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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 190-197

Interdisciplinary approach of orthognathic surgery and prosthodontics for the treatment of jaw discrepancies: A report of four cases


1 Department of Oral and Maxillofacial Surgery and Oral Sciences, Faculty of Dentistry, Umm Al-Qura University, Mecca, Saudi Arabia
2 East Riyadh Dental Center, Ministry of Health, Riyadh, Saudi Arabia
3 Najran Dental Center, Ministry of Health, Najran, Saudi Arabia
4 Yanbu Dental Center, Ministry of Health, Yanbu, Saudi Arabia

Date of Submission28-Sep-2022
Date of Decision16-Nov-2022
Date of Acceptance21-Nov-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Dr. Rayan Sharka
Department of Oral and Maxillofacial Surgery and Oral Sciences, Faculty of Dentistry, Umm Al-qura University, Mecca
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoralsci.sjoralsci_43_22

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  Abstract 


Nonsurgical orthodontic treatment is a choice for many cases of teeth malalignment, especially with the advances in orthodontic treatment. However, orthognathic surgery is sometimes recommended in cases with severe malocclusion, in patients with congenital disabilities, to treat patients with sleep apnea and for adding spaces for dental implants. Besides, it can be considered in patients with esthetic issues that need prosthodontic and restorative work. This paper aimed to show how involving a proper treatment plan using orthognathic surgery when patients required prosthodontic reconstruction maximized results and patient satisfaction compared with prosthetic reconstructions alone or with nonsurgical orthodontic treatment. The authors reported that four patients required prosthetic treatment. Each case had its own set of unique circumstances and challenges. The report showed the difference in treating these cases using nonsurgical orthodontic treatment or orthognathic surgery. Orthognathic surgery was indicated for the last reported case, showing a successful treatment and the patient reporting a high satisfaction level. Orthognathic surgery fastens and maximizes the result and satisfaction of cases with severe jaw discrepancies compared to prosthodontics alone or with nonsurgical orthodontic treatment. However, a proper treatment plan and work in a multidisciplinary team are required.

Keywords: Malocclusion, orthodontics, orthognathic surgery, prosthodontics


How to cite this article:
Sharka R, Alamar M, Alhaider Y, Albakri F, Ezzat Y. Interdisciplinary approach of orthognathic surgery and prosthodontics for the treatment of jaw discrepancies: A report of four cases. Saudi J Oral Sci 2022;9:190-7

How to cite this URL:
Sharka R, Alamar M, Alhaider Y, Albakri F, Ezzat Y. Interdisciplinary approach of orthognathic surgery and prosthodontics for the treatment of jaw discrepancies: A report of four cases. Saudi J Oral Sci [serial online] 2022 [cited 2023 Feb 6];9:190-7. Available from: https://www.saudijos.org/text.asp?2022/9/3/190/366532




  Introduction Top


Nonsurgical orthodontic treatment is a choice for many cases of teeth malalignment, especially with the advances in orthodontic treatment.[1] However, some cases benefit from orthognathic surgery, especially those with severe skeletal and dental discrepancies.[2] With advanced training in oral and maxillofacial surgery, orthognathic surgery becomes a frequent procedure with less harm to the patients.[2]

Orthognathic surgery is sometimes recommended in cases with severe malocclusion, in patients with congenital disabilities, for treating patients with sleep apnea and for adding spaces for dental implants.[3] Furthermore, orthognathic surgery is considered when patients have difficulty in chewing, sleeping, and carrying out daily activities.[3]

Besides, it can be considered in patients with esthetic issues needing prosthodontic and restorative work. For example, in patients with receding and protruding jaws, cleft palate patients to create spaces for a dental implant, and patients with a severe overbite.[4] The former required a definitive and proper treatment plan using advanced software, diagnostic radiograph, and three-dimensional (3D) models, which can be achieved by the teamwork between prosthodontists, orthodontists, and oral and maxillofacial surgeons.[4]

However, in some cases, complex prosthodontic treatments can be indicated to achieve satisfactory results and solve esthetic and functional problems. Therefore, this paper aimed to present four cases that show different treatment modalities using orthognathic surgery when patients required prosthodontic reconstruction compared with prosthetic reconstructions alone or with nonsurgical orthodontic treatment, and also to discuss the crucial lessons and teaching points from these clinical scenarios.


  Case Series Top


Case 1a and 1b

Prosthetic reconstructions alone without nonsurgical orthodontic and orthognathic treatment.

Case 1a

A 28-year-old female was referred from the primary dental care centers to Riyadh Elm University. The patient's chief complaint was, “I want to restore lower posterior broking restoration.” The patient was fit and well, with diet control and lifestyle modification. Furthermore, the patient is a teacher and single. Informed consent was obtained from the patient to use clinical photos for educational and publication purposes.

Radiographic examination was performed using panoramic and intraoral radiographs. The panoramic radiograph showed a symmetrical condyle and nonsurgical endodontically treated teeth #16, #12, #11, #21, #22, #26, #27, #46, and #47. Intraoral radiographs showed multiple inadequate nonsurgical endodontically treated teeth #16, #12, #11, #21, #22, #26, #27, #46, and #47 and defective dental restoration of teeth #16, #15, #14, #25, #46, and #47.

No abnormalities were detected on extraoral examination. Intraoral examination revealed a fair oral hygiene. The general probing depths in both arches were 1–3 mm, with minimal bleeding on probing. The upper dental midline was coincident with the lower dental midline. There was a bilateral crossbite of the posterior teeth, localized anterior crossbite in teeth #21 and #23, and localized open bite in teeth #13 and #12; the vertical overlapping was 10%, and the horizontal overlapping was 0.5 mm of central. The patient had her canine in Class III relationship and molar in the class NA relationship.

[Table 1] shows the proposed treatment plan for case 1a. The patient was offered prosthodontic treatment to protect the existing occlusion, correct the broken teeth, and improve her occlusion. [Figure 1] shows the preoperative and postoperative intraoral views of case 1a.
Table 1: The proposed treatment plan for case 1a

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Figure 1: Pre (a-e) and post (f-j) intraoral views of case 1a

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Case 1b

A 35-year-old female was referred from the primary dental care centers to Riyadh Elm University. She was a fit and well patient. The patient's chief complaint was, “I want to restore my missing teeth.” The patient was married, a teacher, and had one child.

Radiographic examination was performed using panoramic and intraoral radiographs. The panoramic radiograph showed asymmetrical condyle elongation of the head and neck of the right condyle and dense regular trabeculation. Besides, intraoral radiographs showed substandard endodontically treated teeth #14, #15, #21, #24, #26, #37, #36, and #46. Moreover, intraoral radiographs showed distal caries in tooth #13 and defective restoration of teeth #13, #12, #11, #21, #23, and the remaining root #45.

The extraoral examination did not detect any abnormality. Intraoral examination revealed a good oral hygiene. The general probing depths in both arches were between 2 and 3 mm, with minimal bleeding on probing. Generalized plaque-induced gingivitis affected 85% of the gingiva. The upper dental midline was not coincident with the lower dental midline; there are bilateral cross bites of the posterior teeth, localized anterior cross bites in teeth #21 and #23, and localized open bite in teeth #13 and #12; the vertical overlapping was 10%, and the horizontal overlapping was 0.5 mm of central. The lower anterior teeth guided the protrusive movement (#32,31,41, and 42). [Table 2] shows the proposed treatment plan of case 1b. [Figure 2] shows the preoperative and postoperative intraoral views of case 2.
Table 2: The proposed treatment plan for case 1b

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Figure 2: Pre (a-e) and post (f-j) intraoral views of case 1b

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Case 2: Prosthetic reconstructions combined with nonsurgical orthodontictreatment

A 49-year-old female was referred from the primary dental care centers to Riyadh Elm University. A review of the patient's medical history revealed that she had Vitamin D deficiency, and she was taking Vitamin D3 (1000 IU\×1 daily) and calcium (600 mg\×2 daily). Furthermore, the patient is a teacher, married, and has five children. The patient's chief complaint was, “I want to restore my teeth and replace my missing teeth.”

Radiographic examination was performed using panoramic and intraoral radiographs. The panoramic radiograph showed that the maxillary and mandibular residual ridges have minimal-to-moderate bone resorption. Both residual ridges displayed a normal trabecular bone pattern.

No pneumatization of the maxillary sinus and no evidence of current soft or hard tissue pathosis were present on the radiograph. Intraoral radiographs showed that a pattern of woven trabecular bone, intact lamina dura, and periodontal ligament space of uniform dimension were present.

Furthermore, the presence of widening of the lamina dura was noticed regarding teeth #25 and #35. The crown-to-root ratio was favorable throughout the dentition.

The radiographic examination also showed that the patient had defective fixed-partial dentures and inadequate endodontically treated teeth #16, #15, #14, #13, and #35. In addition, the patient had preapical radiolucency with or without inadequate endodontic treatment in teeth #17, #16, #15, #14, #13, #12, #21, #23, and #35. Finally, the intraoral radiograph showed dental caries in teeth #11, #21, #22, #23, and #43.

Extraoral examination revealed a normal skin. The patient exhibited an asymmetrical face. The chin was shifted to the right side. The patient exhibited a convex lateral profile. The patient did not have any pronounced lump or lymphadenopathy. No tenderness was reported during palpation of the muscles of mastication. The patient had a deviation in opening to the right side. Her temporomandibular joints were asymptomatic, with no signs of clicking, crepitus, or tenderness to palpation. She had a tapering facial form. Her hair was brown, her eyes were black, and her skin was medium in color. Lips were normal to dry; the contour was adequately supported, thin vermillion border, short lips, and lip mobility were normal. Neuromuscular coordination was within the normal limits. The nasolabial angle was around 90, and mentolabial angle was 180°. The lips were incompetent. The separation between the lips during a smile by 0.5–1 mm at rest was noticed. The patient exhibited a high smile line. The lip length was 20 mm.

Intraoral examination revealed a good oral hygiene. Mild calculus around lower anterior teeth was noticed. The general probing depths in both arches were between 1 and 3 mm, with minimal bleeding on probing. Soft tissue examination of the lips, tongue, oral mucosa, and pharyngeal tissues was without obvious pathology. Her saliva was normal in quantity and of a serious consistency. Her maxillary labial and buccal frenal attachments were normal in height. The arch form of the hard palate was with a regular contour. The maxillary residual alveolar ridge at the left side had a regular round, broad contour with firm, nonmovable tissue. The arch shape was broad with a tapering U-shaped.

An analysis of the patient's occlusion revealed that the centric occlusion and maximum intercuspation were coincident. The vertical overlapping was 20%, and the horizontal overlapping was 3 mm of anterior teeth. The patient had his canine in Class I (left) and II (right) relationship.

[Table 3] shows the proposed treatment plan for case 2. Following a review of all treatment options, objectives, and limitations, the patient was offered preprosthetic surgery to correct the vertical excess in the maxilla as orthognathic surgery, but she declined this option. The second option was orthodontic treatment with preprosthetic surgical treatment and dental implants, to which the patient consented. [Figure 3] shows the preoperative and postoperative intraoral views of case 2.
Table 3: The proposed treatment plan for case 2

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Figure 3: Pre (a-e) and post (f-j) intraoral views of case 2

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Case 3: Prosthetic reconstructions with orthognathic surgery

A 32-year-old male was referred from the primary dental care centers to Riyadh Elm University. The patient's medical history was remarkable, with controlled high blood pressure, diet control, and lifestyle modification. Furthermore, the patient is a military employer, married, has two children, and has no significant family diseases. The patient's chief complaint was, “I found difficulty eating as my front teeth are not touching together.”

A radiographic examination was performed using panoramic and cephalometric radiographs. The panoramic radiograph [Figure 4] showed that the maxillary and mandibular residual ridges have minimal bone resorption; however, both ridges displayed a normal trabecular bone pattern.
Figure 4: Preorthognathic surgery panoramic radiographs

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The teeth were crowded. The missing teeth were #12, #28, and #35. Tooth #48 was impacted.

Neither the maxillary sinus pneumatization was noticed, nor was there an evidence of current soft or hard tissue pathosis on the radiograph. Cephalometric analysis showed that the Frankfort-mandibular plane angle was 42° (25 + 5), retruded chin, high mandibular plane angle, increased lower facial height, protruded upper incisors, and reclined lower incisors.

No abnormalities were detected on extraoral examination. Intraoral examination revealed a fair oral hygiene. The general probing depths in both arches were 1–4 mm, with minimal bleeding on probing. The keratinized gingival tissues in the maxilla and mandible were thin scallop-shaped, delicate, and translucent. A physiologic pigmentation was noticed above the upper anterior teeth.

Crossbite at teeth #16, #15, #14, #26, #25, and #24. The analysis of the patient's occlusion revealed an anterior open bite (8–10 mm) with Class III malocclusion. The upper midline to the facial midline shifted 2 mm to the right side. The lower midline was shifted 4 mm to the left side. The upper incisors were protruding, and the lower incisors were retroclined.

[Table 4] shows the proposed treatment plan for case 3. Following a review of all treatment options, objectives, and limitations, the patient was offered preprosthetic orthognathic surgery to correct the vertical excess in the maxilla and the anterior open bite. The patient started orthodontic treatment with preprosthetic surgical treatment and implants.
Table 4: The proposed treatment plan for case 4

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After orthognathic surgery and prosthodontic treatment, an extraoral examination revealed normal skin with an asymmetrical face. [Figure 5] shows the posttreatment panoramic radiograph. The chin was shifted to the right side. The patient exhibited a convex lateral profile. The nasolabial angle was 90°. The patient reported his satisfaction with the new prosthesis's esthetics, function, and comfort, and he was very happy with his new smile. [Figure 6] shows the preoperative and postoperative intraoral views of case 3.
Figure 5: Postorthognathic surgery panoramic radiographs

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Figure 6: Pre (a-e) and post (f-j) intraoral views of case 3

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  Discussion Top


This case series reported four cases of patients who required adjustment for their occlusion by aligning their teeth and replacing their missing teeth using dental implants. The case series also showed the difference when treating these cases using nonsurgical orthodontic treatment or orthognathic surgery. Orthognathic surgery was indicated for the last reported case showing successful treatment and the patient reporting a high satisfaction level. From this case series, three lessons need to be discussed.

The first lesson is the importance of a proper treatment plan and working in a multidisciplinary team which involves prosthodontists, orthodontists, and oral and maxillofacial surgeons in successful cases that require orthognathic and prosthodontic works. Indeed, cases with jaw discrepancies and malocclusion require the cooperation of interdisciplinary fields and careful treatment planning.[5]

The second lesson is that the surgical option was chosen for case 3 since the patient presented with a severe Class 2 skeletal discrepancy, a Class II malocclusion, and a large anterior open bite. This clinical scenario is not a typical difficulty but can be contested for occlusal rehabilitation. Furthermore, it is crucial to understand the psychological motivation for dentofacial disfigurement to comprehend the patient's confidence in the treatment plan.[6] The patient was young and had been suffering from impaired dental esthetics. Demographic factors and marriage could be a basis for encouraging him to undergo prolonged treatment phases.[7]

The third lesson is that to reach a successful and satisfying case involving orthognathic surgery, case selection is crucial. Ineffective occlusion is a difficult characteristic for the prosthodontist to restore the missing dentition in the protruded maxilla or mandible; hence, orthognathic surgery can help achieve a proper stomatognathic system.[8] It was found in a cross-sectional study that an interdisciplinary 3D digital treatment simulation before complex esthetic rehabilitation of orthodontic, orthognathic, and prosthetic treatment is indeed helpful for both patients and dental specialists in improving the final result, correcting jaw discrepancies, and building an effective decision before complex esthetic rehabilitation cases.[4]

The final lesson is that involving orthognathic surgery in treating cases with jaw discrepancies can maximize the results. However, in some clinical scenarios, as presented in case 2, it has been reported that a combination of orthodontic and prosthodontic treatment resulted in a more favorable outcome than prosthodontic treatment alone.[8] This is because, for example, involving nonsurgical orthodontic treatment and orthognathic surgery allows the dentist to place restorations that often require a less natural tooth reduction during preparation and are more esthetic, functional, stable, and durable.[9]

Although this paper provided an educational value for day-to-day clinical practice, there were several limitations worth mentioning. The results and clinical management from the presented cases cannot be generalized. Furthermore, the above cases were written after the pertinent event. Thus, this report was created retrospectively. The medical record might not contain all relevant data. Finally, the experiment replication cannot be applied to case reports. It is a challenge to design other identical clinical cases.


  Conclusion Top


Orthognathic surgery fastens and maximizes the result and satisfaction of cases with severe jaw discrepancies compared to prosthodontics alone or with nonsurgical orthodontic treatment. Furthermore, orthognathic surgery requires a careful case selection to achieve both facial and occlusal intended results. The fundamental recommendation for future work is a proper treatment plan, and working in a multidisciplinary dental team is demanded. Furthermore, future reports should incorporate documentation of long-term follow-up. Finally, evaluating the degree of patient satisfaction and social impact following the treatment will also be an area of interest.

Data availability

The data presented in this study are stored in a digitally secured place of the Riyadh Elm University system and available on a reasonable request.

Acknowledgment

The authors thank Dr. Hassan Abed for his effort and time in preparing and contextualizing the manuscript. Also, we thank Dr. Yahya Alshahrani and Dr. Riyadh Alshehri for orthodontics treatment and Dr. Abdullah Al Atel for performing orthognathic surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
English JD, Akyalcin S, Peltomaki T, Pham-Litschel K. Mosby's Orthodontic Review E-Book. St. Louis Missouri, USA : Elsevier Health Sciences; 2014.  Back to cited text no. 1
    
2.
Posnick JC. Orthognathic Surgery Principles and Practice. St. Louis Missouri, USA: Elsevier Health Sciences; 2022.  Back to cited text no. 2
    
3.
Tashima A, Mackay DR. Orthognathic Surgery Tips and Tricks in Plastic Surgery E-Book. Cham, Switzerland : Springer International Publishing; 2022.  Back to cited text no. 3
    
4.
Lv L, He W, Ye H, Cheung K, Tang L, Wang S, et al. Interdisciplinary 3D digital treatment simulation before complex esthetic rehabilitation of orthodontic, orthognathic and prosthetic treatment: Workflow establishment and primary evaluation. BMC Oral Health 2022;22:34.  Back to cited text no. 4
    
5.
Pinho T, Neves M, Alves C. Multidisciplinary management including periodontics, orthodontics, implants, and prosthetics for an adult. Am J Orthod Dentofacial Orthop 2012;142:235-45.  Back to cited text no. 5
    
6.
Bellucci CC, Kapp-Simon KA. Psychological considerations in orthognathic surgery. Clin Plast Surg 2007;34:e11-6.  Back to cited text no. 6
    
7.
Peacock ZS, Lee CC, Klein KP, Kaban LB. Orthognathic surgery in patients over 40 years of age: Indications and special considerations. J Oral Maxillofac Surg 2014;72:1995-2004.  Back to cited text no. 7
    
8.
Spalding PM, Cohen BD. Orthodontic adjunctive treatment in fixed prosthodontics. Dent Clin North Am 1992;36:607-29.  Back to cited text no. 8
    
9.
Jain P, Rahman SU, Mattoo KA, Bansal V. Orthognathic surgery as part of pre prosthetic mouth preparation. Med Sci Clin Res 2019;7:777-780.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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