International Orthodontics 2020; 18: 576–583

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Case Report

Combined orthodontic and surgical

treatment supported by virtual planning in a
severe mandibular asymmetry: A case report

Alberto De Stefani 1, Giovanni Bruno 1, Giorgia Crivellin 2, Laura Siviero 2, Francesca Zalunardo 1, Ugo Baciliero 3,
Antonio Gracco 1

Available online: 14 May 2020 1. University of Padova, Department of Neuroscience, Via Giustiniani, 2,
35100 Padova, Italy
2. Private Practice in Padua, Padua, Italy
3. Regional Hospital of Vicenza, Department of Maxillofacial Surgery, Vicenza, Italy

Correspondence:
Alberto De Stefani, University of Padova, Department of Neuroscience, Via
Giustiniani, 2, 35100 Padova, Italy.
alberto.de.stefani@hotmail.it

Keywords Summary
Orthodontics
Orthognathic surgery This article describes the complex dental treatment of a 17-year-old girl with skeletal Class I, severe
Mandibular asymmetry mandibular asymmetry, maxillary retrusion, normodivergent pattern, left canine and molar Class
Virtual surgical planning II, canting of the occlusal plane, lateral left cross-bite, deep bite, upper and lower incisors retrusion
and an increased curve of Spee. To achieve optimal results, a multidisciplinary approach to
treatment was adopted involving orthodontics and maxillofacial surgery. The surgical phase
was supported by virtual surgical planning with dedicated software. Thanks to the development
of the three-dimensional radiological findings, a visualization and an accurate simulation of all the
surgery-steps help to determine reproducibly and with high precision the best adjustments to do.
Firstly, the excessive curve of Spee, the incisors retrusion and the deep bite were corrected with
orthodontic treatment. The surgical treatment plan consisted of a palatal expansion, maxillary
advancement, zygomatic grafts, bilateral sagittal osteotomy for mandibular correction and gen-
ioplasty. Orthodontic treatment was continued to finish with all the objectives achieved. After two
years, the patient was satisfied with her facial and dental treatment results and with her oral
function as well.

Introduction and social interactions and, consequently, the quality of life, and
Facial asymmetry represents a problem with functional and the treatment of the disharmony is frequently complicated and
aesthetic consequences that can be very serious depending requires a combined orthodontic and surgical intervention [1].
on the gravity of the defect. In recent decades, physical appearance has become a funda-
Facial asymmetry is one of the most important problems in mental factor for social acceptance and plays an important role
orthodontics because this condition can compromise function in the workplace.
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https://doi.org/10.1016/j.ortho.2020.04.004
© 2020 CEO. Published by Elsevier Masson SAS. All rights reserved.
Combined orthodontic and surgical treatment supported by virtual planning in a severe mandibular asymmetry:
A case report

Case Report
The aetiology of the problem is disparate: congenital anomalies, In recent years, the advent of CBCT (cone beam CT) has made it
trauma and temporomandibular disorders are the main aspects possible to reduce costs and the radiant dose to patients in a
to predispose patients to facial asymmetry [2]. In this dishar- very consistent way. The radiant dose is ten times lower than the
mony, it is known that mandible deviations are the most evident traditional CT and it is becoming widely used in many specialities
characteristic of facial asymmetry, particularly the lateral dis- of dentistry and oral surgery.
placement of the chin in relation to the midsagittal plane. The use of dedicated software allows surgeons to perform
Literature describes a variation of prevalence between 11% precise simulations of the surgery and allows them to visualize
and 37%. the results of osteotomies and soft tissue transformation.
The severity of the skeletal asymmetry determines the thera- That explains the importance of using virtual surgical planning to
peutic strategy. Mandibular deviations are very often associated guarantee a better outcome in combined orthodontic-surgical
with a cant of the maxillary occlusal plane. In these cases the treatment [6]. This article aims to describe the orthodontic and
only accurate treatment is double-jaw orthognathic surgery [3]. surgical treatment assisted by virtual planning in order to
The surgical correction of the facial asymmetries can be consid- achieve the best occlusion, function and aesthetic.
erably improved by a virtual surgical planning because it permits
us to obtain a 3D model of the intervention. Virtual planning Diagnosis and aetiology
before the surgical treatment allows the visualisation of the A seventeen-year-old girl came to the University of Padua
maxillary, mandibular and chin movements thanks to the use of Dental Clinic for an orthodontic evaluation. A general medical
prototyped guides [4]. history questionnaire was complete. The patient was in good
The cephalometric analysis represented in the past is an impor- general and oral health but presented a severe facial asymme-
tant instrument to define therapeutic planning. The traditional try. The extraoral examination showed a mandibular asymmetry
2D radiographs have been replaced by 3D analysis thanks to the with chin displacement from the midline and a maxillary ret-
CT (computerized tomography), which avoids radiograph rusion in a normodivergent pattern. The intraoral exam showed
problems such as overlaps of the structures and distortion. CT a maxillary transverse discrepancy with a left canine cross-bite
performs in high definition and perfect detail, which are and mild crowding on the upper and on the lower arches. The
fundamental aspects for surgical planning [5]. patient presented a deep bite and a left canine and molar class II

Figure 1
Extraoral and intraoral views at the beginning of the treatment
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Case Report

projections according to Roth-Jarabak evidenced a skeletal class

I (figure 3). Overjet and overbite were included in normal range.
Morphometric analysis of cervical vertebrae resulted in a com-
plete mandibular growth [7].

Treatment alternatives
Nonsurgical treatment consisting of maxillary and mandibular
arches alignment and occlusal plane levelling was rejected
because this could not have improved the facial aesthetics of
the patient, which was her major concern.
Orthodontic treatment combined with orthognathic surgery was
Figure 2
planned to fulfil the desire of a good dental and facial aesthetic.
Models showing the mild crowding and the mandibular
A bilateral sagittal split osteotomy alone was not possible due to
asymmetry
the excessive maxillary occlusal cant.
A bimaxillary surgical solution was considered the best option to
malocclusion with upper and lower incisor retrusion. The curve achieve the treatment objectives. The orthodontic preparation
of Spee was increased and the occlusal plane presented a severe phase did not require dental extractions because there was no
canting (figures 1 and 2). Cephalometric analysis on the lateral discrepancy in both arches.
radiograph of the skull in posteroanterior and latero-lateral Genioplasty and zygomatic graft were added to obtain a better
aesthetic harmony of the face.

Sequences of treatment planning

Orthodontic brackets were applied on the upper and lower arches
with 0.16 Ni.Ti. arches (figure 4). Lower second molar occlusal

Figure 3 Figure 4
Pre-treatment radiographs Intra-oral views at the beginning of the orthodontic phase
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Combined orthodontic and surgical treatment supported by virtual planning in a severe mandibular asymmetry:
A case report

Case Report
Figure 6
DDS-Pro version 1.9_2017 software for virtual surgical planning
with the simulation of the intervention result

Figure 5
Radiographs before the surgery
Figure 6 shows the modification occurred to the maxilla and the
jaw with different colours. The maxilla was advanced and dero-
tated to correct the occlusal cant. The impaction was predomi-
nantly located on the left side of the maxilla, associated with a
palatal expansion (more evident on the left).
An asymmetrical bilateral sagittal split osteotomy was per-
surfaces were covered with resin to prevent bracket pre-contacts formed to correct the asymmetry and a genioplasty and zygo-
of elements 2.3 and 3.3. After 5 months,19  25 Ni.Ti upper and matic grafts were added to improve the aesthetics.
lower archwires were applied. An elastic phase and a stripping of the anterior teeth of both
Four months later, a radiographic control permitted us to visual- arches were done with upper and lower 19  25 multi-braided
ize the rotation correction and the arches levelling to improve. archwires.
19  25 SS arches were applied for the closure spaces and the Orthodontic retention (Essix) was given to the patient for the
occlusal resin was removed. After 15 months of orthodontic stabilization of the treatment.
treatment preparation, the patient underwent the surgical inter-
vention at the Maxillofacial Surgery unit, department of San Results
Bortolo Hospital Dr. UB (Vicenza, Italy) (figure 5). After 28 months of surgical and orthodontic combined treat-
The surgical treatment consisted of a bimaxillary osteotomies for ment, a good occlusion and a satisfactory facial profile were
asymmetry correction, palatal expansion and maxillary. The obtained. The post-treatment facial photographs showed a bal-
surgical phase was prepared with a virtual surgical planning anced and harmonious face. The severe mandibular asymmetry
that led to precise measurement of maxillary and mandibular with the lateral deviation of the chin from the midline were
movements. The surgical treatment simulation was complete corrected as well as the maxillary cant. The patient was satisfied
with the use of DDS-Pro version 1.9_2017 software analysis on with the treatment results. In addition, an Angle Class I molar
the patient's facial CT [8]. relationship had been established (figures 7 and 8).
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Figure 7
Extraoral and intraoral photographs at the end of the combined orthodontic and surgical treatment of the severe mandibular
asymmetry

Figure 8
Models at the end of the treatment
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Combined orthodontic and surgical treatment supported by virtual planning in a severe mandibular asymmetry:
A case report

Case Report
TABLE I
Cephalometric comparison before/after surgery/after treatment.

Measures Before After After

treatment surgery treatment

Saddle angle 131.7 130.4 135.5

Articular angle 148.1 141.4 138.1

Gonial angle 119.7 125.6 123.9

Sum of angles 399.4 397.4 397.6

Anterior cranial base 69.9 68.4 67.8

Posterior cranial base 34.1 34.7 32.2

Ramus height 39.2 42.7 44.6

Corpus length 83.2 78.2 77.6

Facial height 57.7 60.9 60.5

Jarabak anterior ratio 77.8 77.8 76.4

SNA 77.6 82.2 81

SNB 77.1 79.5 78.1

ANB 0.5 2.6 2.9

Facial axis Ricketts 84.7 90.1 91.5

Overbite 1.7 1.7 2.2

Overjet 3.4 3.2 2.9

FMA 23.4 20.4 16.3

Nasolabial angle 108.3 116.5 110.3

Figure 9
Post-treatment radiographs
Upper lip length 20.4 21.3 20.6

Lower lip length 47.1 47.7 48

Facial convexity 166.5 167.7 165.2

Anterior face height 122 119.9 118.8

Posterior face height 70.5 73.1 71.9

Interincisal angle 138.1 132.1 131.9

The comparison of cephalometric analysis (table I) between the

beginning and the end of the treatment underlines the good
result of the combined orthodontic and surgical intervention.
The superimposition between the cephalometric analysis at the
beginning of the treatment and at the end of it highlights the
evolution of the profile aspect of the patient (figures 9 and 10).
Two years after the treatment, the patient came for a control Figure 10
evaluation and the results were stable (figure 11) [9]. Superimposition before/after treatment
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Case Report

Figure 11
Extraoral and intraoral views two years after the treatment

Discussion The incidence of complications, which can lead to plate removal,

The combined orthodontic and surgical treatment was consid- is approximately 15%.
ered the best choice to achieve a good aesthetic result even Orthodontic preparation before orthognathic surgery is essential
though orthognathic surgery is not completely risk-free. Maxil- to achieve a correct adaptation of the upper and lower arches
lofacial surgery is considered a major surgical procedure and removing dento-alveolar compensation. Here, it justified the
sometimes patients require a reoperation to remove fixation 15 months duration of the presurgical orthodontic treatment.
plates due to pain or infections. The facial appearance in a 17-year-old girl is a determining factor
Titanium is considered the best choice for oral and maxillofacial in the quality of the affective life. A skeletal class III associated
surgery because of its biocompatibility (surgery plates) and with a mandibular asymmetry can cause a loss of self-esteem in
osseointegration (oral implants). adolescence. To respond to the need for an aesthetic correction
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Combined orthodontic and surgical treatment supported by virtual planning in a severe mandibular asymmetry:
A case report

Case Report
of the facial asymmetry, the bimaxillary surgical treatment An accurate treatment planning and cooperation between the
associated with genioplasty and zygomatic grafts demonstrated different specialists led to the success of the final outcome: a
to be the best choice [10,11]. functional occlusion and pleasant facial aesthetics, which met
In addition to the aesthetic aspect, we obtained an ideal occlu- the young patient's requests.
sion and an excellent masticatory function, which are ensuring a
Authors contribution: All authors make substantial contributions to
healthy maintenance of the stomatognathic apparatus. conception and design and acquisition of data and analysis and
A key role in obtaining this result was given by virtual surgical interpretation of data. Authors participate in drafting the article and in
revising it critically for important intellectual content and they give final
planning which, thanks to the development of three-dimen-
approval of the version to be submitted.
sional radiological findings, allowed a visualization and an accu-
rate simulation of the intervention in all its parts to understand Ethical statement: The authors warrant that the article is original, is not
under consideration for publication by another journal and has not been
in a precise and reproducible way which were the best adjust- previously published. The authors declare that they have no competing
ments to be made [12]. financial interests. The authors have stated explicitly that there are no
competitive financial interests in connection with this article.
All authors declare that all procedures followed were in accordance with the
ethical standards of the responsible committee on human experimentation
(institutional and national) and with the Helsinki Declaration of 1964 and later
Conclusion versions. Informed consent was obtained from all patients for being included
A multidisciplinary management involving orthodontics and in the study. This article does not contain any studies with human or animal
subjects performed by any of the authors.
orthognathic surgery, was required to treat a 17-year-old girl
with a skeletal Class I and a severe mandibular asymmetry with Disclosure of interest: the authors declare that they have no competing
interest.
canting of the occlusal plane and an increased curve of Spee.

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