2.2. Case #2

A healthy female (24 year 5 month old) presented with apparent long face syndrome, convex profile, vertical maxillary excess causing gummy smile, incompetent lips, and deficient chin. Intra-oral examination revealed a class II division 1 malocclusion associated with narrow maxilla, deep palatal vault, micrognathia, moderate crowding mild anterior open bite, and distorted occlusal planes.

#### 2.2.1. Diagnosis

Figures 11–14 exhibit the clinical and diagnostic aids that facilitate the formulation of appropriate treatment planning to achieve optimum treatment outcome.

#### 2.2.2. Treatment planning and treatment objectives

Because of the diagnosed severe skeletal dentofacial deformity, joint consultation and thorough patient's data analysis took place by the orthodontist, and the maxillofacial surgeon, the treatment modality offered to the patient, after detailed discussion and displaying of the possible outcome, was a combined orthosurgical care which was willingly accepted.

2.2.3. Treatment progress and results

2.2.4. Conclusions

Presurgical orthodontic phase intended to restore ideal arch form and dentoalveolar alignment (teeth decrowding, root parallelism, and occlusal plane leveling). This will facilitate the surgical mobilization of the arches in 3Ds; so that the appropriate canting of the occlusal plane and

Figure 12. Pretreatment lateral cephalometric analysis of McNamara confirming the long face deformity and retrognathic

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mandible. Tipped down occlusal plane buccally caused backward rotation of the mandible.

When malocclusion is a consequence of facial musculoskeletal imbalance, any attempt to restore facial esthetics and beautiful smile by orthodontic dentofacial orthopedics alone will

proper lip-teeth relationship secures satisfying treatment outcome (Figures 15 and 16).

Figure 13. Pretreatment cephalometric analysis of Jarabak (sagittal, vertical, and dentoalveolar findings).

Figure 11. Pretreatment facial, dentoalveolar, and radiographic photos.


Figure 12. Pretreatment lateral cephalometric analysis of McNamara confirming the long face deformity and retrognathic mandible. Tipped down occlusal plane buccally caused backward rotation of the mandible.


Figure 13. Pretreatment cephalometric analysis of Jarabak (sagittal, vertical, and dentoalveolar findings).

#### 2.2.3. Treatment progress and results

Presurgical orthodontic phase intended to restore ideal arch form and dentoalveolar alignment (teeth decrowding, root parallelism, and occlusal plane leveling). This will facilitate the surgical mobilization of the arches in 3Ds; so that the appropriate canting of the occlusal plane and proper lip-teeth relationship secures satisfying treatment outcome (Figures 15 and 16).

#### 2.2.4. Conclusions

orthosurgical treatment approach which was agreed upon by orthodontist and maxillofacial

A healthy female (24 year 5 month old) presented with apparent long face syndrome, convex profile, vertical maxillary excess causing gummy smile, incompetent lips, and deficient chin. Intra-oral examination revealed a class II division 1 malocclusion associated with narrow maxilla, deep palatal vault, micrognathia, moderate crowding mild anterior open bite, and

Figures 11–14 exhibit the clinical and diagnostic aids that facilitate the formulation of appro-

Because of the diagnosed severe skeletal dentofacial deformity, joint consultation and thorough patient's data analysis took place by the orthodontist, and the maxillofacial surgeon, the treatment modality offered to the patient, after detailed discussion and displaying of the

possible outcome, was a combined orthosurgical care which was willingly accepted.

priate treatment planning to achieve optimum treatment outcome.

surgeon and readily accepted by the patient.

2.2.2. Treatment planning and treatment objectives

Figure 11. Pretreatment facial, dentoalveolar, and radiographic photos.

2.2. Case #2

2.2.1. Diagnosis

distorted occlusal planes.

132 Current Approaches in Orthodontics

When malocclusion is a consequence of facial musculoskeletal imbalance, any attempt to restore facial esthetics and beautiful smile by orthodontic dentofacial orthopedics alone will

Figure 14. Soft tissue and dentoalveolar surgical planning of the case, surgical mobilization of the maxilla, and chin to restore harmony and balance of the facial profile, in addition to dentoalveolar sagittal and vertical orthodontic movements.

2.3. Case #3

smile, and ideal occlusion).

A healthy female patient (23 year old) presented with a chief complaint "I am frustrated with my elongated face, unaesthetic smile, and jam-packed teeth that prevent me from biting objects or chew food efficiently." She was reluctant to wear braces before, but is ready to go

Figure 16. Radiographic representation of LeFort I osteotomy with maxillary superior repositioning and genioplasty for chin augmentation achieved treatment objectives and patient's satisfaction. Phases of treatment (facial esthetics, pleasant

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Diagnosis clinical examination revealed typical long face features with increased lower facial height and almost straight profile. Vertical maxillary excess broke the balance and harmony of the facial parts that caused a clear gummy smile and tipped occlusal plane (Figure 17).

Intraorally, the sagittal relationship showed a class III malocclusion with negative overjet and a complex anterior open bite vertically, where second molars are in occlusion (pivoting) and crowded maxillary arch; the transverse relationship exhibited bilateral buccal crossbite, high palatal vault, and narrow maxilla contained in the normal mandibular arch form. There were

Jarabak and McNamara lateral cephalometric analyses demonstrated the severe skeletal origin of the dentofacial deformity (Figure 2) that cannot be treated by orthodontic approach alone. The vertical maxillary excess caused severe gingival display during full smile and backward rotation of the mandible that surpassed any physiologic eruptive compensation of anterior

extraction spaces in the lower arch as appears in the panoramic radiograph Figure 1.

2.3.1. Cephalometric assessment of vertical and sagittal features

teeth to develop anterior open bite (Figure 18).

through orthodontic treatment to re-establish a pleasant dentofacial appearance.

Figure 15. Phases of treatment (facial esthetics, pleasant smile, and ideal occlusion).

relationship in 3Ds. Surgical hooks were then constructed to start up the surgical phase surgical mobilization of the arches and bring occlusion into normal treatment outcome, and Figure 5 shows the end up with straightening of teeth within orofacial disharmony and unaesthetic smile. Formulating treatment planning in such cases needs mutual collaboration between different health care providers and in particular between orthodontist and maxillofacial surgeon from the very beginning if the treatment objectives and patient's satisfaction are to be realized as in the case presented.

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Figure 16. Radiographic representation of LeFort I osteotomy with maxillary superior repositioning and genioplasty for chin augmentation achieved treatment objectives and patient's satisfaction. Phases of treatment (facial esthetics, pleasant smile, and ideal occlusion).

#### 2.3. Case #3

relationship in 3Ds. Surgical hooks were then constructed to start up the surgical phase surgical mobilization of the arches and bring occlusion into normal treatment outcome, and Figure 5 shows the end up with straightening of teeth within orofacial disharmony and unaesthetic smile. Formulating treatment planning in such cases needs mutual collaboration between different health care providers and in particular between orthodontist and maxillofacial surgeon from the very beginning if the treatment objectives and patient's satisfaction are to

Figure 14. Soft tissue and dentoalveolar surgical planning of the case, surgical mobilization of the maxilla, and chin to restore harmony and balance of the facial profile, in addition to dentoalveolar sagittal and vertical orthodontic movements.

Figure 15. Phases of treatment (facial esthetics, pleasant smile, and ideal occlusion).

be realized as in the case presented.

134 Current Approaches in Orthodontics

A healthy female patient (23 year old) presented with a chief complaint "I am frustrated with my elongated face, unaesthetic smile, and jam-packed teeth that prevent me from biting objects or chew food efficiently." She was reluctant to wear braces before, but is ready to go through orthodontic treatment to re-establish a pleasant dentofacial appearance.

Diagnosis clinical examination revealed typical long face features with increased lower facial height and almost straight profile. Vertical maxillary excess broke the balance and harmony of the facial parts that caused a clear gummy smile and tipped occlusal plane (Figure 17).

Intraorally, the sagittal relationship showed a class III malocclusion with negative overjet and a complex anterior open bite vertically, where second molars are in occlusion (pivoting) and crowded maxillary arch; the transverse relationship exhibited bilateral buccal crossbite, high palatal vault, and narrow maxilla contained in the normal mandibular arch form. There were extraction spaces in the lower arch as appears in the panoramic radiograph Figure 1.

#### 2.3.1. Cephalometric assessment of vertical and sagittal features

Jarabak and McNamara lateral cephalometric analyses demonstrated the severe skeletal origin of the dentofacial deformity (Figure 2) that cannot be treated by orthodontic approach alone. The vertical maxillary excess caused severe gingival display during full smile and backward rotation of the mandible that surpassed any physiologic eruptive compensation of anterior teeth to develop anterior open bite (Figure 18).

Figure 17. Extra-oral and intra-oral photos showing the dentofacial deformity to be objectively assessed by other diagnostic aids (radiographs).

Figure 18. Lateral cephalometric analysis of Jarabak revealing vertical facial height excess, canted occ. plane, straight profile, deficient chin, and high gonial angle.

#### 2.3.2. Problem listing

Data collection and analyses (Figure 3) endorsed the orthosurgical approach of treatment after joint patient's consultation with the health care team and her enthusiastic approval (Figure 19).

2.3.4. Treatment progress

the missing teeth.

Maxillary arch expansion with quad helix appliance initiated simultaneously with leveling and alignment of teeth. Almost ideal arch form was attained, and the occlusal planes were flattened. When the presurgical phase was accomplished, surgical hooks were constructed as shown in Figure 22. LeFort I maxillary osteotomy with superior maxillary repositioning then took place to be followed by postsurgical detailing of occlusion and prosthetic replacement of

Figure 20. Treatment objectives allowed clinicians to formulate proper treatment planning.

Figure 19. Listing the complex discrepancies of skeletal, dentoalveolar, and soft tissue origin is to justify the orthosurgical

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approach of interdisciplinary treatment for the benefit of the patient.

#### 2.3.3. Treatment objectives

Realistic treatment objectives (Figure 20) were strictly reviewed to formulate the appropriate treatment planning, appliance design, and different presurgical orthodontics, surgical, and postsurgical phases of treatment (Figure 21).

Figure 19. Listing the complex discrepancies of skeletal, dentoalveolar, and soft tissue origin is to justify the orthosurgical approach of interdisciplinary treatment for the benefit of the patient.

Figure 20. Treatment objectives allowed clinicians to formulate proper treatment planning.

#### 2.3.4. Treatment progress

2.3.2. Problem listing

profile, deficient chin, and high gonial angle.

nostic aids (radiographs).

136 Current Approaches in Orthodontics

2.3.3. Treatment objectives

postsurgical phases of treatment (Figure 21).

Data collection and analyses (Figure 3) endorsed the orthosurgical approach of treatment after joint patient's consultation with the health care team and her enthusiastic approval (Figure 19).

Figure 18. Lateral cephalometric analysis of Jarabak revealing vertical facial height excess, canted occ. plane, straight

Figure 17. Extra-oral and intra-oral photos showing the dentofacial deformity to be objectively assessed by other diag-

Realistic treatment objectives (Figure 20) were strictly reviewed to formulate the appropriate treatment planning, appliance design, and different presurgical orthodontics, surgical, and Maxillary arch expansion with quad helix appliance initiated simultaneously with leveling and alignment of teeth. Almost ideal arch form was attained, and the occlusal planes were flattened. When the presurgical phase was accomplished, surgical hooks were constructed as shown in Figure 22. LeFort I maxillary osteotomy with superior maxillary repositioning then took place to be followed by postsurgical detailing of occlusion and prosthetic replacement of the missing teeth.

Figure 21. Model surgery and diagnostic set up possible for prosthetic construction.
