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Volume 29 Issue 1 Article 5
2017
Surgical-orthodontic Treatment of a Patient with Severe Skeletal Surgical-orthodontic Treatment of a Patient with Severe Skeletal
Class III Anterior Open Bite and High Mandibular Plane by Class III Anterior Open Bite and High Mandibular Plane by
Preserving the Posterior Facial Height Preserving the Posterior Facial Height
Tz-Ya Hung Resident, Department of Dentistry, Songshan Branch, Tri-Service General Hospital, Taipei, Taiwan
Wei-Cheng Lee Resident, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan
Benjamin Lo Attending doctor, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan
Philip Kuo-Ting Chen Director, Craniofacial Center, Chang Gung Memorial, Hospital, Taoyuan, Taiwan.
Lih-Juh Chou Attending doctor, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan
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Recommended Citation Recommended Citation Hung, Tz-Ya; Lee, Wei-Cheng; Lo, Benjamin; Chen, Philip Kuo-Ting; Chou, Lih-Juh; and Li, Chung-Hsing (2017) "Surgical-orthodontic Treatment of a Patient with Severe Skeletal Class III Anterior Open Bite and High Mandibular Plane by Preserving the Posterior Facial Height," Taiwanese Journal of Orthodontics: Vol. 29 : Iss. 1 , Article 5. DOI: 10.30036/TJO.201703_29(1).0005 Available at: https://www.tjo.org.tw/tjo/vol29/iss1/5
This Case Report is brought to you for free and open access by Taiwanese Journal of Orthodontics. It has been accepted for inclusion in Taiwanese Journal of Orthodontics by an authorized editor of Taiwanese Journal of Orthodontics.
Surgical-orthodontic Treatment of a Patient with Severe Skeletal Class III Anterior Surgical-orthodontic Treatment of a Patient with Severe Skeletal Class III Anterior Open Bite and High Mandibular Plane by Preserving the Posterior Facial Height Open Bite and High Mandibular Plane by Preserving the Posterior Facial Height
Authors Authors Tz-Ya Hung, Wei-Cheng Lee, Benjamin Lo, Philip Kuo-Ting Chen, Lih-Juh Chou, and Chung-Hsing Li
This case report is available in Taiwanese Journal of Orthodontics: https://www.tjo.org.tw/tjo/vol29/iss1/5
39Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Case Report
Class III malocclusions with a hyperdivergent vertical facial pattern are often difficult to treat without
combining the surgical-orthodontic approach. The aim of this article is to present a collaborative management of
a case with severe skeletal class III and anterior open bite. The 19-year-old man was characterized with midface
deficiency, mandibular prognathism, high mandibular plane angle, long lower facial height, and excessive
anterior open bite. The achievement of a stable surgical setup in interdigitation prior to orthognathic surgery
(OGS) is critical for a successful treatment via dental decompensation. Two-jaw surgery with clockwise rotation
of the maxilla and bilateral sagittal split osteotomies was performed to correct the skeletal Class III malocclusion
and anterior open bite. An acceptable smile arc and facial profile were achieved. The total treatment duration
was 28 months. The treatment outcome presented a good facial profile and solid occlusion. Moreover, the
skeletal and dental relationships were stable 2 years after finish. Accurate diagnosis and treatment design, good
patient’s compliance, and effective communication are essential to correct the severe dentoskeletal deformaties.
(Taiwanese Journal of Orthodontics. 29(1): 39-51, 2017)
Keywords: Class III malocclusion; anterior open bite; vertical facial pattern
surgical-orThodonTic TreaTmenT of a paTienT wiTh severe skeleTal class iii anTerior open biTe
and high mandibular plane by preserving The posTerior facial heighT
Tz-Ya Hung,1 Wei-Cheng Lee,
2 Benjamin Lo,
3 Philip Kuo-Ting Chen,
4 Lih-Juh Chou,
3 Chung-Hsing Li,
5
Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan1Resident, Department of Dentistry, Songshan Branch, Tri-Service General Hospital, Taipei, Taiwan
2Resident, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry,
Tri-Service General Hospital, Taipei, Taiwan 3Attending doctor, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry,
Tri-Service General Hospital, Taipei, Taiwan4Director, Craniofacial Center, Chang Gung Memorial, Hospital, Taoyuan, Taiwan.
5
Director, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, Tri-Service General Hospital, Taipei, Taiwan.
Received: Stepmber 8, 2016 Revised: March 10, 2017 Accepted: March 13, 2017Reprints and correspondence to: Dr. Chung-Hsing Li, Division of Orthodontics and Dentofacial Orthopedics, Department of Dentistry,
Tri-Service General Hospital, Taipei, TaiwanNo. 325, Sec. 2, Chenggong Rd, Neihu District, Taipei City 114, Taiwan, ROCTel: 886-2-87927285 Fax: 886-2-87927147 E-mail: [email protected]
40 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
INTRODUCTION
Class III malocclusions represent a small fraction
of the malocclusions in orthodontic patients,1 with an
incidence of 1–4% in Caucasians.2,3,4
However, in the Asian
population the incidence ranges from 9%–19% owing
to the large percentage of Asian patients with maxillary
deficiency.5,6,7,8
The incidence of Class III malocclusion is
reported to be 4–13% in Japanese9 and 4–14% in Chinese
patients.10
In Lin’s study, in Chinese children with age in
9 to 15 years, the prevalence of pseudo- and true Class III
malocclusion was 2.3% and 1.7%, respectively.11
Patients with skeletal Class III malocclusion can
be treated using orthopedics, orthodontic camouflage,
or orthodontic treatment combined with orthognathic
surgery (OGS). The optimal method depends on the age
of the patient, the stage of craniofacial development, the
degree of skeletal discrepancy, the skeletal pattern, and
the facial profile.12,13
Anterior open bite combined with
any malocclusion makes both features difficult to correct,
particularly in concurrent with a Class III malocclusion.14
Camouflage orthodontic treatment can result in
proper occlusion and esthetics in nonsurgical cases
of Class III malocclusion. However, in surgical cases
of Class III malocclusion, dental decompensation is
necessary before surgery to facilitate skeletal corrections.
Several studies have reported that the most effective
treatment option in adult patients with skeletal open bite
is surgical repositioning of either the maxilla or both
jaws.15,16
In addition, Sugawara et al. found that in patients
with skeletal Class III open bite, moving the anterior
maxillary structures down with clockwise rotation of the
palatal plane effectively produces a reasonably stable
correction of the anterior open bite.17
Herein, we present the treatment of an adult patient
with severe skeletal Class III maxillary deficiency
Hung TY, Lee WC, Lo Benjamin, Chen KT, Chou LJ, Li CH
combined with mandibular prognathism, an extremely
high mandibular plane angle, and anterior open bite.
With the aid of the reduction genioplasty, LeFort I
osteotomy, and bilateral sagittal split osteotomy (BSSO),
the clockwise rotation of the maxillomandibular complex
(MMC) altered the existing occlusal plane, the outcome
demonstrated a consonant smile curve, harmonized facial
aesthetics, a stable skeletal relationship and god dental
occlusion.
CASE REPORT
A 19-year-old male patient who had no history of
illness or trauma, presented the following complaints
including inability to bite off food with his incisors,
difficulty chewing, tooth crowding over both arches,
a long face, and occasional involuntary opening of the
mouth.
The extraoral examination revealed that the patient
had skeletal Class III malocclusion with midface
deficiency, mandibular prognathism, a high mandibular
plane, an excessively long lower third of the face, facial
asymmetry, an acute nasolabial angle, a flat labiomental
fold due to straining to compensate for the vertical
discrepancy, lip incompetence with mentalis strain, a flat
smile arc, and uncoordinated dental and facial midlines
(Figures 1).
The intraoral examination revealed that the patient
had Angle’s Class III malocclusion with anterior open
bite and negative overjet, bilateral posterior and anterior
crossbite, non-coincident upper and lower dental midlines,
and large interincisal angle which due to flaring maxillary
incisors and retroclined lower incisors, a reverse curve of
Spee in the lower arch, crowding of both arches, mesial
tipping of the lower arch, and impaction of tooth #18
(Figures 1-3 and Table 1).
41Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Surgical-orthodontic Treatment in Class III
Figure 1. Facial and intraoral photographs, before treatment.
Figure 2. Study models in before treatment.
42 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Hung TY, Lee WC, Lo Benjamin, Chen KT, Chou LJ, Li CH
Figure 3. A Lateral cephalometric film, B panoramic radiographs before treatment.
Table 1. Cephalometric summary.
Measurement Pre-treatment Post-treatmentSkeletal
SNA° 79.8 84.3SNB° 84.9 80.5ANB° -5.1 3.8AO-BO (mm) -2.2 -0.6SN-MP° 44.3 42.1FMA° 37.6 35.2Y-axis° 63 68.6Lower Go angle° 94.4 90Articular angle° 164.7 169.4PFH (mm) 9.6 9.6AFH (mm) 15.3 14.8PFH/AFH (%) 61.5 63.6
Dental1 TO NA (mm) 1.1 1.21 TO SN° 109 102.91 TO NB (mm) 1.6 0.91 TO MP° 74.7 89.2FMIA° 67.7 55.6OCC. PLANE angle° 21.8 23.8
Facial
E-LINE (mm)Upper -7 -1Lower 0 -2
NLA° 90 100Z-Angle° 77 75UPPER LIP (mm) 14 15TOTAL CHIN (mm) 8 16
43Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Surgical-orthodontic Treatment in Class III
TREATMENT OBJECTIVES
● �To correct the midface deficiency, the vertical
maxillary excess and anterior open bite; to correct the
mandibular prognathism and the excessive lower third
of the face; and to correct the canting occlusal plane in
facial skeleton.
● �To improve the acute nasolabial angle and paranasal
depression, to improve the flat labiomental fold and
chin contour, and to shape the bilateral gonial angle in
facial soft tissue.
● �To correct the dental compensation and anterior open bite.
● �To achieve a stable, functional occlusion by establish
Class I canine relationships as well as a consonant
smile arc and competent lip posture.
TREATMENT ALTERNATIVES
The first treatment option included advanced LeFort I
osteotomy, BSSO mandibular setback, clockwise rotation
of the MMC, and vertical reduction genioplasty with
advancement. This option could improve the paranasal
depression and mandibular prognathism and result in a
balanced facial profile.
The second treatment option was one-jaw surgery
mandibular surgery. The intrusion of posterior teeth and
correction of occlusal plane cant would be corrected with
the application of temporary anchorage devices (TADs)
over the posterior maxilla. This method could only correct
the anterior open bite, but compromised facial esthetics
was expected.
The patient chose the two-jaw surgery to achieve a
better facial aesthetics.
TREATMENT PLAN
A comprehensive diagnosis, treatment objectives, and
treatment alternative were presented to the patient. With
patient’s consent, the following treatment plan was chosen:
● �Placement of pre-adjusted edgewise appliances to
level, align and coordinate the dental arches and to
correct dental compensation.
● �OGS: 1) LeFort I osteotomy with advancement,
posterior maxillary impaction and clockwise rotation
of occlusal plane to correct canting occlusal plane
and improve the paranasal depression; 2) BSSO to
correct skeletal discrepancy, anterior open bite, and
mandibular prognathism.
● �Vertical reduction genioplasty with advancement to
improve the flat labiomental fold and chin contour.
● �Surgical-orthodontic combined treatment to get
balanced facial profile and good interdigitation.
TREATMENT PROGRESS
Preoperative orthodontic treatment was carried out
by using the pre-adjusted 0.022-inch edgewise appliances.
Before orthodontic treatment, the maxillary right third
molar was extracted. Leveling, alignment, and arch
coordination were then performed to achieve dental
decompensation. Preoperative orthodontic treatment
lasted for 12 months and was completed using 0.017 ×
0.022 inch stainless steel (SS) arch wires (Figure 4).
The orthognathic surgery consisted of two-
jaw surgery including LeFort I osteotomy, BSSO and
genioplasty. The surgical procedure on the maxilla
involved a one-piece LeFort I osteotomy with maxillary
advancement of about 3 mm on the right side and 5 mm
on the left side to correct the paranasal depression. The
posterior maxilla was impacted about 5 mm on the right
side and 3 mm on the left side to alter the occlusal plane
and correct the anterior open bite. BSSO was performed
on the mandible with backward of 9 mm on the right side
and 12 mm on the left side to establish the correct skeletal
and dental relationships. Genioplasty was performed with
chin advancement 3 mm and reduction 3 mm to correct
the excessive lower facial height and improve the chin
contour.
44 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Hung TY, Lee WC, Lo Benjamin, Chen KT, Chou LJ, Li CH
Postoperative orthodontic treatment started 6 weeks
after surgery (Figure 5 and Figure 6). The orthodontic
treatment kept progressing with detailing and finishing,
achieving Class I canine relationship, normal overbite and
overjet, and coincident facial and dental midlines. After
16 months for detailing and finishing, the patient was
debonded, and Hawley retainers were used for retention
(Figure 7). The total treatment duration was 28 months.
The skeletal and dental conditions were stable after 2
years of follow-up (Figure 8).
Figure 4. A Lateral cephalometric film, B panoramic radiographs before surgery and after presurgical leveling.
45Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Surgical-orthodontic Treatment in Class III
Figure 5. Facial and intraoral photographs, after OGS.
Figure 6. A Lateral cephalometric film, B panoramic radiographs after completion of treatment.
46 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Hung TY, Lee WC, Lo Benjamin, Chen KT, Chou LJ, Li CH
Figure 7. The intraoral photographs, after treatment.
Figure 8. The facial and intraoral photographs in 2 years after debond.
47Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Surgical-orthodontic Treatment in Class III
surgery. However, this procedure cannot resolve midfacial
deficiency. In addition, long-term reports indicated that
the relapse rate for orthodontic molar intrusion is about
30%.20,22
Park et al. reported that 2 to 3 mm of posterior
teeth intrusion can be obtained easily and precisely using
TADs.21
While cases of severe anteroposterior discrepancy
and vertical maxillary excess still require skeletal
posterior maxillary impaction. This procedure increases
the amount of surgical mandibular setback and distal
movement of the chin by changing the occlusal plane in
a clockwise direction.21
In this case, clockwise rotation of
the MMC was performed using LeFort I osteotomy and
BSSO to achieve better facial balance.
Preoperative orthodontic decompensation treatment
could increase the severity of the Class III malocclusion
and facial profile.23
The quality of preoperative dental
decompensation determines the quality, quantity, and
type of OGS, was considered as one of the factors to the
success of the treatment.24,25
In this case, decompensation
of the maxillary and mandibular arches, without
extraction, required 12 months. The overjet changed from
-6 mm to -12 mm. The large negative overjet increased
the amount of surgical mandibular setback.
Several additional orthodontic parameters must be
considered while planning dental decompensation before
orthognathic surgery. The inclination of the anterior teeth
would change after surgical alteration of the occlusal
plane angle. If the maxillary occlusal plane angle is to be
altered using counter-clockwise rotation, the angulation of
the upper anteriors should be decreased before surgery. In
other hand, if the maxillary occlusal plane angle is altered
clockwisely, the angulation of the upper anteriors should
be increased before surgery. However, if the maxilla is
segmentalized, the surgeon could change the angulation
of the maxillary anterior teeth with wider range.26
In the
case presented here, the angulation of the upper anteriors
decreased from 109° to 103° because of clockwise rotation
of the maxilla. It also contributes to the improvement of
the smile arc from from flat to favorable.
TREATMENT RESULTS
The facial profile, excess vertical facial height,
and anterior open bite were improved (Figure 8). A
normal overbite, overjet, Class I canine relationships,
and coincident facial and dental midlines were achieved
(Figure 9). A considerable increase in the nasolabial angle
was observed. The flat labiomental fold was changed to an
acceptable contour. The superimposition of cephalometric
tracings revealed that the maxilla had advanced, thereby
improving the paranasal depression. The impacted
posterior maxilla was affected by changes in the occlusal
plane and improvement in the reverse smile arc. The
anterior nasal spine osteotomy was performed to prevent
widening of the nose. The mandible was set back to
eliminate the mandibular prognathism. Genioplasty was
performed to improve the chin contour. Cephalometric
analysis comparing the initial and final conditions
indicted that the ANB angle increased from -5.1° to 3.8°.
The angle between the maxillary incisor and S-N plane
decreased from 109° to 102.9°. The mandibular incisor
to mandibular plane angle increased from 74.7° to 89.2°
(Figure 10 and Table 1).
DISCUSSION
Accurate diagnosis of the skeletal and dentoaloveolar
components of Class III malocclusion, including maxillary
deficiency, mandibular prognathism, or a combination
of both, is essential for accurate planning and effective
treatment.14,18
Anterior open bite varies from case to case
and is one of the most challenging dentofacial deformities
to treat.19
If severe skeletal class III malocclusion is
combined with anterior open bite, orthodontic correction
is further complicated. Several cases have recently
been reported in which mandibular setback combined
with TADs for maxillary molar intrusion to reduce the
posterior vertical dimension instead of using maxillary
surgical impaction.20,21
This method was reported as less
invasive and effective alternative other than the two-jaw
48 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Hung TY, Lee WC, Lo Benjamin, Chen KT, Chou LJ, Li CH
Figure 9. The study models, after treatment.
Figure 10. Superimposition of cephalometric tracings. Black line, before treatment; red line, after treatment.
49Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Surgical-orthodontic Treatment in Class III
tissue advancement was greater in patients who had both
anterior chin repositioning and vertical chin reduction
than in those who had only anterior chin repositioning.37
Performing both mandibular setback and vertical chin
reduction together has been reported to double the effect
to deepening of the labiomental fold. Hence, without
a proper treatment plan, mandibular setback combined
with superior–anterior repositioning of the chin may
result in overcorrection of the chin prominence.36
In our
case, the patient had mandibular prognathism and long
lower anterior face with a long and flat chin. Thus the
mandibular setback combined with superior–anterior
chin reposition genioplasty was performed to achieve a
balanced facial profile.
In this patient, black triangles developed in the
mandibular incisors. Black triangles, or open gingival
embrasures, are an undesirable outcome of orthodontic
treatment. Black triangles are more frequent in adult
patients than in younger patients and are associated with
alveolar bone resorption.38
Kim et al. reported that in
surgical skeletal Class III patients, vertical alveolar bone
loss was more severe in the mandibular incisors than in
the maxillary incisors. In a 3D cone beam CT study, the
authors observed that lingual alveolar bone loss increased
during orthodontic treatment.39
In another study, the
same authors reported that excessive forward movement
of the lower incisors during pre-surgical orthodontic
treatment results in alveolar bone loss around the incisors.
Therefore, extra attention should be paid to reduce the
risk of alveolar bone loss.40
If the symphysis is narrow
and high and the mandibular incisors undergo pronounced
sagittal movements and derotation, progressive bone
loss may occur over the lingual and labial cortical plates
during orthodontic treatment with a fixed appliance.41
Liou et al. also reported that orthognathic surgery triggers
a 3- to 4-month period of higher osteoclastic activities and
metabolic changes in the dentoalveolar region;42
it may be
also be one of the reason for alveolar bone loss.
Only a few cases in the literatures described
the s tabi l i ty of the changes af ter c lockwise or
counterclockwise rotation of the jaws. Chemello et al. and
Reyneke et al. reported stable results after both clockwise
rotation and counterclockwise rotation of the MMC.27,28
However, Schendel and Epker reported that postsurgical
stability is poor after counterclockwise rotation of the
mandible.29
This resulted from the procedures to increase
in the posterior facial height and stretching of the pterygo-
masseteric musculature. In our case, clockwise rotation
of the maxilla and slight counterclockwise rotation of
the mandible with BSSO setback were performed. This
procedure neither changed the posterior facial height nor
stretched the pterygo-masseteric musculature.
In this case, we stripped the muscle and ligament
attachment to the medial side of the mandibular angle.
This procedure allowed greater mandibular distal segment
setback and prevented rotation of the proximal segment
posteriorly, which might decrease postsurgical stability.30
BSSO osteotomy should be secured with rigid fixation.
The changes in proximal segments might tend to return to
their presurgical position following surgery.31
In addition,
Proffit et al. reported that there is better control of the
ramus position when two-jaw surgery is performed.30
In this case, the ramus position was not changed and the
condyle was in the glenoid fossa. After 2 year follow up
after surgery, a stable skeletal relationship and occlusion
were maintained.
Sarver reported that clockwise rotation of the
occlusal plane can improve a flat or reverse smile arc.32
Tooth display relative to upper lip relation is important
during smile. In this case, clockwise rotation of the
maxillary occlusal plane was performed to achieve a
better smile.
Mandibular setback could increase the depth of
labiomental fold and increase facial convexity.33,34
Vertical
shortening of the chin can also increase the fold depth
and chin projection.35,36
Gallagher et al. reported that soft
50 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1
Hung TY, Lee WC, Lo Benjamin, Chen KT, Chou LJ, Li CH
appliance in severe skeletal Class III cases. Am J
Orthod Dentofacial Orthop. 1987; 92:304-312.
10. A l lwr igh t WC, Burndred WH. A su rvey o f
handicapping dentofacial anomalies among Chinese in
Hong Kong. Int Dent J. 1964; 14:505-519.
11. Lin JJ. Prevalence of malocclusion in Chinese
children age 9-15. Clin Dent. (Chinese) 1985; 5:57-65.
12. Baik, HS. Limitations in Orthopedic and Camouflage
Treatment for Class III Malocclusion. Semin Orthod.
2007; 13:158-174.
13. McIntyre GT. Treatment planning in Class III
malocclusion. Dental Update. 2004; 31: 13-20.
14. Bilodeau JE. Nonsurgical treatment of a Class III
patient with a lateral open-bite malocclusion. Am J
Orthod Dentofacial Orthop. 2011; 140:861-8.
15. Erverdi N, Usumez S, Solak A. New generation
openbite treatment with zygomatic anchorage. Angle
Orthod. 2006; 6:519–526.
16. Kuroda S, Katayama A, Takano-Yamamoto T. Severe
anterior open-bite case treated using titanium screw
anchorage. Angle Orthod. 2004; 74:558–567.
17. Moldez MA, Sugawara J, Umemori M, Mitani H,
Kawamura H. Long-term dentofacial stability after
bimaxillary surgery in skeletal Class III open bite patients.
Int J Adult Orthodon Orthognath Surg. 1999; 15:309-19.
18. Tsai IM, Lin CH, Wang YC. Correction of skeletal
Class III malocclusion with clockwise rotation of the
maxillomandibular complex. Am J Orthod Dentofacial
Orthop. 2012; 141:219-27.
19. Bisase B, Johnson P, Stacey M. Closure of the anterior
open bite using mandibular sagittal split osteotomy. Br
J Oral Maxillofac Surg. 2010; 48:352-5
20. Togawa R, Iino S, Miyawaki S. Skeletal Class III and
open bite treated with bilateral sagittal split osteotomy
and molar intrusion using titanium screws. Angle
Orthod. 2010; 80:1176-84
21. Park HS, Kim JY, Kwon TG. Occlusal plane
change after intrusion of maxillary posterior teeth
by microimplants to avoid maxillary surgery with
skeletal Class III orthognathic surgery. Am J Orthod
Dentofacial Orthop. 2010; 138:631-40.
CONCLUSION
Skeletal Class III malocclusion combined with
anterior open bite is difficult to treat. In this case, the
patient was corrected with two-jaw surgery, excellent
facial profile and dental relationship was achieved.
Clockwise rotation of the occlusal plane can increase
the amount of surgical mandibular setback and distal
movement of the chin. Mandibular setback can also
deepen the labiomental sulcus to correct a long, flat chin,
achieving a balanced facial profile. Factors that cause
black triangles should be considered, and communication
with patients before treatment is very important.
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