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Paweena Tammataratarn
Paweena Tammataratarn
Main Instructor Yuh- Jia Hsieh
Department / Institution Department of Craniofacial Orthodontics, Chang Gung Memorial hospital, Taoyuan, Taiwan
Classification Case report
 This case report describes a modified surgery first approach to manage an adult patient with skeletal Class III malocclusion, anterior open bite and severe crowding of upper anterior teeth.
  A 18-year-old female complained about her prominent chin. Extra orally, she had skeletal Class III malocclusion with concave profile, normal mandibular plane angle and mild asymmetry. Intraoral examination presented anterior open bite from canine to canine, bilateral anterior and posterior lingual cross bite, and severe crowding of upper arch, and mild crowding of lower arch. A two-jaw orthognathic surgery was planned with modified surgery-first approach. Five months of limited presurgical orthodontics treatment was performed to relieve dental crowding, and correct upper dental midline. Le Fort I osteotomy and bilateral sagittal split osteotomies were conducted for maxillary advancement, mandibular setback, and clockwise rotation of maxilla-mandibular complex. Post-operative orthodontic treatment including leveling and alignment, remaining space consolidation, and detailing of the occlusion began immediately after the surgery. The total treatment duration was 1 year and 5 months. After treatment, the patient’s facial esthetics, occlusion, and chewing function were all considerably improved.
Discussion and Summary
 In this case, the presurgical orthodontics is mainly to eliminate anterior occlusal interferences and to align the dental midline with the basal bone. This modified surgery-first approach can simplify pre-surgical occlusion set-up, surgical procedure and postoperative orthodontics. The patient can improve chewing function soon after surgery and post-surgical occlusion detailing is more efficient. Performing limited presurgical orthodontics is an alternative way of surgery-first approach to improve the efficiency and effectiveness of orthognathic surgery in Class III malocclusion with severe dental crowding.

A Modified Surgery- First Approach for Mandibular Prognathism with Severe Crowding and Midline Deviation