Orthodontic-surgical treatment for severe skeletal class II malocclusion with vertical maxillary excess and four premolars extraction: A case report

Abstract

Background: Patient satisfaction with facial appearance at the end of orthodontic camouflage treatment is very important, especially for skeletal malocclusion. This case report highlights the importance of the treatment plan for a patient initially treated with four-premolar-extraction camouflage, despite indications for orthognathic surgery.

Case summary: A 23-year-old male sought treatment complaining about his unsatisfactory facial appearance. His maxillary first premolars and mandibular second premolars had been extracted, and a fixed appliance had been used to retract his anterior teeth for two years without improvement. He had a convex profile, a gummy smile, lip incompetence, inadequate maxillary incisor inclination, and almost a class I molar relationship. Cephalometric analysis showed severe skeletal class II malocclusion (A point-nasion-B point = 11.5°) with a retrognathic mandible (sella-nasion-B point = 75.9°), a protruded maxilla (sella-nasion-A point = 87.4°), and vertical maxillary excess (upper incisor to palatal plane = 33.2 mm). The excessive lingual inclination of the maxillary incisors (upper incisor to nasion-A point line = -5.5°) was due to previous treatment attempts to compensate for the skeletal class II malocclusion. The patient was successfully retreated with decompensating orthodontic treatment combined with orthognathic surgery. The maxillary incisors were repositioned and proclined in the alveolar bone, the overjet was increased, and a space was created for orthognathic surgery, including maxillary impaction, anterior maxillary back-setting, and bilateral sagittal split ramus osteotomy to correct his skeletal anteroposterior discrepancy. Gingival display was reduced, and lip competence was restored. In addition, the results remained stable after 2 years. The patient was satisfied with his new profile as well as with the functional malocclusion at the end of treatment.

Conclusion: This case report provides orthodontists a good example of how to treat an adult with severe skeletal class II malocclusion with vertical maxillary excess after an unsatisfactory orthodontic camouflage treatment. Orthodontic and orthognathic treatment can significantly correct a patient's facial appearance.

Keywords: Camouflage treatment; Case report; Gummy smile; Orthognathic surgery; Skeletal class II malocclusion; Vertical excess.

Figure 1

Photographs of the patient's teeth and appearance. A: Photographs before previous camouflage therapy; B: Pretreatment photographs; C: Pre-surgical photographs; D: Post-surgical photographs; E: Post-treatment photographs; F: 12 mo follow-up photographs.

Figure 2

Dental casts of the patient. A: Pretreatment dental casts; B: Post-treatment dental casts.

Figure 3

Radiographs of the patient. A: Pretreatment radiographs; B: Pre-surgical radiographs; C: Post-surgical radiographs; D: Post-treatment radiographs; E: 12 mo follow-up radiographs.

Figure 4

Superimposed tracings. Black line, pre-treatment; red line, post-treatment.