Interdisciplinary Approach to Treatment of Mandibular Prognathism Case report

Abstract

Skeletno ortodontske anomalije, kao i one koje imaju naglašenu skeletnu komponentu, znatan su problem s gledišta liječenja. Rendgenkefalometrijski postupci predviđanja kraniofacijalnoga rasta primjenom longitudinalnih studija nisu pouzdani jer je krivulja rasta individualna s nepredvidivim vektorom i dinamikom, pri čemu je najvažnije predvidjeti intenzitet varijabilnoga pubertetskoga poticaja rasta. Zbog toga se događa da se planirani tijek konvencionalnog ortodontskog liječenja ponekad mora mijenjati i predvidjeti kirurško rješenje. Pacijentica Zavoda za ortodonciju, Stomatološkog fakulteta u Zagrebu počela je liječenjem u 9. godini, u doba mješovite denticije, kada su se tek naslućivali elementi mandibularnoga prognatizma. U višegodišnjem liječenju primijenjeni su bionator i aktivne ploče. No usprkos dobroj suradnji u vrijeme puberteta, značajnom akceleracijom kondilarnoga rasta klinička slika je pogoršana i postavljena je dijagnoza mandibularni prognatizam. Predviđen je kirurški zahvat te je ortodontsko liječenje usmjereno na uklanjanje elemenata dentoalveolarne kompenzacije i učinaka dotadašnjeg liječenja. Primjenom fiksnog aparata sustava Roth 0,018 postignuta je normalna inklinacija frontalnih zuba u oba zubna luka uz kongruentnost tranverzalnih dimenzija obiju čeljusti, a međučeljusni je sagitalni odnos dijagnosticiran kao izraziti mandibularni prognatizam. Nakon potanke dijagnostičke obradbe i vizije postoperacijskoga rezultata, kirurški je zahvat izvršen osteotomijom s dvama okomitim i jednim vodoravnim rezom. Višak je kosti odstranjen, fiksacija je obostrano učinjena vijcima, a za međučeljusnu fiksaciju uporabljen je fiksni ortodontski aparat. Odnos čeljusti osiguran je interdentalnom vodiljom koja je učinjena neposredno prije zahvata. U retencijskom razdoblju uporabljen je postojeći fiksni aparat, koji je nakon 6 mjeseci zamijenjen monomaksilarnim mobilnim retncijskim napravama. Rezultat ortodontskokirurškog liječenja potvrdio je estetske i funkcijske zahtjeve predviđene planom liječenja.Skeletal orthodontic anomalies, as wel as those having strongly manifested skeletal components, represent a remarkable problem from the aspect of treatment. Roendgencephalometric methods of craniofacial growth prediction, by using longitudinal studies, are not reliable because the growth pattern is strictly individual. Most important, but impossible, is to predict the intensity and variations of pubertal growth spurt. Therefore, in some cases, the course of conventional orthodontic treatment must be changed, and a surgical procedure has to be considered. A female patient of the Department of Orthodontics School of Dental Medicine, University of Zagreb, started her treatment at the age of 9, during the mixed dentition, when the diagnosis mandibular prognathism was foreseen. During a few years of treatment bionator and removable plates were applied. Nevertheless, in spite of excellent collaboration, during puberty, because of remarkable acceleration of condylar growth, true mandibular prognathism was diagnosed. Surgical procedure was indicated. Therefore orthodontic treatment was focused on removal of dentoalveolar compenstory elements as well as previous treatment effects. By using a fixed appliance (Roth 0.018 system) normal inclination of the incisors was achieved in both dental arches as well as congruence of transversal dimensions of both jaws, while the sagittal intermaxillary relationship was diagnosed as mandibular prognatism. After a detailed diagnostic procedure and computerised postoperation result vision, surgery intervention was done on the mandible by osteotomy with two vertical and one horizontal cut. Bone surplus segment was removed. The fixation of skeletal segments was done by screws on both sides, whille the intermaxillary relation was obtained by the fixed appliance. Intermaxillary relation was provided by an interdental guide, made just before surgical treatment. During the retention period the previous fixed appliance was used, and after six months it was replaced by two removable retainers. The orthodontic-surgical treatment results confirmed the functional and esthetic demands foreseen by treatmen planning