Interdisciplinary management of an adult patient with a class III malocclusion Zafer Özgür Pektas, DDSa and Beyza Hancıoglu Kircelli, DDSb School of Dentistry, Baskent University, Department of Oral and Maxillofacial Surgery, Adana, Turkey The coexistence of a skeletal class III deformity and partial edentulism poses a clinical challenge and requires a comprehensive evaluation followed by a multidisciplinary approach. This clinical report presents the integrated management of a class III malocclusion in a 50-year-old woman with partial edentulism. The patient received adjunctive orthodontic treatment with a rigid temporary anchorage device, a Le Fort I maxillary osteotomy, and prosthodontic rehabilitation with removable maxillary copings, an overdenture, and a mandibular partial removable dental prosthesis with precision attachments. (J Prosthet Dent 2013;-:---) Skeletal class III deformities are caused by maxillary deficiency, mandibular excess, or a combination.1 Approximately 40% of class III deformities are caused by maxillary deficiencies alone.2 The correction of a class III deformity is accomplished by combined orthodontic and orthognathic surgical procedures when the deformity is too severe that reasonable correction cannot be obtained by orthodontic treatment alone.2 Le Fort osteotomy has become the most popular midfacial osteotomy to correct maxillary deformity, with or without simultaneous mandibular surgery,3 since it was first introduced by Obwegeser4 in 1969. Complete or partial edentulism in patients with skeletal class III deformities complicates the situation and poses a clinical challenge, especially when occlusal guidance is lost. This report presents the interdisciplinary management of a partially edentulous class III malocclusion, which comprised an adjunctive orthodontic treatment with a rigid temporary anchorage device (TAD), a Le Fort I maxillary osteotomy, and prosthodontic rehabilitation with maxillary metal copings, an overdenture, and a mandibular partial removable dental prosthesis with precision attachments. a
CLINICAL REPORT A 50-year-old woman with functional and esthetic complaints was initially referred to the department of prosthodontics for new prostheses. Her medical history was noncontributory, and cleft lip and palate deformities were ruled out. The temporomandibular joints were healthy and not painful
on palpation, and the range of motion was within normal limits. An extraoral examination revealed a skeletal class III pattern associated with a concave facial profile, a prominent chin, a retrusive maxillary complex, with inadequate upper lip support, and deep nasobuccal folds (Fig. 1A, B). Clinical and radiographic evaluation indicated a worn and unfavorable metal reinforced
1 A, B, Pretreatment extraoral oblique and profile view. Note retrusive maxillary complex, inadequate upper lip support, and deep nasobuccal folds.
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Baskent University. Associate Professor, Department of Orthodontics, Private practice, Adana, Turkey.
b
Pektas and Kircelli
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2 Pretreatment panoramic radiograph, indicating bimaxillary partial edentulism and unfavorable acrylic resin partial fixed dental prosthesis.
Table I.
Pretreatment and posttreatment cephalometric measurement values of
patient
Cephalometric Landmarks Pretreatment Posttreatment Norm Values SNA (degrees)
73.7
78. 9
82.0
SNB (degrees)
79.8
78.7
80.9
ANB (degrees)
-6.1
0.2
1.6
Facial angle (FH-NPo) (degrees)
88.9
87.2
88.6
Convexity (A-NPo) (mm)
-7.9
-1.2
0.7
FMA (MP-FH) (degrees)
20.5
21.4
23.9
Upper lip to E plane (mm)
-14.3
-9.3
-6.0
Lower lip to E plane (mm)
-7.6
-5.6
-2.0
SNA, sella-nasion-A; SNB, sella-nasion-B; ANB, A-nasion-B; FH-NPo, Frankfort Horizontal-nasionpogonion line; A-NPo, A-nasion-pogonion line; FMA, Frankfort Mandibular-Plane Angle; MP-FH, Mandibular Plane-Frankfort Horizontal. Cephalometric analysis processed by using Dolphin Imaging Software, 11.0 (Dolphin Imaging).
fixed dental prosthesis with acrylic resin veneers, which extended from the maxillary central incisors to the maxillary right first molar. In addition, the partial fixed dental prosthesis was supported by an impacted maxillary canine, which presented severe mobility, and all the supporting teeth were root remnants with caries and apparent infection (Fig. 2). The maxillary left canine, second premolar, and second molar were missing. The mandible was edentulous except for the right central and lateral incisor, canine, and second molar. The mandibular incisors and right second molar were supporting a defective metal ceramic fixed dental prosthesis and a partial removable dental prosthesis. Both maxillary and mandibular prostheses
were unsatisfactory and failed to establish an accurate occlusion. In particular, the maxillary restoration presented an excessive protrusion to disguise the skeletal class III deformity. Also, the dental history of the patient revealed previous attempts with several removable partial prostheses, none of which met her expectations. The prostheses that were fabricated in the neutral zone failed to support the soft tissue anterior to the retruded maxilla, whereas those with an increased denture base thickness to buttress the maxillary soft tissue were unstable because of the muscular activity. The patient was referred to an oral and maxillofacial surgeon, an orthodontist, and a prosthodontist. Cephalometric evaluations were performed by the orthodontist to determine
The Journal of Prosthetic Dentistry
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Issue
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the pattern of dentofacial deformity. Cephalometric analysis and diagnostic casts revealed a moderate skeletal class III deformity, attributed to maxillary deficiency; no remarkable mandibular discrepancy was noted (Table I). The cephalometric measurements were performed by using imaging software (Dolphin Imaging Software, 11.0; Dolphin Imaging). This software also can classify the severity of the skeletal deformity as mild, moderate, or severe based on the deviations from the norm values of the sella-nasion-A angle. A standard deviation of 2.4 degrees corresponded to a moderate deformity for this patient as determined by the software. The treatment plan involved managing the impacted maxillary right canine with orthodontics, advancing the maxilla with a 1-piece Le Fort I maxillary osteotomy, and subsequently rehabilitating the occlusion with prosthodontics. Other treatment alternatives that comprised prosthetic restorations alone were also discussed. A maxillary complete arch implantsupported fixed prosthesis would have restored her masticatory function; however, as with a removable prosthesis, the contribution to facial esthetics would have been confined to the dentoalveolar level. Moreover, such a treatment plan with multiple dental implants would have entailed a higher patient cost because the placement of dental implants was not covered by the national health insurance; the cost of a maxillary and mandibular osteotomy was covered. After the patient provided informed consent, the existing maxillary fixed dental prosthesis was removed and the maxillary central incisors, the maxillary right and left first premolars, and the maxillary right first molar were extracted. Also, a titanium intraosseous screw (2.0mm diameter 8-mm length) (intermaxillary fixation screw; Stryker) was placed on the maxillary alveolar crest to be used as a rigid TAD for the orthodontic eruption of the right maxillary impacted canine. Access to the impacted maxillary canine was accomplished, and a bracket was attached to the buccal
Pektas and Kircelli
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2013
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3 Intermaxillary fixation screw as rigid temporary anchorage device for orthodontic eruption of impacted right maxillary canine.
4 Uprighting and extrusion of impacted canine by using elastomeric chain, rigid temporary anchorage device, and cantilever fabricated from 0.017 0.025 inch titanium molybdenum alloy wire
surface (Fig. 3). The impacted canine was first moved upright by traction from an elastomeric chain applied from the rigid TAD. It was secondarily extruded by using a cantilever, fabricated from 0.017 0.025 inch titanium molybdenum alloy wire (Ormco Corp), which went from the rigid TAD to the bracket of the canine after the maxillary advancement (Fig. 4). The patient then was scheduled to undergo a Le Fort I maxillary osteotomy, which was performed as described by Bell.5 After sectioning, downfracture, and mobilization, the osteotomized segment was advanced anteriorly by 5 mm and moved downward by 2.5 mm (Fig. 5A, B). The desired position was determined by using a monoblock type acrylic resin (Scheu-Dental) splint fabricated on the stone casts used for cast surgery. A conventional occlusal acrylic resin splint could not be used because of the multiple tooth loss in both jaws. The maxilla was repositioned with both the mandibular condyles in neutral position and bearing no external force. The fixation of the repositioned maxilla was maintained by using 2 L-shaped titanium miniplates (Leibinger) placed lateral to the pyriform fossa and the zygomatic buttresses on each side. Healing was uneventful, with improved facial esthetics; the maxillary advancement augmented the lip support and eliminated the concave facial profile and deep nasobuccal folds (Fig. 6). Subsequently, the prosthodontic treatment phase was initiated, and the maxillary left first molar was restored with a ceramic crown. The extruded maxillary right canine and maxillary left lateral incisor were restored with metal copings and an overdenture was fabricated (Fig. 7A, B). Cephalometric measurements are shown in Table I. The total treatment time was 12 months. At a 6year follow-up, the patient remained satisfied with the esthetic and functional results (Fig. 8A, B).
DISCUSSION
5 A, Presurgical lateral cephalometric radiograph with intermaxillary fixation screw in place. B, Postsurgical lateral cephalometric radiograph, miniplate, and screw fixation.
Pektas and Kircelli
The contemporary treatment of skeletal class III deformities in adult patients with partial edentulism necessitates a
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Volume
6 Postsurgical extraoral lateral view, showing improvement in soft-tissue profile.
7 A, B, Metal copings and overdenture. comprehensive perspective. In most situations, noninvasive treatment options with decreased risks may result in
compromised function or esthetics. A literature review revealed many clinical reports with acceptable results, in which
The Journal of Prosthetic Dentistry
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Issue
-
class III deformities were treated with orthodontics alone or combined with prosthodontic treatment.6-10 Unfortunately, concerns exist when determining a treatment plan for adults with skeletal problems. The functional stability of a prosthetic rehabilitation for a patient with a maxillomandibular skeletal discrepancy is generally compromised. Orthognathic surgery is required to restore the esthetic balance in patients with moderate-to-severe skeletal problems. However, patients may be reluctant to undergo surgery either because of personal preferences or their compromised health. In addition to the retruded maxilla, the effects of multiple tooth loss and, consequently, the atrophy of the maxillary alveolar were seen as inadequate upper lip support, deep nasobuccal folds, and increased facial wrinkles, all contributed to an aging face. This patient was not willing to accept suboptimal results, and surgical maxillary advancement followed by prosthetic rehabilitation fulfilled all her requirements. From a prosthodontic point of view, acrylic resin denture bases may replace and support the orofacial structures in selected patients. However, this treatment should be limited to those with mild skeletal class III deformities. For the presented patient, the functional restoration could have been accomplished by means of a proper prosthetic restoration, which provided bilateral balancing occlusion. However, this would probably have led to further esthetic concerns, particularly for the midfacial deficiency. The eccentric settlement of the denture due to the retrusive maxilla would have exacerbated the resorptive process in the maxilla. Although esthetic concerns might have been avoided by increasing the occlusal vertical dimension,11 an increased occlusal vertical dimension may cause postoperative problems, including clenching, muscle fatigue, occlusal instability, continued wear, and the resorption of the alveolus. Orthognathic surgery likely offers the best treatment alternative in adults with skeletal class III deformities in
Pektas and Kircelli
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2013
5
8 A, B, Posttreatment extraoral view, 6-year follow-up with satisfactory esthetic and functional results.
which the maxillary retrusion is the primary component. The LeFort I maxillary osteotomy has been the procedure of preference for the correction of many skeletal class III deformities.5,12 Nevertheless, the reluctance of the patient to have surgery may limit an ideal treatment plan.
SUMMARY This patient’s satisfaction with the treatment outcome emphasizes the significance of a comprehensive patient evaluation, an accurate patientoriented diagnosis, and a multidisciplinary
Pektas and Kircelli
approach for the management of patients with partial edentulism and with skeletal deformities.
REFERENCES 1. Guyer EC, Ellis EE III, McNamara JA Jr, Behrents RG. Components of class III malocclusion in juveniles and adolescents. Angle Orthod 1986;56:7-30. 2. Bailey LJ, Haltiwanger LH, Blakey GH, Proffit WR. Who seeks surgical-orthodontic treatment: a current review. Int J Adult Orthodon Orthognath Surg 2001;16:280-92. 3. Hoffman GR, Brennan PA. The skeletal stability of one-piece Le Fort I osteotomy to advance the maxilla part 2. The influence of uncontrollable clinical variables. Br J Oral Maxillofac Surg 2004;42:226-30.
4. Obwegeser HL. Surgical correction of small or retrodisplaced maxillae. The “dish-face” deformity. Plast Reconstr Surg 1969;43:351-65. 5. Bell W. Le Fort I osteotomy for correction of maxillary deformities. J Oral Surg 1975;33: 412-26. 6. Janson G, de Souza JE, Alves Fde A, Andrade P Jr, Nakamura A, de Freitas MR, et al. Extreme dentoalveolar compensation in the treatment of Class III malocclusion. Am J Orthod Dentofacial Orthop 2005;128:787-94. 7. Chan MD. An adult malocclusion requiring a combination of orthodontic and prosthodontic treatment. Am J Orthod Dentofacial Orthop 1997;111:100-5. 8. Daher W, Caron J, Wechsler MH. Nonsurgical treatment of an adult with a class III malocclusion. Am J Orthod Dentofacial Orthop 2007;132:243-51. 9. Hisano M, Chung CR, Soma K. Nonsurgical correction of skeletal class III malocclusion with lateral shift in an adult. Am J Orthod Dentofacial Orthop 2007;131:797-804. 10. Gelgör IE, Karaman AI. Non-surgical treatment of class III malocclusion in adults: two case reports. J Orthod 2005;32:89-97. 11. Sakar O, Beyli M, Marsan G. Combined prosthodontic and orthodontic treatment of a patient with a class III skeletal malocclusion: a clinical report. J Prosthet Dent 2004;92:224-8. 12. Willmar K. On Le Fort I osteotomy; a followup study of 106 operated patients with maxillo-facial deformity. Scand J Plast Reconstr Surg 1974;12:1-68.
Corresponding author: Dr Zafer O Pektas Baskent Universitesi, Adana Uygulama ve Arastırma Merkezi Kisla Saglik Yerleskesi, Kazim Karabekir mah. 4227 Sok. No: 27, 01120 Yuregir, Adana TURKEY E-mail: [email protected] Acknowledgment The authors thank Dr Cem Kircelli for his valuable contributions. Copyright ª 2013 by the Editorial Council for The Journal of Prosthetic Dentistry.
CLINICAL REPORT A 50-year-old woman with functional and esthetic complaints was initially referred to the department of prosthodontics for new prostheses. Her medical history was noncontributory, and cleft lip and palate deformities were ruled out. The temporomandibular joints were healthy and not painful
on palpation, and the range of motion was within normal limits. An extraoral examination revealed a skeletal class III pattern associated with a concave facial profile, a prominent chin, a retrusive maxillary complex, with inadequate upper lip support, and deep nasobuccal folds (Fig. 1A, B). Clinical and radiographic evaluation indicated a worn and unfavorable metal reinforced
1 A, B, Pretreatment extraoral oblique and profile view. Note retrusive maxillary complex, inadequate upper lip support, and deep nasobuccal folds.
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Baskent University. Associate Professor, Department of Orthodontics, Private practice, Adana, Turkey.
b
Pektas and Kircelli
2
Volume
2 Pretreatment panoramic radiograph, indicating bimaxillary partial edentulism and unfavorable acrylic resin partial fixed dental prosthesis.
Table I.
Pretreatment and posttreatment cephalometric measurement values of
patient
Cephalometric Landmarks Pretreatment Posttreatment Norm Values SNA (degrees)
73.7
78. 9
82.0
SNB (degrees)
79.8
78.7
80.9
ANB (degrees)
-6.1
0.2
1.6
Facial angle (FH-NPo) (degrees)
88.9
87.2
88.6
Convexity (A-NPo) (mm)
-7.9
-1.2
0.7
FMA (MP-FH) (degrees)
20.5
21.4
23.9
Upper lip to E plane (mm)
-14.3
-9.3
-6.0
Lower lip to E plane (mm)
-7.6
-5.6
-2.0
SNA, sella-nasion-A; SNB, sella-nasion-B; ANB, A-nasion-B; FH-NPo, Frankfort Horizontal-nasionpogonion line; A-NPo, A-nasion-pogonion line; FMA, Frankfort Mandibular-Plane Angle; MP-FH, Mandibular Plane-Frankfort Horizontal. Cephalometric analysis processed by using Dolphin Imaging Software, 11.0 (Dolphin Imaging).
fixed dental prosthesis with acrylic resin veneers, which extended from the maxillary central incisors to the maxillary right first molar. In addition, the partial fixed dental prosthesis was supported by an impacted maxillary canine, which presented severe mobility, and all the supporting teeth were root remnants with caries and apparent infection (Fig. 2). The maxillary left canine, second premolar, and second molar were missing. The mandible was edentulous except for the right central and lateral incisor, canine, and second molar. The mandibular incisors and right second molar were supporting a defective metal ceramic fixed dental prosthesis and a partial removable dental prosthesis. Both maxillary and mandibular prostheses
were unsatisfactory and failed to establish an accurate occlusion. In particular, the maxillary restoration presented an excessive protrusion to disguise the skeletal class III deformity. Also, the dental history of the patient revealed previous attempts with several removable partial prostheses, none of which met her expectations. The prostheses that were fabricated in the neutral zone failed to support the soft tissue anterior to the retruded maxilla, whereas those with an increased denture base thickness to buttress the maxillary soft tissue were unstable because of the muscular activity. The patient was referred to an oral and maxillofacial surgeon, an orthodontist, and a prosthodontist. Cephalometric evaluations were performed by the orthodontist to determine
The Journal of Prosthetic Dentistry
-
Issue
-
the pattern of dentofacial deformity. Cephalometric analysis and diagnostic casts revealed a moderate skeletal class III deformity, attributed to maxillary deficiency; no remarkable mandibular discrepancy was noted (Table I). The cephalometric measurements were performed by using imaging software (Dolphin Imaging Software, 11.0; Dolphin Imaging). This software also can classify the severity of the skeletal deformity as mild, moderate, or severe based on the deviations from the norm values of the sella-nasion-A angle. A standard deviation of 2.4 degrees corresponded to a moderate deformity for this patient as determined by the software. The treatment plan involved managing the impacted maxillary right canine with orthodontics, advancing the maxilla with a 1-piece Le Fort I maxillary osteotomy, and subsequently rehabilitating the occlusion with prosthodontics. Other treatment alternatives that comprised prosthetic restorations alone were also discussed. A maxillary complete arch implantsupported fixed prosthesis would have restored her masticatory function; however, as with a removable prosthesis, the contribution to facial esthetics would have been confined to the dentoalveolar level. Moreover, such a treatment plan with multiple dental implants would have entailed a higher patient cost because the placement of dental implants was not covered by the national health insurance; the cost of a maxillary and mandibular osteotomy was covered. After the patient provided informed consent, the existing maxillary fixed dental prosthesis was removed and the maxillary central incisors, the maxillary right and left first premolars, and the maxillary right first molar were extracted. Also, a titanium intraosseous screw (2.0mm diameter 8-mm length) (intermaxillary fixation screw; Stryker) was placed on the maxillary alveolar crest to be used as a rigid TAD for the orthodontic eruption of the right maxillary impacted canine. Access to the impacted maxillary canine was accomplished, and a bracket was attached to the buccal
Pektas and Kircelli
-
2013
3
3 Intermaxillary fixation screw as rigid temporary anchorage device for orthodontic eruption of impacted right maxillary canine.
4 Uprighting and extrusion of impacted canine by using elastomeric chain, rigid temporary anchorage device, and cantilever fabricated from 0.017 0.025 inch titanium molybdenum alloy wire
surface (Fig. 3). The impacted canine was first moved upright by traction from an elastomeric chain applied from the rigid TAD. It was secondarily extruded by using a cantilever, fabricated from 0.017 0.025 inch titanium molybdenum alloy wire (Ormco Corp), which went from the rigid TAD to the bracket of the canine after the maxillary advancement (Fig. 4). The patient then was scheduled to undergo a Le Fort I maxillary osteotomy, which was performed as described by Bell.5 After sectioning, downfracture, and mobilization, the osteotomized segment was advanced anteriorly by 5 mm and moved downward by 2.5 mm (Fig. 5A, B). The desired position was determined by using a monoblock type acrylic resin (Scheu-Dental) splint fabricated on the stone casts used for cast surgery. A conventional occlusal acrylic resin splint could not be used because of the multiple tooth loss in both jaws. The maxilla was repositioned with both the mandibular condyles in neutral position and bearing no external force. The fixation of the repositioned maxilla was maintained by using 2 L-shaped titanium miniplates (Leibinger) placed lateral to the pyriform fossa and the zygomatic buttresses on each side. Healing was uneventful, with improved facial esthetics; the maxillary advancement augmented the lip support and eliminated the concave facial profile and deep nasobuccal folds (Fig. 6). Subsequently, the prosthodontic treatment phase was initiated, and the maxillary left first molar was restored with a ceramic crown. The extruded maxillary right canine and maxillary left lateral incisor were restored with metal copings and an overdenture was fabricated (Fig. 7A, B). Cephalometric measurements are shown in Table I. The total treatment time was 12 months. At a 6year follow-up, the patient remained satisfied with the esthetic and functional results (Fig. 8A, B).
DISCUSSION
5 A, Presurgical lateral cephalometric radiograph with intermaxillary fixation screw in place. B, Postsurgical lateral cephalometric radiograph, miniplate, and screw fixation.
Pektas and Kircelli
The contemporary treatment of skeletal class III deformities in adult patients with partial edentulism necessitates a
4
Volume
6 Postsurgical extraoral lateral view, showing improvement in soft-tissue profile.
7 A, B, Metal copings and overdenture. comprehensive perspective. In most situations, noninvasive treatment options with decreased risks may result in
compromised function or esthetics. A literature review revealed many clinical reports with acceptable results, in which
The Journal of Prosthetic Dentistry
-
Issue
-
class III deformities were treated with orthodontics alone or combined with prosthodontic treatment.6-10 Unfortunately, concerns exist when determining a treatment plan for adults with skeletal problems. The functional stability of a prosthetic rehabilitation for a patient with a maxillomandibular skeletal discrepancy is generally compromised. Orthognathic surgery is required to restore the esthetic balance in patients with moderate-to-severe skeletal problems. However, patients may be reluctant to undergo surgery either because of personal preferences or their compromised health. In addition to the retruded maxilla, the effects of multiple tooth loss and, consequently, the atrophy of the maxillary alveolar were seen as inadequate upper lip support, deep nasobuccal folds, and increased facial wrinkles, all contributed to an aging face. This patient was not willing to accept suboptimal results, and surgical maxillary advancement followed by prosthetic rehabilitation fulfilled all her requirements. From a prosthodontic point of view, acrylic resin denture bases may replace and support the orofacial structures in selected patients. However, this treatment should be limited to those with mild skeletal class III deformities. For the presented patient, the functional restoration could have been accomplished by means of a proper prosthetic restoration, which provided bilateral balancing occlusion. However, this would probably have led to further esthetic concerns, particularly for the midfacial deficiency. The eccentric settlement of the denture due to the retrusive maxilla would have exacerbated the resorptive process in the maxilla. Although esthetic concerns might have been avoided by increasing the occlusal vertical dimension,11 an increased occlusal vertical dimension may cause postoperative problems, including clenching, muscle fatigue, occlusal instability, continued wear, and the resorption of the alveolus. Orthognathic surgery likely offers the best treatment alternative in adults with skeletal class III deformities in
Pektas and Kircelli
-
2013
5
8 A, B, Posttreatment extraoral view, 6-year follow-up with satisfactory esthetic and functional results.
which the maxillary retrusion is the primary component. The LeFort I maxillary osteotomy has been the procedure of preference for the correction of many skeletal class III deformities.5,12 Nevertheless, the reluctance of the patient to have surgery may limit an ideal treatment plan.
SUMMARY This patient’s satisfaction with the treatment outcome emphasizes the significance of a comprehensive patient evaluation, an accurate patientoriented diagnosis, and a multidisciplinary
Pektas and Kircelli
approach for the management of patients with partial edentulism and with skeletal deformities.
REFERENCES 1. Guyer EC, Ellis EE III, McNamara JA Jr, Behrents RG. Components of class III malocclusion in juveniles and adolescents. Angle Orthod 1986;56:7-30. 2. Bailey LJ, Haltiwanger LH, Blakey GH, Proffit WR. Who seeks surgical-orthodontic treatment: a current review. Int J Adult Orthodon Orthognath Surg 2001;16:280-92. 3. Hoffman GR, Brennan PA. The skeletal stability of one-piece Le Fort I osteotomy to advance the maxilla part 2. The influence of uncontrollable clinical variables. Br J Oral Maxillofac Surg 2004;42:226-30.
4. Obwegeser HL. Surgical correction of small or retrodisplaced maxillae. The “dish-face” deformity. Plast Reconstr Surg 1969;43:351-65. 5. Bell W. Le Fort I osteotomy for correction of maxillary deformities. J Oral Surg 1975;33: 412-26. 6. Janson G, de Souza JE, Alves Fde A, Andrade P Jr, Nakamura A, de Freitas MR, et al. Extreme dentoalveolar compensation in the treatment of Class III malocclusion. Am J Orthod Dentofacial Orthop 2005;128:787-94. 7. Chan MD. An adult malocclusion requiring a combination of orthodontic and prosthodontic treatment. Am J Orthod Dentofacial Orthop 1997;111:100-5. 8. Daher W, Caron J, Wechsler MH. Nonsurgical treatment of an adult with a class III malocclusion. Am J Orthod Dentofacial Orthop 2007;132:243-51. 9. Hisano M, Chung CR, Soma K. Nonsurgical correction of skeletal class III malocclusion with lateral shift in an adult. Am J Orthod Dentofacial Orthop 2007;131:797-804. 10. Gelgör IE, Karaman AI. Non-surgical treatment of class III malocclusion in adults: two case reports. J Orthod 2005;32:89-97. 11. Sakar O, Beyli M, Marsan G. Combined prosthodontic and orthodontic treatment of a patient with a class III skeletal malocclusion: a clinical report. J Prosthet Dent 2004;92:224-8. 12. Willmar K. On Le Fort I osteotomy; a followup study of 106 operated patients with maxillo-facial deformity. Scand J Plast Reconstr Surg 1974;12:1-68.
Corresponding author: Dr Zafer O Pektas Baskent Universitesi, Adana Uygulama ve Arastırma Merkezi Kisla Saglik Yerleskesi, Kazim Karabekir mah. 4227 Sok. No: 27, 01120 Yuregir, Adana TURKEY E-mail: [email protected] Acknowledgment The authors thank Dr Cem Kircelli for his valuable contributions. Copyright ª 2013 by the Editorial Council for The Journal of Prosthetic Dentistry.
