Professional Documents
Culture Documents
(Case report)
Jenadi Binarto*, Asri Arumsari**, Seto Adiantoro**, Melita Sylvyana**, Abel Tasman Yuza***
*Resident, Department of Oral and Maxillofacial Surgery, RSUP Dr. Hasan Sadikin, Faculty of
Email : drg.jenadi@live.com
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Abstract
is projecting too far ahead of the maxilla, and maxillary retrusion means maxilla that located
posteriorly than normal. These two condition generates malocclusion with large
Case presentation: A 19 years old male patient was referred from an orthodontist to Oral and
difficulties and pain on both TMJ. Clinical examination and cephalometry analysis showed
concave facial profile, mandible prognathism and maxilla retrusion with overjet of 12mm.
Orthognatic surgery was performed with Le Fort 1 Osteotomy and BSSO, a good and balanced
Discussion: Mandibular prognathism and maxillary retrusion are skeletal disorders which
problem. Mandible prognathism and maxilla retrusion require correction of both jaws with Le
Conclusion: Mandibular prognathism and maxilla retrusion require both jaws correction to
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1. Introduction
About 20% of world population has dentofacial deformities, some of them are
mandibular prognathism or class III skeletal malocclusion.1 This skeletal deformity is one
of severe maxillofacial deformities which involves multiple facial deformities and causing
this skeletal deformities are suspected as improper activity growth of the bone exceeding
The most popular orthognatic surgery technique are Le Fort 1 osteotomy for correction
of upper jaw and Bilateral Sagittal Split Osteotomy (BSSO) for correction of lower jaw. 3-8
Both techniques are widely used in orthognatic surgery in complex cases or severe
deformities because they are able to correct most skeletal problems with minimal
The purpose of this case report is to correct mandibular prognathism and maxilla
retrusion using Le Fort I osteotomy and BSSO technique. Discussion includes pre surgery
2. Case Report
A 19 year old male patient was referred from orthodontist with difficulties in mastication
and pain on both side of lower jaw joint. Since infant age, the patient felt his lower jaw was
projecting too forward and had difficulties in swallowing accompanied with facial
appearance problems. About 2 years ago, the patient felt pain on both side of lower jaw
joint which got worse from time to time. Then the patient went to an orthodontist and had
orthodontic treatment to allign his teeth into normal position in allignment and curve of the
jaw. Later, he was referred to Oral and Maxillofacial Surgery department at Hasan Sadikin
Hospital Bandung for further treatment, which is surgery to correct the position of both jaws.
From clinical examination, we found a concave facial profile with dolichocephalic head
type, mandibular prognathism with very high angle of mandible (Figure 1). The patient had
class III skeletal malocclusion, anterior open bite, and overjet of 12mm. There was a slight
midliine shift of lower jaw about 2mm, and also clicking on the right TMJ with pain on both
the position of both side of mandible condyle, but it was obvious that the mandible
dimension is longer than normal on both side and showing a class III molar relation. There
were also impacted teeth of 18 and 28 (Figure 3). Cephalometry analysis showed SNA =
85°, SNB = 98°, and ANB = -13°. Mandibular length (Co-Gn) = 137 mm and maxilla length
(Co-A) = 80 mm, with ratio of maxilla : mandibular length = 1:1,71 concluded as imbalance
of maxilla and mandibular length (> 1:1,3)3. Using McNamara analysis we measured the
skeletal position of maxilla and mandbile from cranial base, which is the linear length of
From both clinical and x-ray examinations, we diagnosed the patient as mandibular
The next step was making a study model to decide the surgical plan, this plan was then
converted into a splint of surgical guide which manufactured from the model. We planned
of ± 8 mm with clockwise autorotation. A splint was made for an occlusion guide of each
surgical step on each jaw surgery. In this case, because we plan a two-jaw surgery, we
The surgery was started with odontectomy of teeth 18 and 28, followed by Le Fort I
osteotomy using intra oral approach and mucoperiosteal flap which was made on 4 mm
over the mucogingival margin starting from the right to left upper first molar. Periosteal
dissection was then performed beginning from first molar to posterior direction until the
posterior maxillary wall and pterygomaxillary border was reached on both sides.
The osteotomy was performed using saw started from lateral nasal wall until the border
of zygomaticomaxillary, about 3 mm over first upper molar. After the osteotomy was
performed, the down fracture was performed using Rowe forceps with slight force pulling
the maxilla to anterior and inferior until the maxilla was separated from nasal wall and
showed a floating maxilla (Figure 5A). The prepared splint of surgical guide was used to
guide the movement of the maxilla into accurate position as planned, and temporary
intermaxillary fixation was applied using wire. With both jaws were fixated, maxilla was
positioned by pressing the mandible to posterior direction and superiorly to ensure the
mandibular condyle was in the correct position. After the final position was achieved, the
maxilla was fixated with miniplate and screw (Figure 5B). Final assessment of the first stage
occlusion was performed by removing the IMF wire. The upper jaw surgery stage was
The next stage was BSSO, started with incision on external oblique ridge with the
approximate height of posterior teeth occlusal, extended inferiorly and lateral side of the
teeth. Elevation of mucosa and connective tissue was performed until the external oblique
ridge exposed, so the coronoid refractor could be applied. Tissue dissection was continued
until the coronoid process was reached. The Kocher clamp applied on coronoid, and
elevation of tissue on medial aspect of mandible was performed until lingual fossa was
identified. The osteotomy was then performed with 45 degree of bevel using reciprocal saw
from lingual fossa until the anterior of mandible ramus, extended inferiorly, descending the
anterior ramus (alligned with lateral border of mandible), until the external oblique ridge and
stopped at distal part of second molar. The cut was continued until the inferior wall of
mandible with bevel of 45 degree angle which was at a position about mesial part of second
molar. After the cut was completed, a split of the mandible was performed using chisel and
mallet with gently and progressive force at cut line until it was separated. With both bone
segment already separated, the second surgical guide splint was used to position the
mandible into the proper desired position according to surgical plan. Intermaxillary fixation
then performed to fix the occlusion and the mandible was fixated with miniplate and screw
at the area of mandible body (Figure 6). The final occlusion was re-check by removing the
surgical splint and intermaxillary fixation. When all stages was done, a closure was made.
First post operative day, the patient had a mild pain and swelling on both jaws. Clinical
examination showed swelling on both sides of cheek and lower jaw. There was no bleedinig
at post operative area, the suture was intact and debris was spooled using NaCl 0,9%
solution. Occlusion was not achieved initially, there was an occlusion gap of about 5 mm
which probably was caused by initial swelling at mastication muscle region and TMJ initial
adjustment (Figure 7). Ligature band was applied on both jaws and the patient was given
On the third day evaluation, the occlusion was well achieved and the ligature band was
removed. The patient had slight numbness at small area on skin surface of left labiomentale
area. The patient was prescribed with methylcobalamin 3x500mcg for 1 month. 1 year after
surgery evaluation, the patient facial appearance had significantly improved (Figure 8), it
was very well comparable a significant improvement in lateral view, soft tissue at upper and
lower lip were balanced and showing great improvement in facial esthetic appearance.
(Figure 9). Occlusion was very well achieved with good mastication function, both TMJ pain
was no longer noticeable (Figure 10). However, there was very little numbness in a small
area of skin surface at labiomentale region. In general, the patient felt very satisfied with
the result of the orthognatic surgery because mastication function was achieved, pain on
3. Discussion
deformities.1,2 This skeletal deformity is not a single entity, and usually a manifestation of
mastication, improper function of TMJ, and imbalance facial appearance 3,4,6 Treatment of
Mandibular prognathism can be classified into 6 groups, this classification was made
according to upper and lower jaw profile in 3 dimensional aspect. This classification is
useful as a guide for a proper plan of orthognatic surgery. 2 (Table 1). In this case report,
the patient had a symmetrical mandibular prognathism with sagittal deficiency of maxilla.
This situtation was also supported with large maxillomandibular discrepancy, which is a
patient was properly performed with two jaw surgery of mandibular setback and maxillary
advancement.
orthognatic surgery planned, but further assessment must be done with cephalometry
analysis. The most common use cephalometry analysis used for orthognatic surgery is
McNamara analysis, one of them is hard tissue evaluation, evaluating the anteroposterior
position of the mandible and maxilla.4,6 To perform the analysis, a line of nasion
perpendicular (which is a line that perpendicular from Frankfur Horizontal Plane and
crossing the nasion) was made and measured to point A and B. Normal profile has 0-1 mm
length between nasion perpendicular and point A, negative value means retrusion of the
jaw and positive value means prognathism. This patient has -3 mm of maxilla and 17 mm
of mandible. These two values concluded that the patient had a large mandibular
prognathism and maxillary retrusion, which also translated that the patient needed a two
The most commonly used and popular technique of orthognatic surgery is Le Fort I
osteotomy for upper jaw correction and BSSO for lower jaw correction. 3-8 History of
orthognatic surgery techniques was started for quite a long time, which first reported by
surgeons.3,4,6 Since then, every dentofacial deformities was corrected with mandible
surgery even the problem was only on the maxilla. First Le Fort I osteotomy was performed
by Cheever for tumor ressection in 1864.7,9 In 1921, Herman Wassmund did a Le Fort I
osteotomy for correction of dentofacial deformity but without any intra operative
mobilisation of the jaw, he used orthopedic traction device on post operative period
instead.7,9 Until 1952 in America, Converse reported his case and did maxillary osteotomy
with large palatal and vestibular flap using Le Fort I combined with midpalatal osteotomy.7,9
Later on, many surgeons improvise the technique, one of them was Epker reported a down
fracture technique to achieve complete mobilisation of the maxilla.9 The huge improvement
of orthognatic surgery emerge in 1959 when Kole introduce the alveolar surgery of both
jaws, followed by Obwegesser who published his first experience in 1970 as the first
For years, the development of variety orthognatic surgery technique was made by
various surgeons, each had their advantages and disadvantages, and also different
indications depending on the case. But among those techniques for maxilla and mandible
correction, the most widely used technique are Le Fort I and BSSO. These two technique
has the ability for correcting most skeletal problems with minimal limitations.3,4,6,9,10
BSSO is very versatile technique which can correct the mandible up to 10mm and
stable.3,4,6 For large advanvement, BSSO still can be performed with fixation technique
modification. But in large setback, BSSO is not that stable. So when the setback is quite
large, BSSO can be combined with Le Fort I osteotomy.3,6 These are indications of BSSO:3
Stages of BSSO technique are as follow: incision, dissection of tissue until lingual fossa
is identified, mandible osteotomy on medial and lateral aspect, split of the mandible,
ostectomy on overlap and sharp edges, and fixation of mandible using miniplate and
screw.6 One of common risks of BSSO is injury of inferior alveolar nerve.3,4,6,11-13 and
report, the patient had small area of numbness at labiomentale region which is quite a
common symptom after BSSO.11 The etiology is suggested by some references as injury
of the inferior alveolar nerve when the mandible split was performed. 11 Therefore, the
neurovascular bundle at the lingual fossa should be very well identified and protected, and
the cut was made with more precision away of the bundle. Some recovery can be achieved
Le Fort I osteotomy is one of orthognatic surgery technique for correcting upper jaw.
This technique also has quite variety of correction capabilites and very useful especially for
asymmetrical face and multiple facial deformities situation. These are some indication of
Le Fort I osteotomy:3,6
imaturation, and progressive dentofacial deformities, especially patient with TMJ etiology
(resorbtion or hyperplasia).3,6
Stages of Le Fort I osteotomy are as follow: Initial reference point, elevation of surgical
area, lateral osteotomy of the maxilla, continued with down fracture and mobilisation of the
maxilla, elimination of posterior and anterior interference when surgical guide splint is
computers for analysis as well as surgical planning.12 Computerized surgical plan could
help not only minimizing complications and risks (e.g injury of inferior alveolar nerve in
BSSO) but also simiplified the surgeon and the patient to achieve the accurate and best
maxilla retrusion, which require a two-jaw surgery using Le Fort I osteotomy technique for
correcting the upper jaw and BSSO for correcting the lower jaw in order to achieve a well
balanced occlusion
In the future, computerized surgical planning and orthognatic surgery simulation could
help not only predicting the accurate end result but also manufacturing accurate surgical
guide, therefore minimizing any mistake, so that ideal end result according to plan can be
achieved.
5. References
3. Borle R. M. (2014). Textbook of Oral and Maxillofacial Surgery, 1st Edition, p.531-574
4. Andersson L., et al. (2010). Oral and Maxillofacial Surgery, p.973-1012. Wiley-
properties, and bone metabolic markers in patients with jaw deformities. Int. J. Oral
6. Kademani D., Tiwana P. S. (2016). Atlas of Oral and Maxillofacial Surgery, p.263-426.
7. Sun Y., Vrielinck L., Lubbers H.T., Lambrichts I. (2013). Accuracy of Upper Jaw
9. Antonio Cortese (2012). Le Fort I Osteotomy for Maxillary Repositioning and Distraction
11. Mensink G., et al. (2015). Experiencing your own orthognathic surgery: A personal case
12. Wittwer G., et al (2011). Evaluation of risk of injury to the inferior alveolar nerve with
techniques using computer-assisted surgery. Int. J. Oral Maxillofac. Surg. 2012; 41:
p79-86.
13. Lisen Espeland and Arild Stenvik (2011). Long-Term Outcome of Orthognathic
Figure 7. Post operative day 1 occlusion with ligature band on upper and lower jaw
Figure 9. Lateral view facial profile comparison, before (A) and after (B) surgery
Figure 10. One year after surgery centric occlusion
Mandible setback
Classification Characteristics Maxilla surgery
surgery