Case report
A 19-year-old man who suffered from maxillofacial deformity and poor
chewing was referred to the outpatient department in our center. He was
subsequently admitted to the inpatient with a diagnosis of the skeletal
Angle Ⅲ malocclusion combined with maxillary dentition defect. The
general examination revealed that he had been healthy and well nourished
and had experienced no systemic diseases. The detailed clinical
examination was as follows: the maxillofacial region was basically
symmetrical. 1/3 of the surface, the middle, and the bottom face was
approximately 65mm, 65mm, 88mm, respective1y. The length of the upper
lip was about 20mm. The orbital plane was basically parallel to the
maxillary plane with a slight concave around the nose. From the lateral
view, the middle of the face was concave and the nasolabial angle was
about 120°. The position of the maxilla was retraction, the position of
the mandible was protruding. The maxillary midline was basically
centered and the mandibular midline was approximately 2 mm to the right.
The reverse overjet of anterior teeth was about 7 mm and the bilateral
first molars were the mesioclusion relationship. The congenital missing
teeth included tooth 14、tooth 15、tooth 23 and tooth 24(Fig.1). The
width of residual alveolar ridge in the absence of teeth was about 3-4
mm. The distance from tooth 14 to tooth 15, tooth 23 to tooth 24 was
about 4 mm and 5 mm respectively(Fig.2a). The occlusal distance was
normal and the results of cephalometric analysis were as follows:
SNA=78°, SNB=83° and ANB=-5°(Fig.2b).
In our case, the treatment process consisted of three parts:
preoperative orthodontic stage, orthognathic surgery stage and implant
repair stage. Yantai Stomatological Hospital Review Board approved the
clinical study and patient has been informed the surgical procedure and
precaution, and signed the consent form. At the orthodontic treatment
stage, we removed the tooth compensation, erected tooth 22, and moved
tooth 25 to the tooth 24 position. Closed scattered spaces from tooth 13
to tooth 25 and concentrated missing spaces on tooth 15 and tooth 25. In
the orthognathic operation stage, sagittal split osteotomy of bilateral
mandibular ramus, anterior maxillary osteotomy and autogenous bone graft
were performed under general anesthesia. The anterior maxillary incision
was located in the tooth 15 and tooth 25 missing area. The anterior
maxilla part moved forward about 2 mm and decreased about 2 mm and the
distal bone mass of the mandible receded about 5 mm. In order to
maintain the continuity, height and fullness of the bone, the removed
mandibular bone was placed in the maxillary incision position(Fig.3).
During the implant restoration phase, the postoperative orthodontics
ended six months after orthognathic surgery. There was no obvious
abnormality in the mucous membrane of the wound area, the bone tissue
healed well, the alveolar ridge was edge-shaped in the bilateral
edentulous region, and the mesiodistal width of the alveolar ridge was
about 7 mm(Fig.4). Cone beam CT showed that the buccolingual bone
width of tooth 15 was about 3 mm, the height of vertical bone was about
16 mm. The buccolingual bone width tooth 25 was about 3 mm, and the
height of vertical bone was about 16mm(Fig. 5).
Bone augmentation operation was performed in the area of bone defect
filled with Bio-oss bone powder, covered with Bio-gide membrane and
fixed with titanium nail, the surface was covered with CGF and sutured
tightly. One year after bone grafting alone, alveolar bone was found to
be plump in the absence of teeth, occlusion space was obtainable, and
mucous membrane was not abnormal. Cone beam CT showed that the
buccolingual bone width of tooth 15 was about 7 mm, the height of
vertical bone was about 14 mm. The buccolingual bone width tooth 25 was
about 6 mm, and the height of vertical bone was about 16mm. Two
straumann implants (4.1×10mm RN) were implanted in tooth 15 and tooth 25
and the postoperative x-ray showed the implant was in good
position(Fig. 6). 7 months after implantation, Cobalt Chromium
porcelain Crowns were used to repair tooth 15 and tooth 25(Fig. 7).
At revisit six months after completion of restoration, Bone tissue
around implants healed well. variable values of cephalometric
measurement before and after treatment were shown in the table 1.