combined maxillary and mandibular midline and mandibular ramus distraction osteogenesis for...

CASE REPORT

Combined maxillary and mandibular midlineand mandibular ramus distraction osteogenesisfor treatment of a Class II patient with implantsas orthodontic anchorage

Ichiro Takahashi,a Hiroshi Kawamura,b and Teruko Takano-Yamamotob

Sendai, Japan

This case report describes the treatment of a woman with severe mandibular retrusion and maxillomandibulartransverse deficiency. Her malocclusion was characterized by a large overjet, a deep overbite, and a V-shapeddental arch, and she had a skeletal Class II profile. Treatement included combined maxillary and mandibularmidline expansion, maxillary downward repositioning, and mandibular ramus lengthening with distractionosteogenesis with implants as orthodontic anchorage. During the postdistraction orthodontic treatmentperiod, some skeletal relapse occurred. Implants provided absolute orthodontic anchorage to overcomethe unexpected skeletal changes. Combined orthodontic treatment with implants for anchorage and distrac-tion osteogenesis successfully expanded the maxilla and the mandible and corrected the mandibulardeficiency. Two-year follow-up records show a morphologically and functionally stable result. (Am J OrthodDentofacial Orthop 2010;137:412-23)

Distraction osteogenesis (DO) is recognized asa major option in the treatment of maxillofacialdeformities with vertical, transverse, anteropos-

terior mandibular, or maxillary deficiencies in growingand adult patients.1 Since mandibular DO was firstdescribed in 1992 by McCarthy et al,2 applications ofdistraction osteogenesis have been developed for vari-ous maxillofacial deformities. Mandibular symphysealdistraction osteogenesis (MSDO),3-5 mandibular bodyand ramus lengthening,2,6,7 the rigid external distractionsystem,8,9 maxillary advancement with an internal dis-traction device,10 and alveolar distraction osteogene-sis11 have all been developed by using various uniquedistraction devices. Combining devices has enabledthe correction of complex maxillofacial deficiencies.The advantages of DO, when compared with bilateralsagittal split ramus osteotomy (SSRO), are graduallengthening of the bones with lengthening of surround-

From the Graduate School of Dentistry, Tohoku University, Sendai, Japan.aAssistant professor, Division of Orthodontics and Dentofacial Orthopedics.bProfessor, Division of Maxillofacial Surgery.

The authors report no commercial, proprietary, or financial interest in the prod-

ucts or companies described in this article.

Reprint requests to: Teruko Takano-Yamamoto, Division of Orthodontics and

Dentofacial Orthopedics, Graduate School of Dentistry, Tohoku University,

4-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan; e-mail, t-yamamo@

mail.tains.tohoku.ac.jp.

Submitted, May 2007; revised and accepted, August 2007.

0889-5406/$36.00

Copyright � 2010 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2007.08.038

412

ing soft tissues such as muscles, tendons, and fibrousconnective tissues; gradual advancement or transverseexpansion of the mandible with minimal influence ontemporomandibular joint (TMJ) conditions12-14; length-ened alveolar bone providing space for aligning teeth;and reduction of skeletal relapse after application.7

However, DO is still rapidly developing in orthodontictreatment, and scientific and clinical evidence needs tobe integrated.

On the other hand, the use of implants as orthodonticanchorage is becoming a popular, stable, and safe treat-ment option for various malocclusions.15-17 It providesan immobile anchor for tooth movement such as distal-ization of molars, intrusion of whole dental arches in-cluding molars, and simultaneous distalization andintrusion of molars.15 In addition, in some patients, itcan also be used for intermaxillary fixation after orthog-nathic surgery. Many types of miniscrews and mini-plates have been developed for these approaches overthe past 10 years and applied to various malocclusions.

In this case report, we demonstrate combined treat-ment of DO and absolute orthodontic anchorage usingimplants in an adult Class II patient with a retrognathicprofile.

DIAGNOSIS AND ETIOLOGY

The patient was a Japanese woman (aged 39 years 1month) with a chief complaint of maxillary protrusion.

mailto:[email protected]

mailto:[email protected]

Fig 1. Pretreatment facial photographs show the large interlabial gap and gummy smile.

Fig 2. Pretreatment dental casts show large overjet, deep overbite, and Class II molar and caninerelationships. The maxillary dental arch was narrow, and the mandibular dental arch was relativelywide.

American Journal of Orthodontics and Dentofacial Orthopedics Takahashi, Kawamura, and Takano-Yamamoto 413Volume 137, Number 3

Her medical history was normal. She had a convex fa-cial profile, a gummy smile, and hypertonicity of thementalis muscle during closing of the lips. She had a se-vere Class II malocclusion with 12.0 mm of overjet, andshe was missing the maxillary right first premolar anda mandibular left first molar. The periodontal parame-ters were acceptable for orthodontic treatment. Theprobing depth of all teeth was less than 3.0 mm, andno bleeding on probing was recorded at the initial exam-

ination. Functionally, her TMJs had no symptoms; how-ever, anterior guidance was nonexistent.

The facial photographs indicated a convex facialappearance, a protruded upper lip, overexposure of themaxillary incisors, a gummy smile, and a large interla-bial gap (Fig 1). The dental casts showed severe maxil-lary protrusion with large overjet, deep overbite, andtransverse deficiency with narrow dental arches (Fig2). The molar relationship was Angle Class II on both

Fig 3. Pretreatment lateral cephalometric and pano-ramic x-rays. Note the missing maxillary right first pre-molar and mandibular left first molar.

Fig 4. Treatment goal (solid line) superimposed on pre-treatment tracing (dotted line).

414 Takahashi, Kawamura, and Takano-Yamamoto American Journal of Orthodontics and Dentofacial Orthopedics

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sides, and a lateral crossbite was found in the left secondpremolar region. Her panoramic radiograph showed thatshe was missing all third molars except for the mandib-ular left one, in addition to a maxillary right first premo-lar and a mandibular left first molar as described above(Fig 3).

Cephalometric analysis indicated that she had a skel-etal Class II jaw deformity (Fig 4). The ANB angle was8.0�, and the Wits appraisal was 6.3 mm. The SNA angleof 80.1� reflected a normally positioned maxilla, and theSNB angle of 72.1� indicated mandibular deficiency. Hermandibular plane angle to the SN plane (MP-SN) was49.5�; this was steeper than that typical of Japanesewomen. In addition to these skeletal problems, she had

labially proclined and extruded maxillary incisors andextruded mandibular incisors with a deep curve of Spee.The linear and angular cephalometric measurements aregiven in the Table. The following problems needed tobe resolved: (1) skeletal Class II anteroposterior jaw rela-tionship, (2) steep mandibular plane angle, (3) narrowmaxillary and mandibular dental arch, (4) gummy smilewith large interlabial gap and tooth exposure, (5) bilateralAngle Class II molar relationships, (6) large overjet, (7)excessive mandibular incisor height and deep overbite,(8) lateral crossbite at the left first premolar, and (9) labialproclination of the maxillary incisors.

TREATMENT OBJECTIVES

Because the patient was concerned about her facialesthetics, treatment options were considered to correctthe mandibular deficiency. The severe skeletal Class IIdeformity directed the orthognathic surgery. To solvethe problems above, the treatment objectives for thispatient were the following: (1) correct the imbalanced

Fig 5. Intraoral photographs immediately after the placement of the distractors: A and C, bone platesprovided absolute anchorage; B, bone- and tooth-borne MSDO distractor.


Class II anteroposterior jaw relationship; (2) coordinatethe widths of the dental arches; (3) reduce the steepmandibular plane angle; (4) reduce the deep overbite;(5) improve the gummy smile, the large interlabialgap, and tooth exposure; (6) correct the molar relation-ship; (7) reduce the overjet; (8) decrease mandibular in-cisor height; (9) correct the lateral crossbite on the leftside; and (10) improve the inclination of the maxillaryincisors.

A 2-dimensional visualization of the treatment goalsfor the patient on the cephalometric tracing is shown inFigure 4. Five millimeters of maxillary impaction, 7 mmof advancement of the mandible, 5 mm of advancementof the chin, and height reduction of the symphysis wereplanned.

The 7 mm of planned mandibular advancement wason the borderline between bilateral SSRO or DO. With-out making the space to align and intrude the anteriorteeth by MSDO and maxillary midline DO, extractionof the premolars would be needed. By using implantsas orthodontic anchorage from the beginning of treat-ment, tooth-bearing alveolar bone generated by DOcould be used as available alveolar bone. In addition,because widening of the dental arches was also needed,we decided to use a combination of MSDO, maxillarymidline DO, and mandibular ramus and body DOto achieve the treatment goals in one-time surgicalintervention without tooth extractions. The followingtreatment was planned to achieve these treatment objec-tives: (1) bilateral mandibular ramus and body DO tosimultaneously increase the ramus height and bodylength, and reduce the mandibular plane angle; (2)MSDO and maxillary midline DO to coordinate thearch widths and partially obtain space to retract the max-illary incisors and intrude the mandibular incisors; (3)impaction of the maxilla to reduce the anterior maxillaryincisor height; (4) genioplasty to improve the retrudedchin and reduce incisor height; (5) retraction and retro-clination of the maxillary incisors to reduce overjet byusing implants as orthodontic anchorage; and (6) flatten-

ing the deep curve of Spee and intruding the mandibularincisors to reduce mandibular incisor height.

TREATMENT ALTERNATIVES

Because the patient’s main concern was related tofacial esthetics, treatment options were considered tocorrect the mandibular deficiency. Her severe Class IIskeletal relationship required orthognathic surgery.Bilateral SSRO and LeFort I osteotomy or a combina-tion of mandibular ramus and body DO, MSDO, andmaxillary midline DO were considered as treatmentoptions. DO can provide bone regeneration to increasethe available arch length for tooth alignment at thebeginning of combined orthodontic and orthognathicsurgical treatment, whereas bilateral SSRO cannotprovide this effect. In addition, since midline DO canenlarge the oral cavity, we selected DO as the primaryoption in her treatment.

TREATMENT PROGRESS

Fixed prostheses for the maxillary right first premo-lar and mandibular left first molar were removed. Fixedappliances (0.022 3 0.028-in preadjusted edgewise)were placed, and segmented passive wires (0.019 3

0.026-in heat-treated heavy wires) were set in eachquadrant of both dental arches. In the treatment plan,all DO procedures were to be performed before ortho-dontic tooth movement because the space created bybone regeneration was needed to align and level thedental arch. Bilateral osteotomy at the angle of the man-dible, mandibular symphyseal osteotomy with genio-plasty, and maxillary midline osteotomy with LeFort Iosteotomy were performed with an intraoral approach.The anterior part of the maxilla was impacted and wiredto the piriform edge. Intraoral distraction devices wereplaced, spanning the osteotomized sites at the mandib-ular angles and symphysis (Fig 5). Bone-borne intraoraldevices (Leibinger, Freiburg, Germany) were placed atthe mandibular angle, and a bone- and tooth-borne

Fig 7. Panoramic x-ray immediately after removal of thedistractor. Distraction gap on right ramus was rigidlyfixed by using a bone plate.


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distraction device (Leibinger) was fixed to the symphy-seal osteotomy site. Both arches were fixed on the rightand left with a resin-made occlusal splint. This dis-tracted the maxillary midline as the mandibular distrac-tion device was activated. Similarly, intermaxillaryfixation transferred the distraction force from the dis-tractor placed on the angle of the mandible to the max-illary bones, thereby inducing downward movement ofthe posterior maxilla. Wiring beside the anterior nasalspine was fixed to maintain the level of the anterior max-illa during distraction.

After a latency period of 7 days, distraction wasstarted by activating the devices twice a day at therate of 1.0 mm per day. Distraction was continueduntil a 10-mm distraction gap was obtained at themandibular angle and a 5.0-mm gap was produced atthe maxillary midline (Fig 6, A and B). Bone plates(Leibinger) were fixed on the bilateral mandibularbody and zygomatic buttress simultaneously duringthe surgical placement of distraction devices for creat-ing implant anchorage.

The distraction devices were maintained until the5-month consolidation period was completed. Immedi-ately after distraction, backward movement of the con-dyles in the glenoid fossa was found; this could havecaused TMJ pain (Fig 6, C-F). When the distractorswere removed, since the consolidation of the distractiongap in the right mandibular angle was incomplete,a bone plate was placed spanning the distraction gapto fix the proximal and distal segments (Fig 7). To pre-vent root resorption of the teeth, postdistraction

Fig 6. A and B, Lateral cephalometric and panoramicx-rays taken after distraction; C-F, Schuller method28

of x-ray photography of the TMJ at the beginning (Cand E) and end (D and F) of distraction indicates the pos-terior displacement of the condyle in the glenoid fossa.

:

Fig 8. Intraoral photographs immediately after removal of the distractors. Treatment was thenstarted by using implanted bone plates (arrowheads) tied to a hook of canine brackets. Note theexpanded dental arches.


orthodontic treatment was started after 5 months of con-solidation.18,19

After the distractors were removed, postoperativeorthodontic treatment was started by using bone platesas anchorage. By fixing the canines to bone plates im-planted as anchors, the maxillary incisors were retractedby using the space made by the maxillary midline DO(Fig 8). The space made at the symphysis was usedfor intrusion of the mandibular incisors and flatteningthe curve of Spee. The anteroposterior relationship ofthe maxillary and mandibular dental arches wasadjusted, and the maxillary incisors were retroclinedand moved lingually to achieve the treatment goal. Asthe treatment progressed, some skeletal relapse wasobserved (Figs 9 and 10). To overcome this, the maxil-lary dental arch was totally distalized to adjust the ante-roposterior dental relationship. The spaces for missingteeth were adjusted to suitable sizes for later prosthetictreatment. After removing all fixed appliances, the boneplates for absolute anchorage were removed, the maxil-lary right premolar region was restored by dentalimplants, and the mandibular left molar was restoredby using a bridge with a shorter span than that usedbefore treatment.

TMJ dysfunction symptoms appeared duringdistraction. The patient particularly suffered from painduring jaw opening and closing. The mandibular con-dyles showed slight resorption after the DO treatment.The symptoms gradually lessened after the DO and dur-ing orthodontic treatment, and disappeared altogether atdebonding.

TREATMENT RESULTS

The skeletal Class II facial profile was improved bycombined mandibular ramus and body and mandibularsymphyseal distraction osteogenesis (Figs 9-11). Thelarge interlabial gap and exposure of the maxillaryincisors were both reduced, and the gummy smile wasimproved (Fig 11). Although the mandibular body waslengthened by 10 mm immediately after distraction,3 mm of relapse was observed during orthodontic treat-ment (Fig 10). In this patient, the expected 7 mm ofadvancement was mostly achieved by the end of activeorthodontic treatment. Changes in linear and angularcephalometric measurements and comparisons withJapanese norms after treatment are given in the Table.20

Relapse in the mandibular body length and total mandib-ular length was observed 1 to 2 years after removal of thedistraction devices by the time of debonding. The 3-mmrelapse at the chin (Fig 10) was related to shortening ofthe mandibular body length as indicated (Table 1). Mostlinear and angular measurements in the Table were sta-ble 2 years after debonding.

The large overjet and deep overbite were improvedby orthodontic treatment after the DO, and a good staticocclusion was obtained by the time of debonding (Fig12). The treatment goals set at the beginning of the treat-ment were achieved, except for a greater retroclinationof the maxillary incisors than planned (Table). Ade-quate intercuspation was achieved during static occlusalcontact. A circumferential retainer was used in the max-illary arch, and a flexible multistrand wire was bondedon the 6 mandibular anterior teeth.

Fig 10. Superimposition of cephalometric tracings atpretreatment, after consolidation, and at debonding.

Fig 9. Lateral cephalometric x-ray at dedonding.


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The edentulous sites were treated after debonding.At the patient’s request, the maxillary right premolarwas restored with a dental implant, and the mandibu-lar left first molar region was reconstructed with abridge (Fig 13). Two years after active treatment,static occlusion was maintained (Figs 14-16), and thepatient was satisfied with both the esthetic and func-tional results.

DISCUSSION

Distraction osteogenesis was developed to lengthenlong bones that load mechanical compressive stressfrom the surrounding soft tissues and muscularfunctions. Although DO has been applied to the maxil-lofacial skeleton to lengthen the mandible2 and isexpected to eventually substitute for conventionalorthognathic surgery, it is not yet largely accepted asa primary option for treatment because of the complex-ity of the procedures, the patient’s burden, and weak sci-entific evidence for application.7,12 Many basic studieswith animals, however, have demonstrated that DOcould be a better treatment option than conventional or-thognathic surgery for complex craniofacial deformitieswhen increased length and width of the bones are

needed.18,19,21-24 DO can actually enlarge the oral cav-ity and regenerate bone on which to align the teeth.Our patient shows that DO can improve many compli-cated problems.

Although some previous studies claim that DO isadvantageous over SSRO for TMJ symptoms, severalunfavorable symptoms occurred in this patient, includ-ing joint pain and a decrease in the amount of maximumjaw opening.16-18 These symptoms could also occur inpatients undergoing mandibular advancement withbilateral SSRO. Age might have caused these unfavor-able TMJ effects of DO. However, the TMJ symptoms,including pain and restricted mouth opening, allimproved after removal of the appliances. Some previ-ous clinical and animal studies also demonstrated a cer-tain risk for condylar resorption or TMJ disorders, butthese effects were transient and reversible.25-27

Even after 5 months of consolidation, bone regener-ation in the right distraction gap was immature, whereas

Fig 11. Facial photographs at debonding. Facial esthetics, gummy smile, and large interlabial gapswere improved.

Tabel 1. Lateral cephalometric measurements

T1 T2 T3 T4 T5 Japanese norms

SNA 79.8� 80.2� 81.3� 79.1� 79.8� 80.8�

SNB 73.3� 76.5� 78.3� 73.6� 74.5� 77.9�

ANB 6.4� 3.8� 3.0� 5.5� 5.4� 2.8�

Upper incisor to SN 117.4� 114.6� 113.9� 94.4� 96.1� 105.9�

IMPA 98.0� 92.6� 95.6� 91.8� 93.5� 93.4�

Occlusal plane to SN 17.5� 14.7� 16.2� 20.7� 18.9� 16.9�

Mandibular plane to SN 48.8� 43.6� 45.0� 45.7� 45.7� 37.1�

Wits appraisal 5.8 mm 2.9 mm �0.7 mm 1.8 mm 2.1 mm —

Go-Me 65.7 mm 73.7 mm 70.8 mm 68.3 mm 68.4 mm 69.0 mm

Ar-Go 37.7 mm 45.1 mm 44.8 mm 43.8 mm 44.0 mm 45.7 mm

Ar-ME 97.5 mm 110.9 mm 110.7 mm 107.0 mm 108.1 mm 103.0 mm

T1, Initial; T2, immediately after distraction; T3, removal of distractors; T4, at debonding; T5, 2 years after debonding.


other distraction gaps had mature bone. Therefore, bonefixation with a bone plate was needed on the mandibularright ramus when the distractors were removed. Asshown in the literature, although patient age could bea factor causing delay of maturation of the regeneratedbone, other factors such as right-left asymmetry in theamount or orientation of the distraction or thin bonygaps found immediately after placing the distractorsmight cause uneven mechanical stability in the distrac-tion gap; this could result in uneven maturation ofregenerated bone.12 Eventually, however, sufficientbone formation was observed, and good mechanicalstability was obtained.

The skeletal relapse was mainly observed during1 to 2 years of postdistraction orthodontic treatmentas described above. In this patient, backward move-ment of the chin could have been caused by relapsein mandibular body length rather than in ramus height.

Thus, skeletal relapse during the treatment could becaused by the tension from the soft tissues. A previousstudy indicated that the mandibular plane angle was re-lated to the amount of the skeletal relapse.7 In thatstudy, patients with MP-SN angles larger than 38�

had greater relapse at Point B than those with shallowermandibular plane angles after 1 year of follow-up. Inour patient, since the MP-SN was 48.8� initially,some relapse was expected during postdistractionorthodontic treatment and was observed. Althoughthe long-term stability of the distracted facial bonesis still unclear, this patient has a stable anteroposteiorrelationship of total mandibular length, mandibularramus height, and mandibular body length 2 years afteractive orthodontic treatment. Thus, it could be consid-ered that the skeletal relapse after distraction occurs1 to 2 years after distraction, and skeletal morphologybecomes stable thereafter.

Fig 13. Posttreatment dental casts including completed prosthetic treatment.

Fig 12. Intraoral photographs at debonding show well-aligned dental arches.


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The large overjet and deep overbite were bothimproved by orthodontic treatment after DO, and goodstatic occlusion was established by the end of the treat-ment. Regenerated bone made by distraction was usedto retract the maxillary and mandibular incisors. Sincetooth movement into actively remodeled bone causedroot resorption in previous studies, we waited for

3 months to move teeth into the distraction gap.18,19

Consequently, the large tooth exposure and interlabialgap seen initially were improved by the incisor retrac-tion. The treatment goals set at the beginning of the treat-ment were achieved. Because of the skeletal relapse ofthe mandible during and after consolidation, the wholemaxillary dental arch was distalized more than planned.

Fig 15. Intraoral photographs 2 years after debonding show that the arches remained well alignedand stable.

Fig 14. Facial photographs 2 years after debonding.


The maxillary incisors were therefore tipped lingually tocompensate for the anteroposterior jaw relationship dur-ing orthodontic treatment after DO by using implants asorthodontic anchorage. Although we used implantedbone plates for anchorage, because the amount of distal-ization of the maxillary dental arch did not exceed 2 to3 mm, mini-implants such as screws could also beused for this tooth movement.16,17 The inclination ofthe maxillary incisors was still acceptable when com-pared with Japanese standards. Whereas DO can bea powerful modality to improve complicated skeletal de-formities such as in this patient, because of some skeletalrelapse, orthodontic treatment with implants as ortho-dontic anchorage contributed to overcoming those prob-lems and obtaining a stable and well-balanced occlusion.

CONCLUSIONS

We presented a patient with complex skeletalproblems treated by combined DO and orthodontictreatment using implants for anchorage. The resultswere acceptable, and the patient was satisfied withthe treatment outcome. The combination of DO andimplants as orthodontic anchorage is a powerfulmodality to improve patients with severe skeletalClass II problems.

We thank the clinicians who assisted in the treat-ment of this patient in the Divisions of Orthodonticsand Dentofacial Orthopedics and Maxillofacial Surgery,Tohoku University Graduate School of Dentistry, Sen-dai, Japan.

Fig 16. X-rays of the TMJ taken with the Schuller method28: A and D, at debonding; B and E, 1 yearafter debonding; C and F, 2 years after debonding. Resorption was seen in the condyles, whereasresorption stopped at 1 year of retention and was stable 2 years after debonding.


March 2010

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