Mandibular Length - effective (McNamara) 108 mm 121 .6 ± 4.5 mm
Soft Tissues:
Lower lip to Ricketts E Plane 3 mm -2 mm
Nasolabial Angle 103° 90° - 11 0°.
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lir1 "':
Treatment progress
The case was started with preadjusted edgewise appliance, 022 slot Roth prescripti on. After the bond up 016 NiTi wires
were placed for ali gnment. After the completion of initial alignment, 17 X 25 NiTi wires were placed in both th e upper and
lower arch for two months. The upper archw ire was changed to 19X25 55. In th e lower arch 01855 w ire with open coil
spring was placed to upright 37. Within a period of three months both the upper and lower arch were on 19X25 55. The
wires were in place for two months followi ng, which face bow transfer on SAM III articu lator was done and surgica l splints
for the impaction and se t back were fabri ca ted. At thi s point Lefort I Osteotomy with 5mm impaction and 3mm setback
along with advancement Gen ioplasty was done. The pati ent was put on settling elasti cs post surgical. After two months of
su rgery, banding of 17,27 and 47 were completed and 17X25 NiTi was placed . Following the leveling and aligning of
second molars, 19X25SS and later 21 X25 55 were placed to express the preprogramming of the prescription. The
appliance was debanded after two months once the torqu e achieved was sa tisfactory and prosth eti c rep lacement of 36
was completed. Begg wra p arou nd retainers were provided in th e upper arch and nexible spiral retain er was placed in
lower arch.
Surgical Treatment Objective Face Bow Transfer
u
+
I
Set back of 3mm with Lefort I impaction of 5mm Face bow transfer was done and models were
was done with adva ncement genioplasty mounted on SAM li t articu lator and splin ts fabrica ted
for th e surgery
II
lir ~
MID TREATMENT PHOTOGRAPHS
Pre surgica l photographs - the increased incisor show at rest and increased
gingival display on smile is evident in th ese photographs.
Treatm ent results
The total treatment durati on was of 15 months with 7 mo nths of presurgica l trea tment followed by su rgery and 8 month, of
post surgical management. The trea tm ent results were idea l smile line with ideal incisa l exposu re during rest and 2mm of
gingiva l display during smile. Lip strain was eliminated and competence achieved. Profile of the patient is improved. Class 1
molar and canine established on both sides. Midlines are coincident. Idea l over jet and overbite established. Group
function is established for harmonious occlusion. Th e occlusion requires more settling on th e ri ght side. Th e relationship of
the lower lip to th e esth etic plane is also improved.
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Table II Comparison of pre and post treatment occlusal details
Occl usal features Post treatment Pretreatment
Incisor relationship Class I Class II
Overj et 2mm 4mm
Overbite 2mm 2mm
Centrelines Coinci dent Lower midline shifted to th e
left by 2mm
Left buccal segment relationship Class I molar and canine Canines end on, overh anging
palatal cusp 26
Right buccal segment relationship Class I molar and canine Canines class II by 3mm,
molar class II by 3mm, mesial
tipped and supra erupted 37
Cross bite Nil N il
Displacements Nil Distally displaced 35
Functional occl usa l features Group function No canine guidance or
group function
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Post treatment photographs - intra oral and extra o ral
Post trea tment cephalogram and OPC
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Table III Cephalometric comparison of presurgical and post surgical
VARIABLE PRESURGICAL POSTSURGICAL
Sagittal Skeletal Relationship:
SNA
SNB
ANB
Wits appraisal AO ahead of BO by 3mm AO ahead of BO by 2 mm
(0
Dental Base Relationship:
Upper incisor to NA ( mm/deg) 3.5 mm; 20' ~i,~-)
Lower Incisor to NB (mm/deg) 8 mm; 40' .,J ~-) 6mm; 35'
Upper Incisor to SN Plane 98' (I \Jv')
Lower incisor to mandibular plane angle (lMPA) 96' '''10)
Dental Relationship:
Inter- incisal angle 117 1! 11 7'
Lower incisor to APo line 5mm D-}"'- 4mm
Over bite 2 mm ~,~- 2 mm
Overjet 4mm l''1~ 2 mm
Vertical Skeletal Relationships:
Maxillary - mandibular planes angle ;. <;" 35'
,
SN Plane - Mand Plane !.,1.- 37'
Upper anterior face height 56mm (~7,5-" ) 52 mm
,~, ·/,fl 71 mm
Lower anterior face height 74 mm
Face height ratio 42:58 4f~ 44:5 6
Jarabak Ratio 54% G'l-'~S 59%
Maxillary Length 90mm "13 ~.? 87 mm
Mandibular Length - effective (McNamara) 110 mm /)\,';'1 113 mm
Soft Tissues:
Lower lip to Ricketts E Plane r - iJ -2 mm
Nasolabial Angle Clb-n~ 11 0'
15
Superimposition pure orthodontics would not suffice to reach the
treatm ent goals, th erefore a combi ned orthodontic -
orthognathic procedure was planned . Superior
positioning of th e maxilla was done, as the maxilla
moves up the mandible rotates around the horizontal
condylar axis to move up with it. The chin thus moves
upward and forward . Indirectly maxillary procedure
repositions the mandible.
In patients w hose facial height should be reduced,
maxillary procedure is the primary procedure. The
maxilla is the focus of surgical treatment in a long face for
two reasons. First, the maxi lla has nearl y always the
verti cal over development w hen compared to the
mandible. The mandible rotates in secondary response
to th e increased posterior vertical height of the maxilla .
Black - pre treatment Normal jaw function, lip function, or good esthetics
Blue - pre surgica l cannot be achieved w ithout correcting the maxi llary
Red - post surgical deformi ty and the second reason of maxillary focus
Comparative evaluation being that moving the maxilla up produce a stable
surgical correction2. In thi s parti cular case, the superior
repositioning of th e maxi lla provided autorotation
,\NB angle is reduced wi th decreased lower facial height which improved th e profile and further an advancement
3nd decrease in the basal plane angle. Facial axis and genioplasty produced a desirable result preventing the
lacia l plane angle is increased w ith increase in antero requirement of an extensive bi jaw surgical procedure.
Josteri or w idth of the chin . There is improvement in th e O cclusal derangement of the left side was corrected by
Josition of the upper and lower lip. Ideal overj et and uprighting 37 and space was created for the
overbite was established . replacement of 36, thus providing a good occlusal table
for th e patient. The primary complaints of the patient
are addressed and the fun ctional and esthetic goals have
Discussion been achieved. Today it is im portant to recognize and
f a jaw relationship is correct, crowd ed and malaligned und ersta nd the pote nt ials and lim itations of
eelh can be corrected by pure O rthodontics. However orthodontics to achieve good esth etics, occlusion and
here are limits to how far a tooth can be moved and long term stability.
hese limits become important w hen the problem is
,keletal and the patient need and priorities cannot be
,atisfied with tooth movement alone. Bibliography
'or adult patients w ith jaw discrepancy and no prospect 1. Orthodontics: Current pri nciples and Techn iques,
·or successful growth modificati on there is no alternative Thomas M . Graber, Robert L. Vanarsdall, Fourth edition,
o surgery and this is emphasized through this case Elsevier Mosby, 2005
·eport where in the patient has undergone orthodontic 2. Surgical O rthodontic treatment, W illiam R. Proffit,
:orrection earlier but unhappy about facial esth etics and Raymond P. White, 3rd edition, Mosby 1991
s very conscious about the uncorrected gummy smile. There is another articl e following this w ith review of
.ip incompetence with increased incisal show and 'Diagnosis and treatm ent planning of excessive gingival
ncreased gingival display on smile is related to th e display- a review'
'ertical maxillary excess, which is the primary concern of
he pati ent. Occlusal derangement on the left side was Communication Address;
:ause of distress to the patient. Cephalometric values Dr. Senthil Kumar
uggest the verti cal maxillary excess and mandibu lar Meenakshi Ammal Dental College,
elrognathism. There was also an increase in th e overj et Alapakkam Main Road, M aduravoyal,
vi lh loss of torque of th e upper anteriors, which is one of Chennai 600 095, Tamilnadu state
he manifestations of a dental compensation of a skeletal Ph . No. 9444048507
liscrepancy. Considering th e prioriti es of the patient, Senth27@[Link]
drmdeepika@[Link]. in
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