CLINICIAN'S CORNER

Correction of facial asymmetry and maxillarycanting with corticotomy and 1-jaw orthognathicsurgery

Hyo-Won Ahn,a Dong Hwi Seo,b Seong-Hun Kim,c Baek-Soo Lee,d Kyu-Rhim Chung,e and Gerald Nelsonf

Seoul and Suwon, Korea, and San Francisco, Calif

aAssisHee UbPostHee UcAssoKyungdProfeKyungeProfeversitfClinicofaciaAll autentiaSuppogoverAddrelege o130-7Subm0889-Copyrhttp:/

Although 2-jaw orthognathic surgery is a typical recommendation for the treatment of facial asymmetry, anothergood treatment alternative is maxillary corticotomy with temporary skeletal anchorage devices followed bymandibular orthognathic surgery. The corticotomy procedure described here can achieve unilateral molar intru-sion and occlusal plane canting correction with potentially fewer complications than 2-jaw orthognathic surgery.The approach allows movement of dentoalveolar segments in less time than with conventional dental intrusionusing temporary skeletal anchorage devices. A 2-jaw asymmetry with occlusal plane canting might be correctedusing maxillary corticotomy and mandibular orthognathics rather than 2-jaw orthognathics. Two patients withfacial asymmetry are presented here. In each one, themaxillary cant was corrected over a period of 2 to 3monthswith 3.5 mm of intrusion of the unilateral buccal segment. After the preorthognathic cant correction, orthognathicsurgery was done to correct the mandibular asymmetry. (Am J Orthod Dentofacial Orthop 2014;146:795-805)

Facial asymmetry is one reason that patients seek or-thognathic surgery combined with orthodontictreatment. Common features of facial asymmetry

include amandibular deviation to the right or left that in-creases gradually from the upper to the lower face. This isusually associated with a cant of the maxilla and themaxillary occlusal plane.1 Severt and Proffit2 reportedthat the frequencies of facial asymmetry are 5%, 36%,and 74% in the upper, middle, and lower thirds of theface, respectively. In such cases, dramatic improvement

tant professor, Department of Orthodontics, College of Dentistry, Kyungniversity, Seoul, Korea.graduate student, Department of Orthodontics, College of Dentistry, Kyungniversity, Seoul, Korea.ciate professor and chair, Department of Orthodontics, College of Dentistry,Hee University, Seoul, Korea.ssor, Department of Oral and Maxillofacial Surgery, College of Dentistry,Hee University Medical Center, Seoul, Korea.ssor and chair, Department of Orthodontics, School of Medicine, Ajou Uni-y, Suwon, Korea.al professor and interim chair, Division of Orthodontics, Department of Or-l Science, University of California at San Francisco, San Francisco, Calif.thors have completed and submitted the ICMJE Form for Disclosure of Po-l Conflicts of Interest, and none were reported.rted by the National Research Foundation of Korea funded by the Koreanment (MEST) (number 2012R1A5A2051388).ss correspondence to: Seong-Hun Kim, Department of Orthodontics, Col-f Dentistry, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul01, Republic of Korea; e-mail, bravortho@gmail.com.itted, August 2013; revised and accepted, August 2014.5406/$36.00ight � 2014 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2014.08.018

of facial balance comes with surgery to the mandible.Correction of the maxillary cant is usually a prerequisite.Consequently, correction typically includes a combina-tion of LeFort I osteotomy and bilateral sagittal splitramus osteotomy.3

Case reports have been published demonstratingnonorthognathic correction of the maxillary cantbefore orthognathic surgery.4,5 Posterior bite-blocksor high-pull headgear has been used to intrude the mo-lars conventionally. Both of these methods require sig-nificant patient cooperation. With either method, it isdifficult to control the direction and quantity of toothmovement.6,7 With the advent of temporary skeletalanchorage devices (TSADs), orthodontic molarintrusion and occlusal plane canting correction havebeen reported, with minimal surgicalintervention.4,5,8,9 Kang et al4 introduced a rhythmicarch system using TSADs and obtained a considerableamount of canting correction. Jeon et al5 reportedcorrection of mandibular prognathism with mandibularsurgery only, correcting the maxillary asymmetry byintrusion of the maxillary molars unilaterally usingTSADs. However, the treatment times were extended,increasing the risk of side effects.10

Since K€ole11 suggested clinical applications of cortico-tomy in 1959, various technical advancements have beenreported.12-15 One is orthopedic force application againstintraosseous anchorage after corticotomy.14,15 A heavierforce is applied than the orthodontic force because the

795

Fig 1. A and B, Palatal and C and D, buccal corticotomy with piezosurgery (SONIC SURGEON 300;Dong Il Technology, Hwasung, Korea); E and F, application of miniplates for intrusion of the posteriorsegment.

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aim of this technique is not tooth movement through thebone but rather bony block movement by compressionosteogenesis.12,16 If the cortical layer of the basal andalveolar bone is removed, medullary bone can be bentby traction force.14

We have called the combination of corticotomyand orthopedic force application using TSADs speedysurgical orthodontics (SSO).14,15 By using thisprotocol, correction of a significant facial asymmetrycan be achieved with single-jaw surgery. Omittingthe corticotomy element means slower correctionand lacks the correction of the supporting bone thatcorticotomy allows. This report includes 2 patientswho demonstrate the clinical application of correctingan occlusal plane cant with corticotomies and ortho-pedic force.

Overerupted maxillary molars and premolars are firstpassively splinted with a prefabricated bondable splint.This splint consists of a 0.036-in stainless steel wire

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with a power arm extension, soldered to mesh-backedpads. Bonding these splints to the buccal and palatal as-pects of the teeth stabilizes the teeth as 1 unit. The cor-ticotomy procedure can be done after the teeth arestabilized.

The corticotomies were performed in 2 stages toensure a good blood supply. The first was done on thepalatal side. The second was done 2 weeks later on thebuccal side (Fig 1).

For the palatal corticotomy, a flap was elevated in theregions of the maxillary premolars and molars after asulcular incision. A vertical corticotomy using piezosur-gery and a round bur with a slow-speed hand piece wasperformed between the first premolar and the secondpremolar with care not to damage the root apices. A hor-izontal corticotomy was next, 3 mm above the root apexfrom the premolars to the distal aspect of thesecond molar. A second vertical corticotomy was per-formed distal to the second molar up to the alveolar crest

Journal of Orthodontics and Dentofacial Orthopedics

Fig 2. Pretreatment extraoral and intraoral photographs of patient 1.

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(Fig 1, A and B). The flap was closed, followed by a2-week healing period.

The buccal corticotomy was combined with place-ment of the TSADs and extraction of the maxillary firstpremolar (part of the treatment plan to resolve crowd-ing). The palatal corticotomy outline is similar to thaton the buccal aspect (Fig 1, C and D). On the midpalatalarea, a miniplate with 2 horizontal arms (Jin Biomed,Bucheon, Korea) that were oriented toward the targetteeth was implanted on the midpalatal area for palatalintrusion. Flap surgery was not necessary because thesoft tissues on the midpalatal area were thin (Fig 1, E).On the buccal side between the first and second molarareas, we placed an I-shaped titanium C-tube plate,with 2 anchoring holes and a 0.036-in diameter tube-shaped head, to serve as the point of orthodontic forceapplication (Fig 1, F). With elastic chain, 500 g of forcewas applied to intrude the posterior segment immedi-ately after the perisegmental corticotomy. At the sametime, the maxillary canine was retracted into the extrac-tion site (Fig 1, F).

American Journal of Orthodontics and Dentofacial Orthoped

PATIENT 1

A 15-year-old girl came to the Kyung Hee dental hos-pital in Seoul, Korea, with the chief complaint of facialasymmetry. She had a straight lateral profile, meso-gnathic facial type, eye-level canting (right side down),lip-line canting (right side high), chin deviation to theright, and an acceptable display of her maxillary anteriorteeth (Fig 2, A). The intraoral photographs showed anAngle Class I malocclusion, severe anterior crowding,an ectopically positioned maxillary left canine, amandibular dental midline discrepancy to the right,and transverse compensation of the maxillary andmandibular molars (Fig 2, B).

The cephalometric analysis indicated a hyperdiver-gent skeletal pattern (FMA, 32.8�), normal relationshipsof the maxilla (SNA, 80.7�) and the mandible (SNB,77.9�), maxillary occlusal plane cant (left side down),menton deviation to the right side (7.0 mm), and uprightmaxillary and mandibular incisors (U1-FH, 108.2�;IMPA, 81.9�) (Fig 3 and Table). Although her condylewas thin and narrow, especially on right side, there

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Fig 3. Pretreatment posteroanterior cephalogram ofpatient 1.

Table. Cephalometric survey of patient 1

Measurement Mean SD Pretreatment PosttreatmentSkeletal-horizontalSNA (�) 81.6 3.2 80.7 80.7SNB (�) 79.2 3.0 77.9 76.1ANB (�) 2.5 1.8 2.8 4.6

Skeletal-verticalPFH/AFH (%) 66.8 4.3 59.9 58.1FMA (�) 25.4 4.6 32.8 36.4SN-OP (�) 17.9 3.8 21.2 24.6SN To PP (�) 10.2 3.2 9.8 10.0

DentalFH-UI (�) 116.0 5.7 108.2 116.5IMPA (�) 95.9 6.4 81.9 88.9Interincisal angle (�) 123.8 8.3 137.0 117.9FMIA (�) 59.8 7.2 65.2 54.5

Soft tissueNasolabial angle (�) 93.2 8.0 97.2 96.1UL-E plane (mm) -0.9 2.2 -1.7 -0.2LL-E plane (mm) 0.6 2.3 -0.7 0.7

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was no clinical symptom of temporomandibular disorderor a centric occlusion-centric relation discrepancy. Onthe axial cut of the cone-beam computed tomography(CBCT) images (Alphard Vega; Asahi Roentgen, Kyoto,Japan), the vertical height difference of the buccalcusp tips between the maxillary left and right first molarswas about 3.5 mm, and both buccal cusp tips hadabnormal torque because of the transverse compensa-tion (Fig 4, A). The torque would be evaluated afterthe cant correction. Accordingly, the diagnosis was aClass I skeletal relationship, steep mandibular planeangle, facial asymmetry, and severe crowding.

The treatment objectives were correction of the facialasymmetry, elimination of crowding of the maxillary andmandibular dentition, and establishment of a normalocclusion. The canting extended to the orbit, correctionof which was not part of the treatment plan. We set agoal to correct the facial asymmetry below the LeFort Ilevel and initially planned 2-jaw surgery. However, thepatient wanted to minimize the expense and scope ofthe surgical intervention. Fortunately, she had a nor-mally positioned maxilla anteroposteriorly and a dentalmidline coincident with the facial midline. The alterna-tive plan she selected was a bilateral sagittal split ramusosteotomy after SSO maxillary cant correction with aunilateral corticotomy. Because the maxillary incisorswere upright and the maxillary left canine was blocked,the plan included unilateral extraction of the left firstpremolar. Corticotomies on both sides were performed

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as described, and an orthopedic intrusion force wasimmediately applied.

In 3 months, intrusion of the maxillary left posteriorsegment was complete. To prevent extrusion of theopposing teeth, a resin bite-block was added on theleft mandibular molars. CBCT scans and superimpositionof the cephalograms confirmed 3.5 mm of intrusion ofthe maxillary left molars (Fig 4, B). The buccal andlingual bonded mesh appliances were removed, andbrackets (Quicklear; Forestadent, Pforzheim, Germany)were placed on the maxillary teeth for further levelingand alignment. Cross elastics were used between theTSADs on the maxillary arch and the mandibular molarsfor transverse decompensation.

After the preoperative orthodontic treatment, themidline of the maxillary dentition coincided with thefacial midline, and the maxillary occlusal canting andthe transverse decompensation were corrected (Figs 5and 6). An asymmetric mandibular setback was thenperformed with bilateral sagittal split ramus osteotomy.Orthodontic treatment was resumed 6 weeks postsur-gery and was completed after 5 months. The totalactive treatment period was 22 months. At debonding,the extraoral photographs showed a distinct improve-ment of the facial symmetry and a beautiful smileline (Fig 7, A). The single-jaw surgery alone achievedgood facial symmetry even in the middle face level. Inthe maxilla, the facial gingival line showed mild asym-metry because of the gingival height of the maxillaryleft canine. The maxillary left canine was positionedhigher before treatment and moved significantly bothdownward and in a distal direction after unilateralextraction of the first premolar; this might have been

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Fig 5. Preorthognathic surgery extraoral and intraoral photographs of patient 1.

Fig 4. Comparison between A, pretreatment and B, after-intrusion axial images of the maxillary leftposterior segment of patient 1. In 3 months, 3.5 mm of intrusion of the maxillary left molars wasachieved, and the molar compensation was corrected.

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responsible for the difference in crown length. Thedental midlines of the maxilla and the mandible coin-cided with the facial midline. A Class I functional occlu-sion with ideal overjet and overbite was obtained (Fig 7,

American Journal of Orthodontics and Dentofacial Orthoped

B). No significant root resorption was evident in thepanoramic radiograph. The posttreatment lateral ceph-alometric analysis and superimposition showed goodinclination of the maxillary and mandibular incisors

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Fig 6. Preorthognathic surgery posteroanterior cephalo-gram of patient 1.

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(U1-FH, 116.5�; IMPA, 88.9�) and a favorable maxillo-mandibular relationship (Fig 8). The occlusal plane wasgreater by 3� than before treatment (SN-OP, 21.2� to24.6�). The treatment results were well maintained at8 months after debonding (Fig 9).

PATIENT 2

A 21-year-old man came with a chief complaint offacial asymmetry. He had a normal skeletal relationshipof the maxilla anteroposteriorly. The occlusal planeswere canted down on the right side. Moderate anteriorcrowding was observed, with a superiorly positionedcanine on the extruded side (Fig 10). Similar to the previ-ous patient, a corticotomy of the maxillary right segmentand extraction of the right first premolar were performed.The right posterior segment was successfully intruded by3.5 mm over 2 months (Figs 10, D-F, and 11). After10 months, the transverse dental compensation wasresolved, and single-jaw surgery was done (Fig 12).

DISCUSSION

The 3-dimensional morphologic variety of facialasymmetry characteristics generates many subtypes.17,18

Precise and accurate diagnosis and surgical treatmentplanning are important to address the underlyingcauses of a facial asymmetry. The clinician willevaluate the asymmetry of the upper third of the face(orbital dystopia) to determine whether it will beincluded in treatment planning. In the mandible, onecan see various degrees of menton deviation, frontal

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ramal inclination, gonion canted toward themidsagittal plane, and arch-form discrepancies.19 Skel-etal asymmetry problems in the maxilla are much lessfrequent or complex than in the mandible, where the de-gree of asymmetry tends to increase with greater dis-tance from the cranium.19

Case selection is critical when considering a maxillarycorticotomy (SSO) combined with single-jaw surgery inpatients with facial asymmetry. The maxillary deformityshould be limited to canting. If sagittal, transverse, andbilateral vertical maxillary skeletal corrections are neces-sary, then SSO would not be an option. After the cortico-tomy is completed, the outcome should be a normalorientation of the occlusal plane and an acceptablemandibular function.

The goals of the orthodontic-corticotomy phasebefore orthognathic surgery are to correct the cant, elim-inate the transverse dental compensation, and align theteeth to their proper positions.20 For the cant correction,the clinician will analyze the differential force applica-tions between the buccal and palatal sides. With carefulplanning, torque control can be achieved simultaneouslywith intrusion. Without such precise treatment planningof the SSO phase, the result can be an extended treat-ment time.

What are the benefits of SSO when compared with 2-jaw surgery? After 2-jaw orthognathic surgery, the pa-tient may experience a longer and more uncomfortablehealing period, a change in the alar base, and a periodof restricted nasal breathing. The corticotomy procedurepresented here requires 2 in-office surgical approaches,under local anesthesia, and takes about 30 minutes.Postsurgical healing is less eventful. Corticotomy hasbeen used as an alternative method to orthognathic sur-gery or conventional orthodontics in borderline cases ofadults.11,14 By removing the cortical layer, toothmovement is faster, and less root resorption isexpected compared with conventional orthodonticintrusion.21 As Suya12 explained in “corticotomy-facili-tated orthodontics,” the tooth has a role as a handlewhen bands of medullary bone move as a block. Toothmovement after corticotomy is primarily bony blockmovement rather than individual tooth movement. His-tologic study with dogs showed that the appearance ofnecrotic tissue that was called “hyalinization” wasrestricted to 1 week in the corticotomy group, insteadof lasting 4 weeks in the orthodontic movement–onlycontrol group.22 This quick removal of hyalinization tis-sue can be explained by the regional acceleratory phe-nomenon.

Corticotomy is associated with a reduced chance ofroot damage during surgery. Note that the amount ofcanting correction is not limited to the width of

Journal of Orthodontics and Dentofacial Orthopedics

Fig 7. Posttreatment extraoral and intraoral photographs of patient 1.

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corticotomy. It is preferable to remove the cortical layeras much as the planned intrusion to facilitate compres-sive osteogenesis. However, intrusion up to 6 mm hasproved to be clinically acceptable.14,16 Two-jaw surgeryachieves impaction without additional dental intrusion,but there is a limit to how much impaction is possible.With a corticotomy, not only does a wide path of corticalplate removal provide bone block, but also the additionaldental intrusion allows for more cant correction than or-thognathics could achieve. The TSAD anchors include aC-tube in the buccal posterior maxilla or zygomaticbuttress and a miniplate in the midpalatal suture. Thesedevices work together to provide compression osteogen-esis and intrude the posterior fragment.23 Orthopedicintrusion with a corticotomy (SSO) permits rapid reposi-tioning of the dental segments.24 The regional acceler-ated phenomenon during compression accelerates thecompletion of the treatment.

Many studies of orthodontic intrusion with TSADshave reported complications such as root resorption

American Journal of Orthodontics and Dentofacial Orthoped

or extended treatment time.21,22 Corticotomy-induced compression osteogenesis by orthopedictraction produced faster tooth movement and conse-quently a reduced risk of root resorption.21,25 In thepatients presented here, 3.5 mm of intrusion wasachieved in 2 to 3 months. The root lengths of themaxillary first and second premolars and the firstmolar were evaluated between pretreament andafter-intrusion with CBCT (Invivo5 software;Anatomage, San Jose, Calif). The palatal root of thefirst molar was shortened by 2.4 mm in patient 1. Allother root lengths were shortened less than 1 mm. Asignificant amount of intrusion was achieved duringa relatively short time without notable root resorption.

The miniplate is more suitable than the mini-implantfor SSO because of the heavier force requirements (250 gper each side). For the palatal area, implantation of theminiplate in the midpalatal area is recommended. Thethinner soft tissue layer and thicker cortical bone depthprovide better initial stability than would the palatal

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Fig 8. A,Posttreatment superimposition between the pretreatment and final cephalometric tracings;B,the posteroanterior cephalogram; and C, the panoramic radiograph of patient 1.

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slope. No nerves or vessels pass through this area. On thebuccal side, the skeletal anchorage is positioned atleast 2 to 3 mm above the horizontal corticotomy lineto avoid the area of active bone remodeling and obsta-cles such as dilacerated roots, an expanded maxillarysinus, or a severe alveolar ridge resorption.26 The mini-plate can also be used for distalization of the wholedentition or canine retraction, without the need of addi-tional TSADs.

One important issue regarding occlusal cantingcorrection is stability. Proffit et al27 demonstratedthat vertical asymmetry correction by surgery of the

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maxilla is quite stable. Others also reported that maxil-lary stability after LeFort I osteotomy for cant correc-tion does not differ from that for maxillaryadvancement.28 There have been no long-term studiesabout the stability of orthodontic intrusion with TSADsfor the treatment of canted occlusal planes. There arelimited data on the correction of anterior open bite.Lee and Park29 reported a 10.4% relapse rate for theintruded maxillary molars and an 18.1% relapse ratefor overbites at 1 year posttreatment. Baek et al30

also reported a 22.9% relapse rate for intruded maxil-lary molars and a 17.0% relapse rate for overbites at

Journal of Orthodontics and Dentofacial Orthopedics

Fig 9. Eight-month retention extraoral and intraoral photographs of patient 1.

Fig 10. Intraoral photographs of patient 2: A-C, on the day of corticotomy; D-F, after intrusion.

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Fig 11. Comparison between A, pretreatment and B, after-intrusion axial images of the maxillary rightposterior segment of patient 2. In 2 months, 3.5 mm of intrusion of the maxillary right molars wasachieved.

Fig 12. Posteroanterior cephalograms: A, pretreatment, B, after intrusion, and C, after 1-jaw orthog-nathic surgery of patient 2. The midsagittal reference line, maxillary occlusal plane, and menton devi-ation are shown.

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3 years posttreatment. There are no long-term data onthe stability of maxillary posterior impaction with cor-ticotomy. Corticotomy is expected to be more stablethan conventional orthodontic intrusion because it isconsidered bony block movement rather than individ-ual tooth movement only. Further studies will be usefulon the effects of various force intervals after cortico-tomy and its long-term stability.

CONCLUSIONS

Maxillary corticotomy combined with TSADs (SSO)achieved unilateral molar intrusion and occlusal planecanting correction. It is a potentially less expensive,in-office alternative to cant correction with 2-jaw

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orthognathic surgery. In selected patients with facialasymmetry, maxillary cant correction with maxillary cor-ticotomy combined with TSADs can allow a 1-jaw sur-gery treatment plan that would otherwise require2-jaw orthognathic surgery.

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