IS SURGERY THE ONLY OPTION?

Over the years practicing orthodontics and treating mal-occlusions and TMJD (temporomandibular disorders), treatment of the Class III (under bite) type of mal-occlusion has been the most rewarding experience, having a patient or their parents thank me for saving them from surgery. My goal is to inform the consumer that there are alternatives to surgery, not always but in majority of cases.

What is a Class III mal-occlusion? 
Class III malocclusion is considered to be one of the most difficult and complex orthodontic problems to treat. Prevalence of class III malocclusion in Caucasians ranges from 0.8 to 4.0% and rises up to 1213% in Chinese and Japanese populations. Skeletal class III malocclusion may either be associated with a maxillary retrusion (shorter upper jaw), a mandibular protrusion (longer lower jaw), or a combination of the two.
A poor facial appearance is often the patient's chief complaint, but may be accompanied by functional problems, temporomandibular disorders, or psychosocial handicaps.




Majority of these cases end up as surgical cases. The treatment usually involves a bilateral saggital split osteotomy of the lower jaw and/or advancement of the upper jaw with a Le Fort I osteotomy with pre-surgical and post-surgical orthodontics.



The surgery usually takes about seven hours to perform. The post-surgical complications like any surgery are nausea, numb upper and lower jaw, swelling, bruising, drooling, nose bleeding. Patients are restricted to soft and blended food.

But is this the only treatment option?

Case Report:
Patient L.A. 11.5 years of age presented to my office in 2010 for a 3rd opinion on his orthodontic treatment. The two previous orthodontists had recommended to hold off with treatment until patient reaches 16 years of age and at that time commence with pre-surgical orthodontics and surgery once initial alignment was completed.
After gathering the necessary records I came to the conclusion that this case could be treated non-surgically. A final consultation was scheduled and I discussed my plan of action which included of:

Phase I, treatment with a modified Tandem appliance to promote growth of the maxillary jaw forward, which is indicated in the mixed dentition stage.



Phase II, commencement with straight wire braces and the addition of CS 2000 springs in later stages of treatment.


Patient's parents agreed to my recommendations and were happy that the possibility of surgery was reduced.
L.A. was scheduled for treatment and following are the before, during and after images. Treatment ended in Summer of 2012 and patient was recently seen for follow up and did not show any relapse.

Pre-treatment

Mid treatment 6 months treatment with

Tandem appliance

Phase 2 braces and CS 2000

Completion of treatment in 2012

Cephalometric comparisons from start to finish

Discussion:

This case report describes the non-surgical intervention and treatment of a skeletal Class III mal-occlusion. With the advancements in today's dental technology and treatment procedures, surgical intervention should not be the first resort for treatment. As this case shows normal skeletal base relationships and normal occlusion can be achieved in a less invasive procedure and non-surgically.

In conclusion, I am not advocating that surgery should not be an option, but it is imperative to seek multiple opinions before a final decision for treatment is decided upon.

The author:

My name is Ramin Mehregan D.M.D. I graduated in 1992 from Boston University School of Graduate Dentistry. In 1999 I started my training with Dr. Clayton Chan (www.occlusionconnections.com) in the field of Gneuromuscular Dentistry which focuses in the treatment of TMJD disorders and full mouth rehabilitation. Upon completion of my training I continued my training in the field of orthodontics/orthopedics. Gneuromuscular Occlusion/Dentistry combines the application of sound gnathologic occlusal mechanics of occlusion with scientific and physiologic principles of NMD (Neuro-muscular-dentistry) in a balanced manner. Gneuromuscular is a discipline of dentistry that is now being recognized as key to comprehensive TMD, restorative and orthodontic dentistry that has been the missing link in our dental society.