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CLINICAL DENTISTRY AND RESEARCH 2014; 38(3): 29-36 Case Report

CorrespondenceEzgi Atik, DDS

Department of Orthodontics,

Faculty of Dentistry, Hacettepe University,

Sıhhiye, 06100, Ankara, Turkey

Phone: +90 312 3052290

Fax: +90 312 3091138

Email: ezgibaytorun@hotmail.com

Ezgi Atik, DDS Research assistant, Department of Orthodontics,

Faculty of Dentistry, Hacettepe University,

Ankara, Turkey

İlken Kocadereli, DDS, PhDProfessor, Department of Orthodontics, Faculty of Dentistry,

Hacettepe University,

Ankara, Turkey

Ersoy Konas, MDInstructor, Department of Plastic, Reconstructive and

Aesthetic Surgery, Faculty of Medicine, Hacettepe University,

Ankara, Turkey

Mehmet Emin Mavili, MDProfessor and Head, Department of Plastic, Reconstructive and

Aesthetic Surgery, Faculty of Medicine, Hacettepe University,

Ankara, Turkey

DRAMATIC PROFILE CHANGE OF A SEVERE CLASS III ADULT PATIENT WITH RED I AND 1 YEAR-4 MONTH FOLLOW-UP: A CASE

REPORT

ABSTRACT

The objective of this case report is to evaluate the effects of

maxillary distraction osteogenesis in an adult patient with

maxillary deficiency by using a rigid external distraction device.

A 25,6 year old adult male patient referred to our clinic with a

chief complaint of poor esthetic facial appearance and functional

insufficiency. He showed maxillary hypoplasia, mesofacial growth

pattern and negative overjet. As the presurgical orthodontic

therapy was completed, the distraction was performed at the

rate of 1mm/day until required advancement was gained. After

DO nearly 13.9 mm advancement was achieved. SNA increased

from 78.1° to 92°. The vertical position of the mandible and

the face was kept stable, and the soft tissue profile became

more balanced. Maxillary rigid external distraction improved the

soft tissue profile by increasing nasal projection, normalizing

the nasolabial angle, and making the upper lip more prominent.

Occlusion and facial profile changes was found to be stable in 1

year-4 month follow-up.

Keywords: Class 3, Maxillary Deficiency, Rigid External

Distraction

Submitted for Publication: 07.08.2013

Accepted for Publication : 09.26.2014

CLINICAL DENTISTRY AND RESEARCH 2014; 38(3): 29-36 Olgu Bildirimi

Sorumlu Yazar Ezgi Atik

Hacettepe Üniversitesi,

Diş Hekimliği Fakültesi, Ortodonti Anabilim Dalı

Sıhhiye 06100 Ankara, Türkiye

Telefon: +90 312 3052290

Faks: +90 312 3091138

E-mail: ezgibaytorun@hotmail.com

Ezgi AtikAraş.Gör., Hacettepe Üniversitesi,

Diş Hekimliği Fakültesi, Ortodonti Anabilim Dalı,

Ankara, Türkiye

İlken KocadereliProf. Dr., Hacettepe Üniversitesi,

Diş Hekimliği Fakültesi, Ortodonti Anabilim Dalı,

Ankara, Türkiye

Ersoy KonaşDoç. Dr., Hacettepe Üniversitesi,Tıp Fakültesi,

Estetik, Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı,

Ankara, Türkiye

Mehmet Emin MaviliProf. Dr., Hacettepe Üniversitesi, Tıp Fakültesi,

Estetik, Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı,

Ankara, Türkiye

ŞİDDETLİ SINIF III ERİŞKİN HASTANIN RED I İLE DRAMATİK PROFİL DEĞİŞİKLİĞİ VE 1YIL 4 AY SONRAKİ TAKİBİ:

VAKA RAPORU

ÖZET

Bu vaka raporunun amacı maksiller yetersizliğe sahip erişkin bir

hastada rijit eksternal distraktör kullanılarak maksiller distraksiyon

osteogenezisin etkilerini değerlendirmektir. 25 yıl 6 ay yaşında

erişkin erkek hasta kliniğe zayıf estetik görünüm ve fonksiyonel

yetersizlik şikayetleriyle başvurmuştur. Hasta maksiller hipoplazi,

mezofasiyal büyüme paterni ve negatif overjet özellikleri

göstermekteydi. Cerrahi öncesi ortodontik tedavi tamamlanınca,

istenilen ilerletme elde edilene kadar günde 1mm olacak şekilde

distraksiyon işlemi uygulandı. Distraksiyon sonrası yaklaşık

13.9 mm ilerletme elde edildi. SNA açısı 78.1°’den 92°’ye

yükseldi. Mandibulanın ve yüzün vertikal pozisyonu stabil kaldı,

ve yumuşak doku profili daha dengeli hale geldi. Maksiller rijit

eksternal distraksiyon, nazal projeksiyonu arttırarak, nazolabiyal

açıyı normal hale getirerek ve üst dudağı daha belirgin hale

getirerek yumuşak doku profilini düzeltti. Okluzyon ve fasiyal

profil değişiklikleri 1 yıl 4 ay sonraki takipte stabil bulundu.

Anahtar Kelimeler: Sınıf III, Maksiller Yetersizlik, Rijit

Eksternal Distraksiyon

Yayın Başvuru Tarihi : 08.07.2013

Yayına Kabul Tarihi : 26.09.2014

30

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TREATMENT OF A CLASS III ADULT PATIENT WITH RED I

INTRODUCTION

Maxillary retrusion can be defined as deficiency of maxillary development. This deficiency can comprise development in transverse, vertical and sagittal planes. Sagittal deficiencies are correlated with soft tissue alterations such as retrusive upper lip, decreased nasolabial angle and concave profile. Sagittal skeletal deficiencies of the maxilla lead to functional problems such as difficulties in respiration and nutrition in addition to esthetic problems and frequently requires surgical treatment.1,2 Conventional surgical treatment of severe maxillary hypoplasia is limited because of soft tissue limitations, long operation time, bleeding, need of bone graft and infection risk. In this situation rigid external distraction (RED) is another treatment alternative.3

Distraction osteogenesis a biologic process of new bone formation between the surfaces of bony segment that are gradually separated by incremental traction. As a result of the gradual displacement of surgically created bony fractures, increased amounts of bone and soft tissue are created.4

The purpose of this case report is to present maxillary advancement with the use of RED of a severe skeletal Class III adult patient.

CASE REPORT

A 25.6 year old adult male patient referred to our clinic with a chief complaint of poor esthetic facial appearance and functional insufficiency (Figure1). His medical history showed nothing remarkable. He did not report any habit and the etiology of the malocclusion was presumed to be developmental. Extraoral examination showed symmetric face, normal lower facial height (LFH: 46.10), severe concave profile with midfacial hypoplasia. The patient exhibited an Angle Class III malocclusion with circular cross-bite between the upper second molars (Figure1). Maxillary left second premolar and mandibular right first molar were extracted because of profound caries. The lower incisors had root treatment due to the cystic lesion about 6 years ago. Maxillary midline was deviated to the left side comparing with the facial midline. The cephalometric analysis showed a severe skeletal Class III relationship (ANB: -9.10) because of maxillary deficiency (SNA: 78.10, maxillary depth: 87.20) and mandibular protrusion (SNB: 87.20) (Figure 2, Table 1). An anterior cross-bite of –13 mm was observed and the occlusion was Angle Class III malocclusion on both sides (Figure 1).

Figure 1. Pre-treatment extra oral and intra oral photographs of the patient

Figure 2. Pre-treatment radiographs

The treatment objectives were to correct the concave facial appearance, establish ideal overjet and overbite and achieve an acceptable functional occlusion. A detailed analysis revealed that the patient required a linear advancement of 16 mm. The treatment plan included maxillary advancement through the use of distraction osteogenesis after orthodontic treatment. RED was chosen because more than 10 mm of advancement was needed. After maxillary distraction osteogenesis (DO) we planned to perform maxillary orthognathic surgery because of the deviation of the maxillary midline. The patient was thoroughly informed about the distraction protocol before the procedure. The orthodontic treatment was initiated with a quad-helix appliance to expand the upper arch. Before bonding the

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CLINICAL DENTISTRY AND RESEARCH

upper teeth, the maxillary left canine was extracted because of periodontal problems. Before distraction, the arches were leveled and aligned with fixed orthodontic appliances (Figure 3). After leveling and aligning of the arches, an intraoral appliance was fabricated from commercially orthodontic headgear facebow with a long external outer bow and an inner bow. As the presurgical orthodontic treatment was completed, the patient underwent a conventional Le Fort I osteotomy under general anesthesia. After a latency period of 5 days, distraction was performed at the rate of 1mm/day until required advancement was gained (Figure 4). The RED system was removed at the end of 8 weeks of consolidation. All surgical procedures were performed in the Department of Plastic and Reconstructive Surgery at Hacettepe University Hospital. After RED protocol was completed, interdigitation of the posterior teeth was obtained by means of 6-ounce elastics. After the postsurgical orthodontic therapy was completed, the appliances were removed and fixed retainers were placed. The patient was referred for prosthetic treatment after orthodontic treatment. There were not any complications and the patient was seen for follow up period of 1 year-4 month post distraction.

RESULTS

After distraction osteogenesis, the patient achieved acceptable occlusion and dramatic facial profile improvement (Figure 5). The maxillary midline was still deviated to the left side at the end of the treatment because the patient refused another maxillary surgery. The pretreatment, postdistraction, postretention angular and linear cephalometric measurements are given in Table 1. The superimposition of pre- and post-treatment cephalometric radiographs is shown in Figure 6. The nasolabial angle was increased from 106.3° to 117.3° (Figure 7). The average predistraction SNA angle was 78.1° and the postdistraction SNA angle was 92°, for an average increase of 13.9°. The average predistraction ANB angle was -9.1° and postdistraction was 4°, with an increase of 13.1°. The skeletal convexity increased by 13 mm. Maxillary depth angle increased by 12.8°. The change in the angle of the upper incisors to the Frankfurt Horizontal plane averaged -7.5° and the angle of the lower incisors to the APo plane averaged -10.6°. Lower facial height decreased from 46.1° to 42.3° with a decrease of 3.8°. MP-FH, GoGnSn and Go angles were decreased by respectively 3.7°, 3.4° and 6.9°. Palatal plane inclination relative to SN plane was reduced

Figure 3. Pre-surgical extra oral and intra oral photographs of the patient.

Figure 4. Extra oral photograph of the patient during distraction protocol

Figure 5. Post-treatment extra oral and intra oral photographs of the patient

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TREATMENT OF A CLASS III ADULT PATIENT WITH RED I

from 9.7° to 6.4° with a decrease of 3.3°. Cephalometric evaluation at 12 week after distraction showed maxillary advancement of 13.9 mm at point A relative to the SN plane and its perpendicular. Anterior and posterior nasal spine was moved 2 mm upward relative to the FH plane

and 16 mm forward relative to the PTV plane. Overjet and overbite were increased by respectively 15.9 and 8.8 mm. The 1 year and 4 month post-treatment occlusion and facial profile were stable (Figure 8). Comparison of the final and post-treatment cephalograms showed minimal changes in the skeletal pattern (Figure 9 and Table 1). The maxilla had moved 2.5 mm backward, the mandible had

Figure 6. Cephalometric superimposition (black line: initial, red line: final).

Figure 8. Extra oral and intra oral photographs of the patient after 1year, 4 month of post-treatment.

Figure 7. Post-treatment radiographs

Figure 9. Cephalometric superimposition (red line: final, green line: 1 year, 4 month post-treatment).

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CLINICAL DENTISTRY AND RESEARCH

moved downward slightly, the maxillary molars had settled

downward, there was a slight reduction in the inclinations

of the mandibular and the maxillary incisors.

DISCUSSION

The rigid external distraction system which consists of

the external distraction devices allows management

of patients from childhood to adulthood, with perfect

functional and estheticoutcomes.5,6,7,8,9 RED protocol has

several advantages against Le Fort 1 osteotomy, including

the decreased morbidity and operative time, relative

ease to change distraction vectors, feasibility of large

advancements of the maxilla to correct a concave facial

profile secondary to maxillary retrusion. The disadvantages

of the RED system are; the unaesthetic appearance of

the external component of the device, changes such as

oronasal communications, increased risk of velopharyngeal

incompetence when attempting large movements.10

Advancement of the maxilla is more difficult to treat with

conventional surgical and orthodontic approaches in

patients who have severe maxillary retrusion especially

in cleft lip and palate patients. With the RED device,

adjustment of the vectors of distraction is possible at any

time during the distraction process, and the osteotomy

Table 1. Cephalometric measurements at T1, T2 and T3 (T1:pre-treatment, T2: post-treatment, T3: 1 year- 4 month of post-treatment)

Variables T1 T2 T3

SNA 78.1° 92° 91°

SNB 87.2° 88° 88°

ANB -9.1° 4° 3°

Max.Depth 87.2° 100° 97.4°

MP-FH 28.0° 24.3° 27.3°

SN-PP 9.7° 6.4° 5.3°

LFH 46.1° 42.3° 48.7°

Mx1-FH 118.9° 111.4° 110.2°

Md1-APo 11.4° 0.8° 0.7°

GoGnSn 32.3° 28.9° 31.5°

Gonion 139.8° 132.9° 138°

Nasolab.angle 106.3° 117.3° 116°

Convexity -9.0mm 4.0mm 2.3mm

Overjet -13.0mm 2.9mm 2.5mm

Overbite -6.1mm 2.7mm 2.4mm

Low. Lip-E -4.1mm -2.9mm -3.8mm

ANS-FH 38mm 36mm 35mm

ANS-PTV 68mm 84mm 82mm

PNS-FH 35mm 33mm 34mm

PNS-PTV 15mm 31mm 29mm

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TREATMENT OF A CLASS III ADULT PATIENT WITH RED I

design meets aesthetic requirements.11 In the present case, a high Le Fort I osteotomy was performed to allow maximal correction of the patient’s facial profile because maxillary hypoplasia was observed not only in dentoalveolar region but also in the malar regions. Cephalometric tracings of pre- and postdistraction records showed forward displacement and elongation of the reduced maxilla. 13.9-mm maxillary advancement via distraction was achieved. The SNA and maxillary depth angle, which related anterio-posterior positioning of the maxilla in relation to the cranial base were increased, providing anterior maxillary advancement. Facial esthetic was improved significantly, nasal projection was increased, the upper lip moved forward, the nasolabial angle increased, and the lower lip protrusion was reduced. These changes may have resulted from the effects of maxillary advancement by the RED system.11,12,13

During distraction osteogenesis, it is important to maintain the vertical height of the midface as soon as possible, because downward movement of the maxillofacial complex during distraction accelerates clockwise rotation of the mandible and causes reduced overbite. In our patient, the mandible did not rotate downward so that it contributed to improving his overbite.Comparison of the final and 1-year -4 month post-treatment cephalograms showed minimal changes in the skeletal pattern. This result may be related to lower relapse rates after distraction because of good soft-tissue adaptations as several reports indicated.14-18

CONCLUSION

Maxillary rigid external distraction improved the soft tissue profile by increasing nasal projection, normalizing the nasolabial angle, and making the upper lip more prominent. The concave facial profile became convex, with improved facial balance and aesthetics.

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4. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res 1989; 238: 249-281.

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8. Swennen G, Dujardin T, Goris A, De Mey A, Malevez C. Maxillary distraction osteogenesis: a method with skeletal anchorage. J Craniofac Surg 2000; 11: 120-127.

9. Kuroda S, Araki Y, Oya S, Mishima K, Sugawara T, Takano-Yamamoto T. Maxillary distraction osteogensis to treat maxillary hypoplasia: comparison of an internal and an external system. Am J Orthod Dentofacial Orthop 2005; 127: 493-498.

10. Molina F, Ortiz Monasterio F, de la Paz Aguilar M, Barrera J. Maxillary distraction: aesthetic and functional benefits in cleft lip-palate and prognathic patients during mixed dentition. Plast Reconstr Surg 1998; 101: 951-963.

11. Polley JW, Figueroa AA. Rigid external distraction: its application in cleft maxillary deformities. Plast Reconstr Surg 1998; 102: 1360-1372.

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17. McCarthy JG, Stelnicki EJ, Mehrara BJ, Longaker MT. Distraction osteogenesis of the craniofacial skeleton. Plast Reconstr Surg 2001; 107: 1812-1827.

18. Wiltfang J, Hirschfelder U, Neukam FW, Kessler P. Long-term results of distraction osteogenesis of the maxilla and midface. Br J Oral Maxillofac Surg 2002; 40: 473-479.