A case of extreme skeletal class III Malocclusion beyond the envelope of discrepancy, managed effectively by a modified ortho-surgical protocol.

Correction of severe anteroposterior skeletal discrepancy, as described in this case of Extreme Skeletal Class III Malocclusion, can be challenging and fraught with difficulties. Conventional, single stage Bi-jaw Orthognathic surgery, with pre-and post-surgical orthodontics is associated with drawbacks such as risk of relapse and an unsatisfactory outcome, with persisting occlusal discrepancies and skeletal abnormalities, especially when the magnitude of skeletal correction is large. Excessive mandibular setback restricts tongue space, narrows the posterior airway and pharyngeal spaces, and is prone to relapse from the forward pterygomasseteric pull; while large maxillary advancements are accompanied by wound dehiscence, bone exposure and delayed union at the site of pterygomaxillary disjunction, and risk of relapse due to backward palatopharyngeal pull. Bi-jaw surgeries invariably involve considerable blood loss and prolonged operating time with its attendant anaesthetic risks. These drawbacks may be obviated by employing a two staged protocol of Bi-jaw surgeries allowing a minimum time period of 3 months to elapse between them, which allows the oral and maxillofacial musculature to adapt itself to the new jaw position following the first surgery, thus creating a better and more stable environment for the succeeding one. This reduces the chance of relapse thereafter, and produces more effective and stable long term results. The intervening time period also allows for observation of the repositioned jaw and arch relations achieved, and scrutiny for any positional changes in this post-surgical phase, which thereby allows modifications in the planned surgery of the next jaw, thereby achieving the most ideal final outcome.

A Case of Extreme Skeletal Class III Malocclusion Beyond the Envelope of Discrepancy, Managed Effectively by a Modified Ortho-Surgical Protocol.

INTRODUCTION: Correction of a severe anteroposterior skeletal discrepancy, as described in this case of extreme skeletal class III malocclusion, can be quite challenging and fraught with difficulties. Conventional, single-stage bi-jaw orthognathic surgery with pre-and post-surgical orthodontics is associated with drawbacks such as the risk of relapse and an unsatisfactory overall long-term outcome, with persisting occlusal discrepancies and skeletal abnormalities, especially when the magnitude of skeletal correction required is large. Excessive mandibular setback can restrict tongue space, cause narrowing of posterior airway and pharyngeal space, and be prone to relapse from the forward pterygomasseteric muscle pull, while large maxillary advancements are often accompanied by wound dehiscence and bone exposure at the site of pterygomaxillary disjunction, delayed union or malunion at the osteotomy and disjunction sites, and risk of relapse due to backward palatopharyngeal muscle pull. In addition, bi-jaw surgeries invariably involve an appreciable blood loss and a prolonged operating time with its attendant anaesthetic risks such as respiratory insufficiency. AIM AND OBJECTIVES: To develop an orthosurgical protocol wherein excessive skeletal discrepancy can be successfully managed, achieving the desired magnitude of correction, with little or no relapse. To assess its efficacy and superiority over the hitherto-employed single-stage bi-jaw procedures in the management of severe skeletal discrepancies. MATERIALS AND METHOD: A two-staged, shorter 'single-jaw at a time' operative procedure with an intervening period of three months between the two surgical phases was employed. RESULTS: Drawbacks of conventional orthognathic surgery may be obviated by employing a two-staged protocol of bi-jaw surgeries allowing a minimum time period of 3 months to elapse between them. This period of time intervening between the maxillary advancement and mandibular setback allows the oral and maxillofacial musculature to adapt itself to the new jaw position following the first surgery, thus creating a better and more stable environment for the succeeding one, thereby reducing the chances of relapse thereafter, and producing more effective and stable long-term results. Moreover, the intervening time period also allows for observation of the repositioned jaw and arch relations achieved, and scrutiny for any positional changes in this post-surgical phase, which thereby allows modifications in the planned surgery of the next jaw, so as to achieve the most ideal final outcome following the second jaw surgery. A shorter operating time, reduced operator fatigue and less blood loss are other obvious advantages over the conventional bi-jaw procedures. CONCLUSION: An effective and stable correction of the extreme class III skeletal deformity and malocclusion was achieved, with a dramatic enhancement of facial balance, symmetry and proportion in this patient, following a modified orthosurgical management protocol. The staged protocol of 'maxilla first and mandible after' orthognathic surgery with conventional pre- and post-surgical orthodontics helped in pushing the envelope of skeletal discrepancy correctable by orthognathic surgery, thereby achieving large quantum of jaw movements, with ideal and stable functional as well as aesthetic results. This is suggestive of its efficacy and superiority over the hitherto-employed single stage bi-jaw procedures in the management of severe skeletal discrepancies.

Comparative evaluation of anchorage loss between self-ligating appliance and Conventional pre-adjusted edgewise appliance using sliding mechanics - A retrospective study.

BACKGROUND: Although a number of studies have been undertaken to evaluate the friction characteristics of self-ligating brackets, there have been only few studies which have actually evaluated the clinical efficiency of these self-ligating brackets. This study was done to evaluate the clinical efficiency of Passive SLB (Smart Clip) in terms of anchorage loss and total treatment duration by comparing it with a Conventional pre-adjusted edgewise (M.B.T.) bracket system. METHODS: This was a retrospective study in which the study sample comprised of ten patients treated with Passive SLB (Smart Clip, 0.022″) and ten patients treated with Conventional pre-adjusted edgewise (M.B.T.) bracket system (0.022″) who required therapeutic extraction of U/L first premolars as a part of their orthodontic treatment plan. Pretreatment and post treatment lateral cephalograms were taken to evaluate the amount of anchorage loss. The total time required to complete the treatment was also recorded. RESULTS: Anchorage loss observed with Passive SLB (Smart Clip) sagittally was 1.90 ± 0.68 mm in the maxilla and 1.90 ± 0.43 mm in the mandible and vertically was 0.52 ± 0.53 mm in the maxilla and 0.70 ± 0.69 mm in the mandible. Anchorage loss observed with Conventional pre-adjusted edgewise (M.B.T.) bracket system sagittally was 2.08 ± 0.43 mm in the maxilla and 1.95 ± 0.44 mm in the mandible and vertically was 0.50 ± 0.49 mm in the maxilla and 0.68 ± 0.53 mm in the mandible. The average time taken for the completion of treatment in Passive SLB (Smart Clip) and Conventional pre-adjusted edgewise (M.B.T.) bracket system was 14.0 ± 2.4 and 17.2 ± 2.6 months respectively. CONCLUSION: There was no statistically significant difference in the quantum of anchor loss between Smart Clip self-ligating bracket system and Conventional pre-adjusted edgewise (M.B.T.) bracket system although Smart Clip self-ligating bracket system is efficient in reducing the overall treatment time.

Self ligating lingual appliance.

Adult demand for orthodontics has grown considerably over the past 10 years propelling increased demand for Esthetic Orthodontics. Lingual appliances are a viable option toward providing Esthetic Orthodontics. The lingual surface of the teeth has a unique morphology that makes it difficult to place brackets in ideal positions. Indirect bonding has become the established methods of overcoming these discrepancies, along with the latest designs of self ligating brackets which offer more efficient mechanics and shorter treatment time.