2020, Number 1
Facial changes after orthodontic-surgical correction of vertical maxillary excess
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ABSTRACT
Introduction: The smile is a facial expression that is given by the contraction of 17 muscles found around the eyes and mouth. Facial balance is a fundamental point when establishing a surgical orthodontic treatment plan, due to the importance given to the face, both for the different structures found there and for the social value it represents. The aetiology of vertical alterations is considered multifactorial, and includes genetic and environmental aspects, together with the great variability present between individuals. Clinical case: We report a 21-year-old female patient, with class I skeletal, class I molar right and class III molar left due to the absence of dental organ #35, class I canine bilateral, 8 mm gingival smile, 6 mm incisor exposure at rest, lip incompetence, anterior edge-to-edge bite, right posterior crossbite. Treatment consisted of pre-surgical orthodontics, bimaxillary orthognathic surgery, post-surgical orthodontics and retention. Objectives: The treatment objectives were orthodontic-surgical correction of the vertical maxillary excess, to grant occlusal stability and facial aesthetics. Results: An adequate maxillary-mandibular relationship, bilateral class I canine, class I molar right and class III molar left, coincidence of midlines, facial aesthetics and occlusal stability were achieved. Conclusion: The study of the components of facial balance is a fundamental complement to the treatment of patients with facial alterations and with the evaluation of the soft tissues it is possible to predict the aesthetic changes that the patient will have at the end of the treatment. The orthodontist must be aware of the treatment alternatives in order to offer them to the patient. Maxillofacial surgery and orthodontics must integrate the study of facial aesthetics in the diagnosis in order to provide the patient with a comprehensive treatment.INTRODUCTION
The smile is a facial expression that is caused by the contraction of 17 muscles around the eyes and mouth.1 The smile occurs in two phases, in the first phase there is a contraction of the upper lip and nasolabial fold by the action of three muscles: upper lip elevator, zygomaticus major, and upper buccinator fibres; in the second phase there is a contraction of the periocular musculature by the elevation of the upper lip.1
It is easy to say that the most important part of facial balance is the smile, but this is not entirely true, the patient's vertical proportions are also an important aspect.1
Facial balance is a fundamental point when establishing a surgical orthodontic treatment plan, due to the importance that has been given to the face, both for the different structures that are found there, and for the social value that it represents. Thus, the face has acquired great importance in various disciplines, such as artistic, biological, and anthropological, and each of them, according to their ideology, have viewed the human face and its constituents from different angles.2
Excessive facial dimension development was considered a clinical problem until the late 1960s. Because of the similar aesthetic, facial and cephalometric characteristics of these patients and the maxillary vertical excess as a common denominator, in 1985 it was given the name maxillary vertical excess.3
Schendel was the first to describe in the literature the term "long face syndrome" to refer to maxillary vertical excess which was generally defined as hyperdivergent (vertical growth), and which was characterised by an enlarged lower facial third, resulting in the appearance of a long face.4
The aetiology of vertical alterations is considered multifactorial, and includes genetic and environmental aspects, together with the great variability present among individuals. Among the most important genetic factors are the neuromuscular pattern, heritability of vertical facial dimensions and ethnic characteristics. Environmental factors include, among others, mouth breathing and digital sucking, etc.2,5
Patients with this problem have characteristic features such as a normal upper third, a generally narrow nose, as well as a narrow alar base and depression of the nasolabial area, an enlarged middle third, dryness of the nasolabial commissure, excessive dental exposure at rest, increased interlabial distance, retroposition of the chin, inferior rotation of the posterior portion of the maxilla, mandible tends to rotate downwards and backwards, long but narrow pharyngeal space, swelling of the nasal mucosa, lip incompetence, etc.5
Gingival exposure in smiles depends on several factors, so achieving ideal levels of gingival exposure is usually difficult as it requires accurate identification and correction of the cause of the problem, which may be skeletal, dental or both.5-7
CLINICAL CASE
21-year-old female patient presenting at the High Specialty Center "Dr. Rafael Lucio" whose reason for consultation is "I want to close my mouth properly", she does not refer to allergies or bad habits. She presents with a dolichofacial biotype, oval face, facial midline does not coincide with the upper dental midline, gingival smile of 8 mm and incisor exposure at rest of 6 mm, with a straight profile, deficiency of the middle facial third (Figure 1), edge to edge bite in the anterior sector, unilateral right posterior crossbite, a 0 mm overjet, bilateral class I canine, class i molar right and class I molar III left due to the absence of dental organ #35, slight upper and lower crowding (Figure 2).
Treatment planAccording to the evaluation of the radiographic studies (Figures 3 and 4), extraoral and intraoral photographs, and cephalometric data (Table 1), it was decided to carry out orthodontic-surgical treatment and thus fulfil the planned objectives.
Pre-surgical phase: cementation of CCO slot 0.022" × 0.028" brackets, starting with NiTi 0.014" archwires in both arches to begin with alignment and levelling. Treatment continued with 0.016" NiTi, 0.016" × 0.022" NiTi, 0.019" × 0.025" NiTi, 0.019" × 0.025" steel archwires.
After 18 months the case was re-evaluated with radiographic studies and study models together with the Department of Oral and Maxillofacial Surgery and orthognathic surgery was scheduled. Surgical archwires were placed prior to surgery, 0.019" × 0.025" stainless steel archwires with surgical hooks. The first phase of treatment consisted of 20 months.
Surgical phase: it was decided to perform bimaxillary surgery, in the upper jaw a high Le Fort type 1 osteotomy was performed due to the hypoplasia of the middle third presented by the patient, a maxillary advancement of 4 mm was performed and a maxillary intrusion of 6 mm in the anterior and 5 mm in the posterior. An SSRO (sagittal split ramaus osteotomy) was performed on the mandible, with mandibular anterorotation. The second phase consisted of three weeks, from surgery to the first post-surgical appointment, prior recovery.
Post-surgical orthodontic phase: 21 days after surgery, intermaxillary elastics were indicated in order to correct midline, muscle patterns and improve settlement. In retention, upper and lower circumferential retainers were indicated. The last phase consisted of nine months.
RESULTS
The duration of treatment was 32 months, the coordination of both were achieved, the excess vertical growth of the patient was corrected; bilateral canine class I, a positive arch smile, correct anterior guidance (overjet and overbite) and coincidence of the midlines were achieved, the edge-to-edge bite in the anterior sector and the crossbite in the right posterior sector were eliminated(Figures 5 and 6). The radiographic examination showed root parallelism and adequate inclination of the incisors (Figures 7 and 8, Table 2).
DISCUSSION
The gingival smile is the patient's major aesthetic concern, for which some non-invasive techniques have been described that improve appearance but do not correct function. Guerra Leal in 2011, and Cope and Sachdeva in 1999 describe camouflage orthodontics by producing compensatory movements that can improve facial appearance, however, the final result exhibits unattractive features.8,9
Although the orthopaedic approach is an option when the problem is sagittal or transverse, the outcome of treatment for vertical skeletal problems remains controversial.10
Meneses López in 2005 proposed that botulinum toxin injection reduces gingival exposure during the smile due to immobilization of the perioral muscles, although this is not a permanent solution.6,8-11
Falcón Guerrero in 2018 studied the lengthening of the upper lip through V-Y plasty and gingivoplasty, as minimally invasive alternatives to decrease gingival exposure. Guerra et al in 2011 discussed that these procedures did not guarantee stability over time.8,12
Another option is the use of TADs, for intrusion in the anterior sector and thus try to reduce the gingival smile, although this option has its limitations.13
Epker and Wolford, in 1980, proposed the Le Fort I impaction osteotomy, which allows the correction of the maxillary vertical excess, because it eliminates the excess and repositions the maxilla superiorly, while reducing the height of the alveolar process and shortening the lower facial third. Additionally, Nielsen in 2011 highlights that the procedure provides long-term functional stability, since it is fixed through the osteosynthesis material that contributes to stability during the bone consolidation process. Patients with maxillary vertical excess or any other dentofacial deformity that distorts facial harmony may have low self-esteem, which can improve after orthognathic surgery, achieving greater security during their psychosocial development.8,13
CONCLUSION
The study of the components of facial balance is a fundamental complement to the treatment of patients with facial alterations. It must be taken into account that with the evaluation of the soft tissues it is possible to predict the aesthetic changes that our patient will have at the end of the treatment.
The orthodontist must be aware of the treatment alternatives in order to offer them to the patient.
Nowadays, both in maxillofacial surgery and in orthodontics, the study of facial aesthetics is integrated into the diagnosis to provide a comprehensive treatment to the patient.
REFERENCES
AFFILIATIONS
1 Residente del Posgrado de Ortodoncia.Universidad Nacional Autónoma de México campus Centro de Alta Especialidad (CAE-UNAM). México.
2 Egresado del Posgrado de Cirugía Maxilofacial. Universidad Nacional Autónoma de México campus Centro de Alta Especialidad (CAE-UNAM). México.
3 Egresado del Posgrado de Ortodoncia. Universidad Nacional Autónoma de México campus Centro de Alta Especialidad (CAE-UNAM). México.
4 Coordinador del Posgrado. Universidad Nacional Autónoma de México campus Centro de Alta Especialidad (CAE-UNAM). México.
5 Cirujano adscrito del Posgrado de Cirugía Maxilofacial. Universidad Nacional Autónoma de México campus Centro de Alta Especialidad (CAE-UNAM). México.
CORRESPONDENCE
Gabriela Verónica Robalino León. E-mail: gabyvrobalinoleon@gmail.comReceived: Marzo 2020. Accepted: Mayo 2020.