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(Case report)

Jenadi Binarto*, Asri Arumsari**, Seto Adiantoro**, Melita Sylvyana**, Abel Tasman Yuza***

*Resident, Department of Oral and Maxillofacial Surgery, RSUP Dr. Hasan Sadikin, Faculty of

Dentistry, Padjadjaran University, Bandung 40161, Indonesia

**Department of Oral and Maxillofacial Surgery, RSUP Dr. Hasan Sadikin,

Bandung 40161, Indonesia

***Department of Oral and Maxillofacial Surgery, RSGM, Faculty of Dentistry, Padjadjaran

University, Bandung, Indonesia

Email :



Introduction: Mandibular prognathism is defined as a condition of mandible size and position

is projecting too far ahead of the maxilla, and maxillary retrusion means maxilla that located

posteriorly than normal. These two condition generates malocclusion with large

maxillomandibular discrepancy, TMJ disorders, and imbalance of facial profile. Management

includes combination of orthodontic and orthognatic surgery.

Aim/Objectives: Correction of mandibular prognathism and maxillary retrusion using Le Fort I

osteotomy and Bilateral Sagittal Split Osteotomy (BSSO) technique.

Case presentation: A 19 years old male patient was referred from an orthodontist to Oral and

Maxillofacial Surgery Department at Hasan Sadikin Hospital Bandung with masticatory

difficulties and pain on both TMJ. Clinical examination and cephalometry analysis showed

concave facial profile, mandible prognathism and maxilla retrusion with overjet of 12mm.

Orthognatic surgery was performed with Le Fort 1 Osteotomy and BSSO, a good and balanced

end result occlusion was achieved with improvement of facial profile.

Discussion: Mandibular prognathism and maxillary retrusion are skeletal disorders which

require combination of orthodontic and orthognatic surgery. Orthodontic treatment is to correct

teeth position into normal allignment, followed by orthognatic surgery to solve the skeletal

problem. Mandible prognathism and maxilla retrusion require correction of both jaws with Le

Fort 1 osteotomy and BSSO techniques.

Conclusion: Mandibular prognathism and maxilla retrusion require both jaws correction to

achieve a good and balanced result.

Keywords: Mandibular Prognathism, Maxillary Retrusion, Orthognatic Surgery, Le Fort 1

Osteotomy, and Bilateral Sagital Split Osteotomy (BSSO).


1. Introduction

About 20% of world population has dentofacial deformities, some of them are

mandibular prognathism or class III skeletal malocclusion.1 This skeletal deformity is one

of severe maxillofacial deformities which involves multiple facial deformities and causing

imbalance of facial esthetic, mastication, and temporomandibular joint.1-5 The etiology of

this skeletal deformities are suspected as improper activity growth of the bone exceeding

the normal one.5 Treatment of mandibular prognathism requires combination of orthodontic

and orthognatic surgery.2-4

The most popular orthognatic surgery technique are Le Fort 1 osteotomy for correction

of upper jaw and Bilateral Sagittal Split Osteotomy (BSSO) for correction of lower jaw. 3-8

Both techniques are widely used in orthognatic surgery in complex cases or severe

deformities because they are able to correct most skeletal problems with minimal

complications.4,6 The success of orthognatic surgery also depends on the knowledge of

analysis, surgery indications, and good skill technique of the surgeon.3

The purpose of this case report is to correct mandibular prognathism and maxilla

retrusion using Le Fort I osteotomy and BSSO technique. Discussion includes pre surgery

analysis, intra operative technique and post operative evaluation.

2. Case Report

A 19 year old male patient was referred from orthodontist with difficulties in mastication

and pain on both side of lower jaw joint. Since infant age, the patient felt his lower jaw was

projecting too forward and had difficulties in swallowing accompanied with facial
appearance problems. About 2 years ago, the patient felt pain on both side of lower jaw

joint which got worse from time to time. Then the patient went to an orthodontist and had

orthodontic treatment to allign his teeth into normal position in allignment and curve of the

jaw. Later, he was referred to Oral and Maxillofacial Surgery department at Hasan Sadikin

Hospital Bandung for further treatment, which is surgery to correct the position of both jaws.

From clinical examination, we found a concave facial profile with dolichocephalic head

type, mandibular prognathism with very high angle of mandible (Figure 1). The patient had

class III skeletal malocclusion, anterior open bite, and overjet of 12mm. There was a slight

midliine shift of lower jaw about 2mm, and also clicking on the right TMJ with pain on both

sides of TMJ (Figure 2).

From x-ray examincation of orthopantomogram (OPG), we weren’t able to view clearly

the position of both side of mandible condyle, but it was obvious that the mandible

dimension is longer than normal on both side and showing a class III molar relation. There

were also impacted teeth of 18 and 28 (Figure 3). Cephalometry analysis showed SNA =

85°, SNB = 98°, and ANB = -13°. Mandibular length (Co-Gn) = 137 mm and maxilla length

(Co-A) = 80 mm, with ratio of maxilla : mandibular length = 1:1,71 concluded as imbalance

of maxilla and mandibular length (> 1:1,3)3. Using McNamara analysis we measured the

skeletal position of maxilla and mandbile from cranial base, which is the linear length of

Nasion Perpendicular (N Perp) to point A and B. It was noted a maxilla retrusion of 3 mm

and mandibular prognathism of 17mm (Figure 4).

From both clinical and x-ray examinations, we diagnosed the patient as mandibular

prognathism (class III skeletal malocclusion) and maxilla retrusion.

The next step was making a study model to decide the surgical plan, this plan was then

converted into a splint of surgical guide which manufactured from the model. We planned

a two-jaw surgery using Le Fort I osteotomy advancement of ± 5 mm and BSSO setback

of ± 8 mm with clockwise autorotation. A splint was made for an occlusion guide of each

surgical step on each jaw surgery. In this case, because we plan a two-jaw surgery, we

made two splint of surgical guide.

The surgery was started with odontectomy of teeth 18 and 28, followed by Le Fort I

osteotomy using intra oral approach and mucoperiosteal flap which was made on 4 mm
over the mucogingival margin starting from the right to left upper first molar. Periosteal

dissection was then performed beginning from first molar to posterior direction until the

posterior maxillary wall and pterygomaxillary border was reached on both sides.

The osteotomy was performed using saw started from lateral nasal wall until the border

of zygomaticomaxillary, about 3 mm over first upper molar. After the osteotomy was

performed, the down fracture was performed using Rowe forceps with slight force pulling

the maxilla to anterior and inferior until the maxilla was separated from nasal wall and

showed a floating maxilla (Figure 5A). The prepared splint of surgical guide was used to

guide the movement of the maxilla into accurate position as planned, and temporary

intermaxillary fixation was applied using wire. With both jaws were fixated, maxilla was

positioned by pressing the mandible to posterior direction and superiorly to ensure the

mandibular condyle was in the correct position. After the final position was achieved, the

maxilla was fixated with miniplate and screw (Figure 5B). Final assessment of the first stage

occlusion was performed by removing the IMF wire. The upper jaw surgery stage was

completed and closure was made.

The next stage was BSSO, started with incision on external oblique ridge with the

approximate height of posterior teeth occlusal, extended inferiorly and lateral side of the

teeth. Elevation of mucosa and connective tissue was performed until the external oblique

ridge exposed, so the coronoid refractor could be applied. Tissue dissection was continued

until the coronoid process was reached. The Kocher clamp applied on coronoid, and

elevation of tissue on medial aspect of mandible was performed until lingual fossa was

identified. The osteotomy was then performed with 45 degree of bevel using reciprocal saw

from lingual fossa until the anterior of mandible ramus, extended inferiorly, descending the

anterior ramus (alligned with lateral border of mandible), until the external oblique ridge and

stopped at distal part of second molar. The cut was continued until the inferior wall of

mandible with bevel of 45 degree angle which was at a position about mesial part of second

molar. After the cut was completed, a split of the mandible was performed using chisel and

mallet with gently and progressive force at cut line until it was separated. With both bone

segment already separated, the second surgical guide splint was used to position the

mandible into the proper desired position according to surgical plan. Intermaxillary fixation
then performed to fix the occlusion and the mandible was fixated with miniplate and screw

at the area of mandible body (Figure 6). The final occlusion was re-check by removing the

surgical splint and intermaxillary fixation. When all stages was done, a closure was made.

First post operative day, the patient had a mild pain and swelling on both jaws. Clinical

examination showed swelling on both sides of cheek and lower jaw. There was no bleedinig

at post operative area, the suture was intact and debris was spooled using NaCl 0,9%

solution. Occlusion was not achieved initially, there was an occlusion gap of about 5 mm

which probably was caused by initial swelling at mastication muscle region and TMJ initial

adjustment (Figure 7). Ligature band was applied on both jaws and the patient was given

methylprednisolon for 3 days.

On the third day evaluation, the occlusion was well achieved and the ligature band was

removed. The patient had slight numbness at small area on skin surface of left labiomentale

area. The patient was prescribed with methylcobalamin 3x500mcg for 1 month. 1 year after

surgery evaluation, the patient facial appearance had significantly improved (Figure 8), it

was very well comparable a significant improvement in lateral view, soft tissue at upper and

lower lip were balanced and showing great improvement in facial esthetic appearance.

(Figure 9). Occlusion was very well achieved with good mastication function, both TMJ pain

was no longer noticeable (Figure 10). However, there was very little numbness in a small

area of skin surface at labiomentale region. In general, the patient felt very satisfied with

the result of the orthognatic surgery because mastication function was achieved, pain on

both TMJ was gone as well as improvement in facial appearance.

3. Discussion

Mandibular prognathism or class III skeletal malocclusion is one of severe dentofacial

deformities.1,2 This skeletal deformity is not a single entity, and usually a manifestation of

multiple skeletal deformities.2,4 Problems in mandibular prognathism are difficulties in

mastication, improper function of TMJ, and imbalance facial appearance 3,4,6 Treatment of

mandibular prognathism requires orthodontic and orthognatic surgery.2,3,4

Mandibular prognathism can be classified into 6 groups, this classification was made

according to upper and lower jaw profile in 3 dimensional aspect. This classification is
useful as a guide for a proper plan of orthognatic surgery. 2 (Table 1). In this case report,

the patient had a symmetrical mandibular prognathism with sagittal deficiency of maxilla.

This situtation was also supported with large maxillomandibular discrepancy, which is a

sign of existing maxillary retrusion.2,3,4,6 As recommended according to its classification, the

patient was properly performed with two jaw surgery of mandibular setback and maxillary


This mandibular prognathism classification could give a simple differentiation of

orthognatic surgery planned, but further assessment must be done with cephalometry

analysis. The most common use cephalometry analysis used for orthognatic surgery is

McNamara analysis, one of them is hard tissue evaluation, evaluating the anteroposterior

position of the mandible and maxilla.4,6 To perform the analysis, a line of nasion

perpendicular (which is a line that perpendicular from Frankfur Horizontal Plane and

crossing the nasion) was made and measured to point A and B. Normal profile has 0-1 mm

length between nasion perpendicular and point A, negative value means retrusion of the

jaw and positive value means prognathism. This patient has -3 mm of maxilla and 17 mm

of mandible. These two values concluded that the patient had a large mandibular

prognathism and maxillary retrusion, which also translated that the patient needed a two

jaw orthognatic surgery for correction.

The most commonly used and popular technique of orthognatic surgery is Le Fort I

osteotomy for upper jaw correction and BSSO for lower jaw correction. 3-8 History of

orthognatic surgery techniques was started for quite a long time, which first reported by

Obwegessor in 1849 who performed an osteotomy on mandible and followed by other

surgeons.3,4,6 Since then, every dentofacial deformities was corrected with mandible

surgery even the problem was only on the maxilla. First Le Fort I osteotomy was performed

by Cheever for tumor ressection in 1864.7,9 In 1921, Herman Wassmund did a Le Fort I

osteotomy for correction of dentofacial deformity but without any intra operative

mobilisation of the jaw, he used orthopedic traction device on post operative period

instead.7,9 Until 1952 in America, Converse reported his case and did maxillary osteotomy

with large palatal and vestibular flap using Le Fort I combined with midpalatal osteotomy.7,9

Later on, many surgeons improvise the technique, one of them was Epker reported a down
fracture technique to achieve complete mobilisation of the maxilla.9 The huge improvement

of orthognatic surgery emerge in 1959 when Kole introduce the alveolar surgery of both

jaws, followed by Obwegesser who published his first experience in 1970 as the first

surgeon to perform both mandible and maxillary total osteotomy together.3,4,6,7,9

For years, the development of variety orthognatic surgery technique was made by

various surgeons, each had their advantages and disadvantages, and also different

indications depending on the case. But among those techniques for maxilla and mandible

correction, the most widely used technique are Le Fort I and BSSO. These two technique

has the ability for correcting most skeletal problems with minimal limitations.3,4,6,9,10

BSSO is very versatile technique which can correct the mandible up to 10mm and

stable.3,4,6 For large advanvement, BSSO still can be performed with fixation technique

modification. But in large setback, BSSO is not that stable. So when the setback is quite

large, BSSO can be combined with Le Fort I osteotomy.3,6 These are indications of BSSO:3

• Horizontal mandibula excess, deficiency and asymmetry

• Open bite correction (but some debated of its stability)

• Cross bite correction

• Advancement of mandible (up to 10-12 mm)

• Setback of mandible from small to moderate magnitude (7-8 mm)

• Correction of minor asymmetries

• Advacement of mandible for correcting sleep apnea

Stages of BSSO technique are as follow: incision, dissection of tissue until lingual fossa

is identified, mandible osteotomy on medial and lateral aspect, split of the mandible,

ostectomy on overlap and sharp edges, and fixation of mandible using miniplate and

screw.6 One of common risks of BSSO is injury of inferior alveolar nerve.3,4,6,11-13 and

sometimes numbness in localized area on huge mandibular movement.11 In this case

report, the patient had small area of numbness at labiomentale region which is quite a

common symptom after BSSO.11 The etiology is suggested by some references as injury

of the inferior alveolar nerve when the mandible split was performed. 11 Therefore, the

neurovascular bundle at the lingual fossa should be very well identified and protected, and
the cut was made with more precision away of the bundle. Some recovery can be achieved

by prescribing B complex vitamin and methylcobalamin for nerve tissue regeneration.

Le Fort I osteotomy is one of orthognatic surgery technique for correcting upper jaw.

This technique also has quite variety of correction capabilites and very useful especially for

asymmetrical face and multiple facial deformities situation. These are some indication of

Le Fort I osteotomy:3,6

a. Commonly used for deformity correction in multiple planes

b. Shortening of the maxilla, especially in premolar location

c. Reposition of the maxilla superiorly

d. Reposition and widening of the maxilla inferiorly

e. Reposition of the maxilla in 3 dimensional aspect (requires maxilla segmentation)

Contraindication of Le Fort I osteotomy are uncontrolled periodontal disease, skeletal

imaturation, and progressive dentofacial deformities, especially patient with TMJ etiology

(resorbtion or hyperplasia).3,6

Stages of Le Fort I osteotomy are as follow: Initial reference point, elevation of surgical

area, lateral osteotomy of the maxilla, continued with down fracture and mobilisation of the

maxilla, elimination of posterior and anterior interference when surgical guide splint is

applied, and followed by fixation using miniplate and screw.6

Contemporary orthognatic surgery technique is commonly guided by the help of

computers for analysis as well as surgical planning.12 Computerized surgical plan could

help not only minimizing complications and risks (e.g injury of inferior alveolar nerve in

BSSO) but also simiplified the surgeon and the patient to achieve the accurate and best

expected result of orthognatic surgery.12,13

4. Conclusion and Suggestion

Mandibular prognathism or class III skeletal malocclusion is one of severe dentofacial

deformity, and oftenly cannot be solved by orthodontic treatment alone. Mandibular

prognathism requires combination treatment of orthodontic and orthognatic surgery.

Mandibular prognathism with large maxillomandibular discrepancy often also having a

maxilla retrusion, which require a two-jaw surgery using Le Fort I osteotomy technique for
correcting the upper jaw and BSSO for correcting the lower jaw in order to achieve a well

balanced occlusion

In the future, computerized surgical planning and orthognatic surgery simulation could

help not only predicting the accurate end result but also manufacturing accurate surgical

guide, therefore minimizing any mistake, so that ideal end result according to plan can be


5. References

1. Saraswathi D. (2008). Mandibular Prognathism: Sagittal Split Ramus Osteotomy.

Journal of Dental Sciences & Oral Rehabilitation 2008, p32-34.

2. Cho H. J., Nguyen T. (2008). A classification system of mandibular prognathism. Oral

Surgery 1 (2008) 125-134. Blackwell Munksgaard.

3. Borle R. M. (2014). Textbook of Oral and Maxillofacial Surgery, 1st Edition, p.531-574

Jaypee Brothers Medical Publisher (P) Ltd.

4. Andersson L., et al. (2010). Oral and Maxillofacial Surgery, p.973-1012. Wiley-

Blackwell Publishing Ltd.

5. Saito D., et al. (2016). Relationship among maxillofacial morphologies, bone

properties, and bone metabolic markers in patients with jaw deformities. Int. J. Oral

Maxillofac. Surg. 2016; 45:985-991.

6. Kademani D., Tiwana P. S. (2016). Atlas of Oral and Maxillofacial Surgery, p.263-426.

Saunders, and Imprint of Elsevier.

7. Sun Y., Vrielinck L., Lubbers H.T., Lambrichts I. (2013). Accuracy of Upper Jaw

Positioning With Intermediate Splint Fabrication After Virtual Planning in Bimaxillary

Orthognathic Surgery. The Journal of craniofacial surgery November 2013.

8. Bergamo A. Z. N., et al. (2011). Orthodontic-Surgical Treatment of Class III

Malocclusion with Mandibular Asymmetry. Braz Dent J (2011) 22(2): 151-156.

9. Antonio Cortese (2012). Le Fort I Osteotomy for Maxillary Repositioning and Distraction

Techniques. The Role of Osteotomy in the Correction of Congenital and Acquired

Disorders of the Skeleton, Prof. James Waddell (Ed.).

10. Edela Puricelli (2007). A New technique for mandibular osteotomy. Head & Face

Medicine 2007, 3:15.

11. Mensink G., et al. (2015). Experiencing your own orthognathic surgery: A personal case

report. Angle Orthodontist, Vol 85, No 5, 2015, p890-896.

12. Wittwer G., et al (2011). Evaluation of risk of injury to the inferior alveolar nerve with

classical sagittal split osteotomy technique and proposed alternative surgical

techniques using computer-assisted surgery. Int. J. Oral Maxillofac. Surg. 2012; 41:


13. Lisen Espeland and Arild Stenvik (2011). Long-Term Outcome of Orthognathic

Surgery, Principles in Contemporary Orthodontics, Dr. Silvano Naretto (Ed.).

6. Figures and Tables

Figure 1. Pre operative facial profile

Figure 2. Centric occlusion pre operative

Figure 3. Pre operative orthopantomogram

Figure 4. Cephalogram and Cephalometry analysis

Figure 5. Le Fort I osteotomy. (A) After down fracture

(B) After fixation with miniplate and screw
Figure 6. After BSSO and fixation with miniplate and screw

Figure 7. Post operative day 1 occlusion with ligature band on upper and lower jaw

Figure 8. One year after surgery facial profile

Figure 9. Lateral view facial profile comparison, before (A) and after (B) surgery
Figure 10. One year after surgery centric occlusion

Mandible setback
Classification Characteristics Maxilla surgery

Class I Symmetrical mandibular prognathism Symmetry Unnecessary

Mandibular prognathism with asymmetry

Class II Differential Unnecessary
of the chin in horizontal pane

Mandibular prognathism with asymmetry Differential

Class III Differential
of the chin in coronal plane impaction

Mandibular prognathism with sagittal Symmetrical

Class IV Symmetry
deficiency of the maxilla advancement

Mandibular prognathism with vertical Symmetrical

Class V Symmetry
height excess of the maxilla impatcion

Combination of 2 or more parameters

Class VI Varies Varies

Table 1. Classification of mandibular prognathism and recommended treatment 2