Surgery-First Approach in a Case of Mandibular Asymmetry

Abstract

For many years, the conventional method of treatment in dentoskeletal Class III patients included orthodontic treatment before orthognathic surgery. Recent improvements in technology, however, lead to an additional safe option for treatment: the surgery-first approach. [1] In the surgery-first approach, the skeletal bases and the facial esthetic concerns are fixed from the beginning of treatment. The approach is primarily indicated in cases that do not need extensive presurgical orthodontic alignment, leveling, and decompensation. It can be used to treat a variety of malocclusions that meet certain criteria, such as mildly crowded anterior teeth, a flat to the mildly accentuated curve of Spee, normal to slightly proclined or retroclined incisors, and minimal transverse discrepancies. [2] Compared with the traditional approach, surgery-first protocols lead to a significantly reduced total treatment time. [3] This could be because (1) the dental decompensation in the surgery-first approach is resolved partly by surgery so that the complexity of the orthodontic treatment is reduced, and/or (2) the phenomenon of postoperatively accelerated orthodontic tooth movement shortens the treatment period. [2] Recently, a precise treatment plan became possible with the help of three-dimensional (3D) imaging and simulation. [4] Virtual surgical planning, combined with a method of transferring the plan to surgery, permits maxillofacial surgeons to make an accurate diagnosis, provides a predictable means for 3D reconstruction, and facilitates the analysis of postoperative changes in both hard and soft tissues. [5] Ultimately, 3D surgical planning systems make it possible to handle complex cases, such as asymmetry problems. [6] Given this recent progress in the field, the objective of this case report is to present the orthodontic treatment in an adult patient with a skeletal Class I, hyperdivergent pattern, mandibular asymmetry, and lip incompetence by using the surgery-first approach. dIagnosIs and etIologyThe patient, an adult, aged 25 years 10 months, presented for orthodontic treatment. The patient's chief complaints were difficulty with keeping lips passively closed due to lip incompetence, and facial asymmetry. Facially, the patient presented with the asymmetry of the lower third with mandibular deviation to the left side. In the intraoral exam,