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Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com

CASE REPORT

Total subapical mandibular osteotomy to correct class
II dento-facial deformity
Munoz R
1
,Golaszewski J
2
,Diaz, A
3

1,2,3- Oral and Maxillofacial Surgeon.
Dr ANGEL LARRALDE Carabobo Universitary Hospital, VENEZUELA


ABSTRACT:
Many patients with class II dentofacial deformities, skeletal alterations, where the
jaw may occurs regarding the retruded maxilla or in other cases presenting
anatomical changes. There are many options for treating this type of malocclusion
using orthodontic appliances or orthodontic-surgical procedures. Depending on the
nature of the problem and its severity, the surgical correction of Class II
dentofacial deformities may involve surgery or bimaxillary monomaxilar. This
paper reports a case of class II dentofacial deformity, which was treated by the
technique of subapical osteotomy total, following the completion of presurgical
orthodontics. In this paper we present a female patient aged 24 who presented
Class II dentofacial deformity. Facial analysis showed deficiency third height
lower face, neck, chin line between 42mm approx normal values, the overjet was 6
mm with a marking groove and quantified mentolabial 5mm dental midlines.
Patients in the immediate postoperative period have the ability to open and close
his mouth with mild discomfort and decreased facial edema. After the initial period
of Hypoaesthesia, is associated with a recovery of the sensitivity of the lower lip,
as well as the oral mucosa and gingiva.


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KEYWORDS. Osteotomy, total subapical, overjet, Dentofacial deformities Class
II


Cite this Article: Munoz R

,Golaszewski J, Diaz, A:

Total subapical mandibular osteotomy
to correct class 2 dento-facial deformity: Journal of Head & Neck physicians and
surgeons Vol 2 Issue 1 2014 : Pg 91-101

INTRODUCTION:

Class II malocclusions are the most frequent of dentofacial deformities seen in
clinical practice, occurring in 13% of the population (Proffit, et al., 1998) Many
patients with class II dentofacial deformities, which may occur retruded jaw in
relationwith to the maxilla or other anatomic abnormalities. There are many
options for treating this type of malocclusion using orthodontic appliances or
orthodontic-surgical procedures (Cassidy et al., 1993). Depending on the nature of
the problem and its severity, the surgical correction of class II dentofacial
deformities may involve surgery monomaxillary or bimaxillary. The sagittal split
osteotomy is the technique used for Excellence (Trauner et al., 1957). Subapical
osteotomy was first described by Hullinhen (Hullihen et al.,1849) . However, this
surgery was limited to the anterior portion only. Hofer 1942 and Kole (1959),
popularized the subapical technique.

Total mandibular alveolar osteotomy was described by Macintoch (1974) for the
correction of apertognathia or anterior open bite. Eliades and Hegdvedt (1996)
reported a case where describe a combination of sagittal split osteotomy with full
subapical osteotomy for correction of Class II malocclusions successful branch
2
.
Pangrazio-Kulbersh (2001) compared the total subapical osteotomy with bilateral
sagittal split osteotomy for correction of class II dentofacial deformities, showing
both long-term stable results. They refer in their article that the subapical
osteotomy was used in the case where the depth wanted mentolabial improve.
(Boye et al., (2012) described the overall subapical osteotomy technique where
perfom a identification of mental nerve, and they make a careful removal of
cortical bone around the mental foramen with total replacement upwards or

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downwards with respect to the channel. Among the disadvantages described for
full subapical osteotomy included the time required to perform the surgery
meticulously avoiding mental nerve damage, loss of tooth vitality, loss of teeth or
alveolar necrosis. This article report a case of class II dentofacial deformity, which
had deep sulcus mentolabial and projected chins, which were treated by complete
subapical osteotomy technique with a modification of the original technique (Fig
1).

SURGICAL TECHNIQUE:
After nasotracheal intubation was performed aseptic and antiseptic techniques,
local anesthetic infiltrated Lidocaine 2% with Epinephrine 1:80,000 in the
mandibular region. A circunvestibular incision was made from canine to canine,
and lower vestibular incision in the molar area taking into account the damage to
the mental nerve and the minimum subperiosteal dissection is necessary in order
to perform the operation using mucoperiosteal tunnel. Performing the subsequent
vertical line marking on the third molar region and anterior midline level quantized
with respect to the height of the mental nerve, obtained in the prediction surgical
panoramic radiograph and lateral cephalic radiographic. Then proceed to make the
retro molar vertical osteotomy with reciprocating saw avoiding injuring the lingual
mucosa. Then proceeds to perform horizontal osteotomy from the retro molar
mucoperiosteal tunnel through to the anterior midline of the apexes 5mm dental
considering avoid injury to the oral mucosa. Likewise, it proceeds to the
contralateral side for dentoalveolar subapical block release.

When the dentoalveolar segment is completely separated from the base portion, we
proceeds to move it, and is reset to the pre-planned position, the entire
dentoalveolar segment is now stabilized and fixed by osteosynthesis plates 2.0
system and monocortical screws, both in the zone anterior and posterior. The
buccal mucosa is then sutured with absorbable suture (fig 2).
CASE REPORT:
Female patient is 24 years of age who presented class II dentofacial deformity (Fig
3). Facial analysis showed deficiency lower third height facial chin line between

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normal neck approx 42mm, 6mm its overjet was marked with a groove and
quantified mentolabial sulcus in 5mm; dental midlines facial were aligned, she had
an adequate soft pogonion projection with an aesthetically chin. Subsequent
evaluation is requested preoperative clinical examination, conventional
radiographs (lateral cephalic Rx, Rx panoramic, skull PA Rx)( Fig 4), model
studies were made.Then he proceeded to perform preoperative cephalometric
tracings and surgical prediction (Protocol Bell, Obwegeser, Epker, Wolford) and
model surgery for surgical planning.




Fig 1. Total subapical osteotomy Muoz, Golaszewski, Diaz (2013)

(a)

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(b)

(c)

(d)
Fig 2. Intraoperative clinical fotographs. Subperiosteal dissection (a). references lines for
osteotomies (b). frontal view of the osteotomies (c). clinical fotographs of rigid fixation (d)

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(a) (b) (c)
Fig 3. Clinical phothographs frontal view (a), lateral view (b) presurgical intraoral view (c)



(a) (b)

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Fig 4. Preoperative conventional radiographs. Panoramic (a). Lateral cephalogram (b)


(a) (b) (c)
Fig 5. Preoperative fotographs. Frontal (a) and lateral (b) views. Postoperative intraoral view (c)

A


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B

Fig 6. Postoperative conventional radiographs. Panoramic (a) lateral cephalogram (b)

After performing the preoperative was scheduled make subapical osteotomy
technique for advancing Total 6mm. It was made to order by the case Orthodontist
for placement of surgical pins and proceed with the surgery. During surgery
proceeded to the performance of the technique described above.
DISCUSSION:
Today subapical osteotomy has been reported in the literature, most of these
reports are limited to surgical procedures to the anterior portion, while the
subapical osteotomy total reasonable surgical alternative for the correction of
certain class II dentofacial deformities, currently has very few reports (Dietz et al.,
1977) One of the reasons for the popularity of poor technique Mandibular basal
osteotomy may be due to the intricacy (Boye, 2012) implies an increase of between
1.5 to 2 times the time taken in performing a bilateral sagittal split osteotomy
branch. Surgery in our report did not imply an increase in surgical time
development of a conventional act .From the perspective of patients the technique
has a higher number of advantages. The pain and dysphagia associated with
bilateral sagittal split osteotomy branch is lower in the basal mandibular osteotomy
technique (Murray et al., 1980)

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Patients in the immediate postoperative period have the ability to open and close
your mouth with mild discomfort and decreased facial edema. Subsequent to the
initial period Hypoaesthesia, recovery is associated sensitivity of the lower lip as
well as the oral mucosa and attached gingiva. It must be handled with caution to
avoid injury to the apices of the teeth and the inferior alveolar nerve, which can
lead to devitalization of dental unit.

We feel that the total subapical osteotomy was indicated because it preserved the
integrity of the complete lower dental arch and also allowed antero-posterior and
vertical correction of the malocclusion resulting in an excellent aesthetic and
functional result. We believe it is a technique that should be used by trained
surgeons, because the success of the technique is based on the cautious and
meticulous handling of soft tissue as well as the appreciation of the anatomical
structures of the area. In addition to respecting the basic principles of surgery
avoiding excessive subperiosteal dissection when performing osteotomies.

CONCLUSION:
This technique should be used by trained surgeons, because the success of the
technique is based on caution and meticulous management of soft tissue as well as
the appreciation of the anatomical structures of the area. In addition to respecting
the basic principles of surgery avoiding excessive periosteum when performing the
osteotomies. Due to the sensitivity of the performance of this technique and
possible complications is considered important the choice of patients under the
indications of this technique. This technique should be considered in handling
potential surgical class II dentofacial deformities, due to its excellent postoperative
cosmetic result.




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REFERENCES:
1. Proffit WR, Fields Jr HW, Moray LJ: Prevalence of malocclusion and orthodontic treatment
need in the United States: estimates from the NHANES III survey. Int J Adult Orthodon
Orthognath Surg 13: 97e106, 1998
2. Cassidy Jr DW, Herbosa EG, Rotskoff KS, Johnston Jr LE: A comparison of surgery and
orthodontics in borderline adults with class II, division malocclusions. Am J Orthod
Dentofacial Orthop 104: 455e470, 1993
3. Trauner R, Obwegeser H: The surgical correction of mandibular prognathism and retrognathia
with consideration of genioplasty. I. Surgical procedures to correct mandibularprognathism
and reshaping of the chin. Oral Surg Oral Med Oral Pathol 10:677e689, 1957
4. Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, caused
by a burn, successfully treated. Am J Dent Sci 9:157, 1849
5. Hofer O: Operation der prognathie und mikrogenie. Dtsch Zahn Mund Kieferh 9:121, 1942
6. Kole H: Surgical operations on the alveolar ridge to correct occlusal abnormalities.Oral Surg
Oral Med Oral Pathol 12: 277e288, 1959
7. MacIntosh RB: Total mandibular alveolar osteotomy. Encouraging experiences with an
infrequently indicated procedure. J Maxillofac Surg 2: 210e218, 1974
8. Eliades T, Hegdvedt AK: Orthodontic-surgical correction of a class II, division 2
malocclusion. Am J Orthod Dentofacial Orthop 110: 351e357, 1996
9. Pangrazio-Kulbersh V, Berger JL, Kaczynski R: Stability of skeletal class II correction with 2
surgical techniques: the sagittal split ramus osteotomy accxcxnd the total mandibular
subapical alveolar osteotomy. Am J Orthod Dentofacial Orthop 120: 134e143, 2001
10. Boye et al. Total subapical mandibular osteotomy to correct class 2 division
dento-facial deformity. Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 238e242
11. Dietz VS, Gianelly AA, Booth DF: Surgical orthodontics in the treatment of a class II,
division 2 malocclusion: a case report. Am J Orthod 71: 309e316, 1977
12. Murray RB: Mandibular sagittal subapical osteotomy: a case study. Am J Orthod 77:469e485,
1980




Acknowledgement- None
Source of Funding- Nil
Conflict of Interest- None Declared

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Ethical Approval- Not Required

Correspondence Addresses :
Altos de la Colina Psiquiatra de Brbula
25-15. NAGUANAGUA -CARABOBO VENEZUELA
20-42 Phone: +58-414-4000602 (Fax) +58 241 867.31.04
E-mail: dr.rubenmuoz@gmail.com



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