A 20 year-old male patient with a complaint of un-even bite presented with a Class III skeletal relationship with prognathic mandible, increased lower facial height, concave profile Class III incisor and molar relationship and anterior open bite [Figures 1-9]. The patient had no relevant family and medical history. He was highly positive for the treatment. The cephalometric analysis confirmed the clinical findings. [Table 1].
Prognathic mandible
Increased lower facial height
Class III incisor and molar relationship
Anterior open bite
Concave profile and compromised esthetics
Pre-treatment prophylaxis, restorations
Combination therapy
Surgical plan: Le- Forte I osteotomy superior and forward placement of maxilla and Bilateral l sagittal split osteotomy for mandibular setback
Non extraction Orthodontictherapy with 0.022 ' Roth Pre-adjusted Edgewise Appliance
Long term retention plan
Le- Forte I osteotomy with superior impaction of maxilla allows the auto rotation of mandible, which would reduce the lower facial height, and the forward placement of maxilla, which would help to improve the soft tissue balance. It would also help to correct the Class III skeletal relationship along with the Bilateral sagittal split osteotomy with mandibular setback.
The pre-surgical Orthodontics was planned to increase the reverse overjet to facilitate the proper positioning of the jaws during the surgery.
After initial restorative and prophylactic measures, pre-surgical orthodontics was begun with 0.022 x 0.028'' Roth Pre-adjusted Edgewise prescription appliance. Initially, 0.016 NITI wires were used to align the arches, and later shifted to heavier 0.019'' x 0.025'' SS arch wires sequentially. Mild Class II elastics were used to correct the incisor position and to increase the reverse overjet to 6 mm.
Face bow transfer and articulation of models on a semi-adjustable articulator was done and two surgical wafers (for maxillary positioning and for final mandibular setback) were fabricated as per the mock surgery carried out on models.
Le- Forte I surgical procedure was carried out as decided and the maxilla was repositioned 3 mm anteriorly and 3 mm superiorly. Bilateral sagittal split osteotomy was performed and the mandible was set back by 7 mm. Rigid type of fixations were used in both the jaws. The surgical and post-surgical phase passed on without any complications.
Post -surgical Orthodontics was initiated after a period of 4 weeks and with the arch wires sequentially changed from 0.017'' x 0.025'' NITI to 0.021'' x 0.025'' SS wires. Finishing and settling of occlusion was carried out using short elastics. Mild Class III elastics were maintained throughout the phase of treatment. The overall treatment duration was about 22 months. Upper and lower Hawley's type of retainers was given with instructions to wear full time.