International Journal of Surgery Case Reports 84 (2021) 105934

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Combined orthodontic and orthognathic treatment with 3D-printing

technique offers a precise outcome: A case report of two years followup
Xiaolei Hu a, d, 1, Ping Ji a, b, e, 1, Tao Wang a, b, e, *, Xiaomian Wu a, b, c, **, 1
a
Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, College of Stomatology, Medical University, Chongqing, China
b
Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education, College of Stomatology, Chongqing Medical University, China
c
Department of Orthodontics, College of Stomatology, Chongqing Medical University, China
d
Key Laboratory of Clinical Laboratory Science, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, China
e
Department of Oral and Maxillofacial Surgery, Stomatological Hospital, The Affiliated Hospital of Stomatology, Chongqing Medical University, China

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Precision Medicine and evidence-based clinical treatment approach are proposed
Precision medicine worldwide in medical science nowadays. Orthodontic first approach (OFA) and Computer-aided surgical simu­
Computer-aided surgical simulation (CASS) lation (CASS) combined 3D-printing technique offered more chances for the doctors to obey the principle of
Combined orthodontic and orthognathic
Precision Medicine in the orthodontic and orthognathic approach.
treatment (COOT)
3D technique
Case presentation: We reported a 20-year-old patient, with skeletal Class III relationship and asymmetric
Surgery first mandible, was treated by OFA. And with the CASS combined 3D-Printing Technique, the presurgery simulation
Case report and 3D-printed surgery guiding splint and stable splint offered the Combined Orthodontic and Orthognathic
Treatment (COOT) a powerful and accurate guiding. The results exhibited that the patient had a perfect maxilla
and mandible relationship and significant improvement in profile.
Clinical discussion: There is still a debate between “surgery first” (SF) and conventional OFA. In this study, we
analyzed the trend of different approaches in the COOT, which was a team work and required mainly the
collaboration of orthodontist and Orthognathic surgeon. This study showed the precision of the CASS could offer
for the OFA to evoke people immersing in saving time in COOT.
Conclusion: All of these indicated that CASS was a powerful and precise method for COOT, which could offer the
patient an esthetic and stable result.

1. Introduction treatment and surgery in the COOT.

Nowadays, some technique or approaches were worldwide applied
The success and long term of posttreatment stability was concerned without solid evidence, while about 234 million surgical procedures are
by every clinician. The success and long term of postsurgery stability of undergoing each year [3–5]. “Surgery first” (SF) could save some time in
Combined Orthodontic and Orthognathic Treatment (COOT) require not most cases, but the time could not compensate the possibility failure of
only the high quality of pre-surgery and post-surgery orthodontic long term stability. The SF is not so new and novel as most people
treatment but also the precision of craniomaxillofacial (CMF) surgery consider it, and it was first proposed ten years before by Nagasaka et al.,
[1]. The computer-aided surgical simulation (CASS) could offer a three- which should be careful in selected case [6]. In some countries, SF is
dimensional (3D) composite skull model to accurately represent the considered as new or novel. What’s more, in some areas, as least in the
CMF skeleton, the dentition and the facial soft tissue for patient [1,2]. Asian region as we know, the SF is encouraged rather than performed
All of these information mentioned above are utilized to rebuild an only in selected case [7]. However, after longtime clinical observation,
anatomical reference frame to perform orthognathic surgery stimu­ the systematic review and meta-analysis showed that compared with SF,
lating. So, CASS is an accurate method to connect the orthodontic the OFA could offer a better long term of postsurgery stability [8]. The

* Correspondence to: T. Wang: Floor 6, No 7, Shangqingshi Road, Yuzhong District, Chongqing 400015, China.
** Correspondence to: X. Wu, Floor 9, No 7, Shangqingshi Road, Yuzhong District, Chongqing 400015, China.
E-mail addresses: taosan@126.com (T. Wang), wuxiaomian@hospital.cqmu.edu.cn (X. Wu).
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.ijscr.2021.105934
Received 2 February 2021; Received in revised form 22 April 2021; Accepted 24 April 2021
Available online 30 April 2021
2210-2612/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
X. Hu et al. International Journal of Surgery Case Reports 84 (2021) 105934

result of COOT could not only play an vital role on the patient’s and cross bite, it indicates that there is a family medical history related
craniofacial function but also on the patient’s esthetic and daily life to her craniofacial deformity.
through all their lifetime. Thinking over again the trend in the approach, The intraoral examination (Fig. 1) showed that she had both anterior
selection in COOT is extremely urgent. crossbites and posterior crossbites on both sides from central incisors to
Presurgical orthodontic decompensation, orthognathic surgery, and first molar. And both canine and molar showed end-on Class III rela­
postsurgical orthodontic adjustment are the main steps of classic tionship on both sides with severe lingually inclined lower incisors. Her
orthodontic-first approach (OFA) for conventional surgical and ortho­ mandibular dental midline deviated 3 mm to the left while the maxillary
dontic approach. The presurgical stage is a time consumer, and some­ dental midline was coincident with the facial midline, with − 2.5 mm
times the decompenstion contains a temporary period of deterioration of overjet and − 2.0 mm overbite.
the facial profile [7,9]. However, inappropriate dental alignment could The panoramic radiograph presented the impacted third molars. A
limit the optimal skeletal positioning during surgery in SF approach and lateral cephalometric analysis showed the mandibular prognathism and
the other disadvantage of SF make it unable to be the main approach in maxillary hypoplasia with a skeletal Class III relationship (ANB -3.1,
clinical practice [10]. The CASS is highly accurate and effective in Wits appraisal, SNA 78.5, SNB 81.6) (Table 1 and Fig. 1C). The
stimulating the orthognathic surgery process. What’s more, when the mandibular incisors were severe lingually inclined (IMPA 81.3). And the
CASS technique combined with 3D printing technology by a rapid pro­ chin overgrowth was obviously.
totyping machine, this process will become more powerful. It will not
only stimulate the surgery process and predict the surgery outcome, but 2.2. Treatment objective
also produce the surgery splint and the associated appliance to make
sure the precision of stimulated surgery in computer could be trans­ The following objectives were established: (1) dental decompensa­
ferred to the outcome of the patient during the surgery. In this study, we tion, (2) correct anterior and posterior crossbites, (3) establish ClassI­
reported a case with the detail of this approach to show the precision of canine and molar relationship, (4) obtain a normal occlusion with
this approach. This case was performed in our hospital, an academic normal overjet and overbite, (5) correct the mandibular asymmetry and
stomatological Hospital and also an affiliated hospital of medical uni­ (6) improve the middle facial depression to achieve an esthetic facial
versity, and reported in line with the SCARE guideline 2020 [11]. profile.

2. Methods and results 2.3. Principle of precision medicine in the treatment alternatives

2.1. Subject collection, diagnosis and etiology 1) SF. SF approach would save time for dental decompensation. How­
ever, the natural dental compensation, such as the lingually inclined
A 20-year-old college student turned to us for help and complained lower incisors, could disturb the precision of surgery in correcting
long face, mandibular prognathism, anterior crossbite. She reported that the Class III skeletal pattern. What’s more, SF also required longer
there is not special about her drug history and psychosocial history. In time for postsurgical orthodontic adjustment and the patient had to
her pretreatment facial photographs, she showed a concave profile with suffer occlusion trauma before the postsurgical orthodontic adjust­
middle facial depression, increased lower facial height and a significant ment finished.
asymmetry with chin deviating to the left. And considering her father 2) OFA. And the CASS could stimulate where the bone should be cut
has the same syndrome of concave profile with middle facial depression and how much each bone had to move precisely. While the CASS

Fig. 1. Presurgery data and Presurgical orthodontic decompensation.

A: Pretreatment photographs. B: Dental Cast of pretreatment. C: Pretreatment radiation examination. D: Dental Case of Presurgery (after presurgical orthodontic
decompensation).

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X. Hu et al. International Journal of Surgery Case Reports 84 (2021) 105934

Table 1 After consider the advantages and disadvantages of each approach,

The pretreatment and posttreatment cephalometric analyses. Cephalomertic the patient chose the OFA.
analyses of the patient pretreatment and posttreatment was performed with
Dolphin Imaging Software.
Measurement Norm Pretreatment Posttreatment 2.4. Principle of precision medicine in the treatment progress

SNA ( )
◦
82.0 ± 3.5 75.4 81.9
SNB (◦ ) 80.9 ± 3.4 79.6 80.5
For the presurgical orthodontic decompensation, 0.022 × 0.028-in
ANB (◦ ) 1.6 ± 1.5 − 4.2 1.4 straight wire brackets were boned to all the teeth. The initial upper and
MP-SN (◦ ) 32.4 ± 4.7 45.8 38.7 lower archwires were 0.014 NiTi archwires for decompensation and
MP-FH(◦ ) 23.9 ± 4.5 45.8 24.5 further leveled and aligned followed by 0.016 NiTi, 0.018 NiTi,
IMPA (◦ ) 95.0 ± 7.0 72.9 82.9
0.016 × 0.022 NiTi, 0.018 × 0.025 NiTi, 0.019 × 0.025 NiTi, and
Facial plane to SN(◦ ) 80.5 ± 4.0 80.7 82.6
Facial angle (FH-NPo)(◦ ) 89.0 ± 3.0 95.8 96.8 0.019 × 0.025 stainless steel arch wires. When the presurgical ortho­
Occ plane to FH (◦ ) 6.8 ± 5.0 10.0 7.4 dontic decompensation was done, the patient’s CBCT and cephalometric
Wits appraisal (mm) − 1.0 ± 1.0 − 15.1 − 6.9 radiograph, dental cast were taken. After these data were input, the
Lower face height (ANS-Gn) (mm) 65.0 ± 4.5 72.9 69.1 CASS was performed to stimulate the surgery and produce surgery splint
Upper face height (N-ANS) (mm) 50.0 ± 2.5 58.3 54.3
U1-L1 (◦ ) 130.0 ± 6.0 143.4 139.3
and the associated appliance (PTY MEDTEC). After segmentation,
U1-SN (◦ ) 102.8 ± 5.5 97.8 99.1 reconstruction and measurement, the analyzes of the patient’s dentition,
U1-NA (mm) 4.3 ± 2.7 6.6 5.5 occlusion, profile, maxillary and mandibular asymmetry, TMJ, intra­
L1-NB (mm) 4.0 ± 1.8 3.2 4.5 mandibular course of the mandibular canal, respiratory tract were per­
Overjet (mm) 2.5 ± 2.5 − 2.9 3.2
formed (Fig. 2).
Overbite (mm) 2.5 ± 2.0 0.4 1.1
Upper lip to E-plane (mm) − 6-0 ± 2.0 − 6.0 − 1.3 The stimulated plan of the CASS indicated that the LeFort I osteot­
Lower lip to E-plane (mm) − 2.0 ± 2.0 − 1.2 − 0.6 omy should be used in combination with the bilateral sagittal split
Y-Axis (SGn-SN) 67.0 ± 5.5 72.6 70.0 osteotomy (BSSO) to correct the crossbites and the asymmetrical
mandibular deformities (Fig. 3A, B and C). In brief, referenced to the
incisal edge of maxillar central incisor, the maxilla should be moved
could predict the outcome of the COOT and the presurgical ortho­
3.70 mm foreword and 1.68 mm upward, and referenced to the anterior
dontic decompensation would remove tooth obstruct which will be
nasal spin, the maxilla should be moved 3.26 mm foreword and 2.15 mm
during surgery and allow the surgery to represent the precise stim­
upward. Referenced to the incisal edge of lower central incisor, the
ulating of CASS.
mandible should be moved 2.80 mm backward and 1.04 mm right, and

Fig. 2. Data input for Computer-aided surgical simulation (CASS) and analyzes for the patient. A: The simulated maxilla and mandible relationship in dental cast; B:
Radiation examination presurgery; C: The skeletal relationship of maxilla and mandible presurgery; D: 3D markers for the maxilla and mandible; E: Location of the
mandibular canal; F: Airway.

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Fig. 3. CASS was performed for the patient. A CASS: a The overview of the osteotomy; b and c The amount of maxilla should be moved in the LeFort I osteotomy to
change the occlusive plan; d The amount of chin should be moved in genioplasty; e and f: The amount the mandible should be moved in the bilateral sagittal split
osteotomy (BSSO).

referenced to the gnathion, the mandible should be moved 6.01 mm postsurgery orthodontic adjustment three month after surgery (Fig. 4B).
upward and 2.14 mm right (Fig. 3D and E). For the LeFort I osteotomy, And the follow up was every month for orthodontic treatment. One year
the maxillary osteotomy should be 2.44 mm at the edge of right pyriform after orthopedic surgery the fixed bone-screw materials were removed.
fossa, 2.46 mm at the edge of light pyriform fossa, 2.21 mm at the right And a two years follow-up of posttreatment, it was shown in the Fig. 4D.
zygomatic process, 2.40 mm at the left zygomatic process, 2.34 mm at
the right maxillary tuberosity, 2.46 mm at the left maxillary tuberosity,
and 2.66 mm interference at the nasal septum (Fig. 3D and E). For the 2.6. Outcomes measured present the principle of precision medicine
BSSO, the osteotomy at the right mandibular ramus should be 4.99 mm
at anterior, 3.03 mm interference upward and 4.76 mm backward. For Posttreatment, the radiation was done and the dental model was
the left mandibular ramus, the osteotomy should be 4.11 mm at anterior, taken. And the outcomes were measured. After the COOT, all the
4.10 mm interference upward and 0.91 mm backward. For the genio­ treatment objectives were achieved. First, the natural dental compen­
plasty, chin portion of the jawbone should be moved 4.83 mm back­ sation was corrected. Second, the anterior and posterior crossbites were
ward. After discussed with the patient, she accepted to have the LeFort I treated. Third, the ClassIcanine and molar relationship were established
osteotomy and BSSO. However, the “Tapered face” is popular among and the patient’s masticatory efficiency was improved significantly
web celebrities, and the patient also preferred to keep her original which was reported by the patient. Fourth, a normal occlusion with
profile of her chin. normal overjet and overbite were obtained. Fifth, the mandibular
With the simulated data of CASS, the surgery guiding splint, the asymmetry was corrected. After treatment, the centerlines of the upper
stable splint and related appliances were produced which could trans­ and lower dentition were coincident with the skeletal centerline.(Fig. 4C
ferred and kept the accuracy of CASS to the surgery and outcome of the and D).Sixth, the middle facial depression was treated. The patient’s
treatment (Fig. 4A). dish face was disappeared and an esthetic facial profile was achieved
(Figs. 4C and D and 5; Table 1).
The comparison of pretreatment and posttreatment lateral cephalo­
2.5. Postsurgery orthodontic adjustment and follow-up metric analysis results showed that the patient’s skeletal was signifi­
cantly changed. The ANB was changed from − 4.2 to 1.4 and the MP-FH
After orthopedic surgery the patient was in hospital with conven­ was changed from 45.8 to 24.5. The patient was satisfied with her
tional care and a full liquid diet for three weeks. And the radiation ex­ profile, smile and the masticatory efficiency obtained by the COOT. And
amination was performed to check the outcome of surgery. Then the the stability of this result could be found in the photographs of Fig. 5C-b
patient had vertical elastic for one month after surgery and started after two years of follow-up.

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X. Hu et al. International Journal of Surgery Case Reports 84 (2021) 105934

Fig. 4. CASS combined 3D-printing technique for the surgery of the patient. A: With the simulated data of CASS, the 3D-printing technique was able to produce
splints and relative appliances (a). The surgery guiding splint (b,c) and relative appliances were utilized during the surgery for fixing and the stable splint (d) was
applied post-surgery for vertical elastic. B: Two weeks post-surgery and starting to have vertical elastic for one month. C: Posttreatment Dental cast. D: Posttreatment
photographs:One and half years postsurgery.

3. Discussion apnoea and so on [13–17]. The Precision Medicine is supported by lots

of countries and even a race among different countries is undergoing.
There are two approaches in the COOT. One is with the Precision For example, trying to obtain the leadership position in the next 10 years
Medicine principle and the help of digital technology to diagnose, among countries investigating in genomic medicine, the French
design, prepare, treat and finely adjust the subject as accuracy as we can. launches a plan, Genomic Medicine 2025, which would be supported by
And on the other hand, the another approach is try to reduce the government and public financing of € 670 million by the year 2020 [18].
treatment duration, to decrease the patient’s financial and physical In the orthodontic field, orthodontists also considered the evidence more
suffering and to better the patient’s worse profile during pre-surgery carefully, and the 3D-printing technique is utilized in 3D-printed splint,
orthodontic treatment. However, all of these could not compensate the aligners, bracket and so on [19–20].
failure of surgery or long term of posttreatment stability. SF is one of the While the SF approach could save treatment time, but it still has
options and there are other new approaches were creating. For example, some disadvantages in the COOT. First, it is difficult to perform elastics
the new approach to correct the anteroposterior and transverse maxil­ postoperatively to counteract muscle traction. In order to have elastics,
lary deficiencies in only one-step surgical intervention [12]. We propose mini screws had to be implanted or orthodontic brackets should be
that for these cases, the careful selected case and more evidence are placed one week before surgery without archwire. While the brackets
required. were places in each tooth to offer the hooks for elastics, it increased the
Precision Medicine obey the principle of evidence-based clinical risk of accidental aspiration during surgery. Second, SF might cause
treatment approach and have evoked more and more attention among occlusal trauma in the period from the time of surgery was completed to
clinicians. Targeting immune checkpoints, immunotherapies have rev­ the time of alignment was finished. And the unstable occlusion would
olutionised oncology and made the Precision Medicine vital and hot aggravate the periodontal disease, while the periodontal disease was
recently [13]. In order to change the gap between traditional disease- spread widely world wise in adult [21]. And most of the COOT cases
focused medicine and patients’ needs, Precision Medicine is now not were performed in adult patients. Third, SF approach might induce
only focusing in cancer, but also in the precision care about managing unnecessary orthodontic pain and discomfort. In order to accelerate the
multimorbidity, cardiorenal syndrome, public health, obstructive sleep treatment process, orthodontic treatment was conventionally started

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X. Hu et al. International Journal of Surgery Case Reports 84 (2021) 105934

Fig. 5. Comparision in radiation examination. A: The

comparison of cophalometric photographs: Pretreat­
ment (a), Presurgery (b) and Posttreatment(c); radi­
ation examination: Pretreatment (d), Presurgery (e),
Presurgery (f) and Posttreatment (g) (White line: the
centerline of upper dentition and the skeletal
centerline; Black line: the centerline of lower denti­
tion). B: Ricketts superimposition. Pretreatment
(Green) and Posttreatment (Red). C: The postsurgery
stability of COOT combined 3D-printing technique
for the surgery of the patient. a: Pretreatment. b:
Three months postsurgery. c: One and half years
postsurgery. d: Two years following up. (For inter­
pretation of the references to colour in this figure
legend, the reader is referred to the web version of
this article.)

2 weeks postoperatively and orthodontic archwires were changed every she liked it (Figs. 4D and 5C). Both the negative and positive side of the
second to third week, and patients were persuaded to use of an occlusal patient’s result showed the powerful and precise of the CASS, which
splint while eating routinely regarding postoperative stability [6,10]. All could be proposed to be the main approach in COOT around the world
of these might add discomfort to patients. In most time, patients was still (Figs. 2,3,4 and 5). And a long term of follow-up also showed a stable
suffering postoperative pain and swelling 2 weeks after surgery and result.
changing orthodontic archwires every two to three weeks could add
orthodontic pain and increase the risk of root absorption, especially 4. Conclusion
when the dentition was too crowding. Fourth, result from clinical meta-
analysis showed that compared with conventional orthodontics-first 1 3D-technique combined OFA and CSSA should be proposed for
approach, surgery-first/early-orthognathic approach yield poorer post- COOT worldwide.
treatment stability, especially, the mandible tending to rotate counter­ 2 CASS is a powerful and precise method for COOT, which could
clockwise more [8]. So, careful patient selection was proposed of SF, or offer the patient an esthetic and stable result.
encouragement for SF as a main approach in daily clinical practice could
be a disaster for the patients and also for the doctor around the world. Ethical approval
In this study, the CASS combined 3D-Printing technique exhibited
the main principle of Precision Medicine and offered the high level of All the conduct in this case report was approved by the Ethical
accuracy for COOT (Figs. 2, 3 and 4). On the one hand, the patient Committee of the Affiliated Hospital of Stomatology, Chongqing Medi­
obeyed to the main suggestions of the CASS, and had the BSSO to correct cal University.
the crossbites and asymmetrical mandibular deformities and had the
LeFort I osteotomy to change the occlusive plan (Fig. 4). And she got a Consent
normal maxilla and mandible relationship, significantly improved pro­
file and self-confident smile (Figs. 4 and 5). On the other hand, the pa­ Written informed consent was obtained from the patient for publi­
tient like the “Tapered face” and refused the genioplasty which was cation of this case report and accompanying images. A copy of the
suggested by the CASS and our previous plan (Fig. 3D). As a result, her written consent is available for review by the Editor-in-Chief of this
chin was not perfect by our professional view (the Wits Appraisal was journal on request.
changed from − 15.1 mm to − 6.9 mm)and the genioplasty was need, but

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X. Hu et al. International Journal of Surgery Case Reports 84 (2021) 105934

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