Surgical Management of Skeletal Class II Deformity Patients- a Case Series

Class II malocclusions constitute a high percentage of ortho-surgically treated cases. Approximately 70% of the patients have associated skeletal discrepancy characterized by an exaggerated sagittal distance between the maxilla and the mandible, which could result in maxillary prognathism, mandibular retrognathism, or both (2) Class II malocclusion can be treated by a combination of maxillary and mandibular surgeries, maxillary surgery alone or by mandible surgery solely depending on the underlying skeletal discrepancy i.e Maxillary Le Fort I superior repositioning with autorotation of mandible, Bi-jaw surgery—bilateral sagittal split osteotomy (BSSO) along with maxillary Le Fort I impaction., Genioplasty-advancement of chin. Material and methods: 10 cases of Skeletal Class –II malocclusion were selected randomly irrespective of age, sex, caste, religion, etiology and socioeconomic status, good general health without any systemic disease. Study was conducted in the Department of Oral and Maxillofacial Surgery, Karnavati School of Dentistry, Uvarsad. Conclusion: 14 According to the outcomes of the cases it provided a reliable esthetic and functional enhancement of the patient when maxilla was superiorly positioned, with mandibular advancement, genioplasty for retruded chin according to the treatment planned for each patient.


Introduction
Class II malocclusions constitute a high percentage of ortho-surgically treated cases [4], Approximately 70% of the patients have associated skeletal discrepancy characterized by an exaggerated sagittal distance between the maxilla and the mandible, which could result in maxillary prognathism, mandibular retrognathism, or both [2]. Class II malocclusion can be treated by a combination of maxillary and mandibular surgeries, maxillary surgery alone or by mandible surgery solely depending on the underlying skeletal discrepancy i.e Maxillary Le Fort I superior repositioning with autorotation of mandible, Bi-jaw surgery-bilateral sagittal split osteotomy (BSSO) along with maxillary Le Fort I impaction., Genioplasty-advancement of chin. When there are severe skeletal components also associated with that malocclusion, such as a vertical growth pattern and a retruded mandible, a combined surgical approach is often the best treatment option [5]. Treatment choices for preadolescents and teenagers are particularly difficult because of the uncertainty regarding the magnitude and direction of remaining growth. The results obtained by surgical management of such cases usually ensure a better esthetic, functional stability [1]. The goal of orthognathic surgery is basically to achieve harmony between functional stability and esthetic enhancement [3,6,7] which thereby fulfils patients need. So here in this study we have evaluated result of 10 patients of skeletal class II deformity treated surgically and their outcomes we have discussed.

Aims and Objectives
The aim of the study was to surgically correct with either Bilateral sagittal split osteotomy, Lefort I osteotomy, genioplasty or Bijaw surgery as indicated in skeletal class II deformity patients. The objective of this study was: To study different cases of skeletal class II malocclusion, to surgically correct facial asymmetry, to achieve stable occlusion, to achieve satisfactory esthetics and function.

Methods of Data Collection
Definition of Study Subject 10 cases of Skeletal Class -II malocclusion were selected randomly irrespective of age, sex, caste, religion, etiology and socioeconomic status, good general health without any systemic disease. Study was conducted in the Department of Oral and Maxillofacial Surgery, Karnavati School of Dentistry, Uvarsad for evaluation of different treatment modalities such as Maxillary Le Fort I superior repositioning with autorotation of mandible, Bi-jaw surgery-bilateral sagittal split osteotomy (BSSO) along with maxillary Le Fort I impaction., Genioplasty-advancement of chin for surgical management of skeletal Class-II deformity.
It is a retrospective human study and ethical committe and all authors have got institutional review board approval.

Method (Study Design)
According to each patient requirement different osteotomy procedures were carried outfor 10 different patients. They were as follows: as Maxillary Le Fort I superior repositioning with autorotation of mandible, Bi-jaw surgery -Bilateral sagittal split osteotomy (BSSO) along with maxillary Le Fort I impaction., Genioplasty -advancement of chin for surgical management of skeletal Class-II deformity.

Discussion
Deformities at an early age, when the patient is still growing, have the potential to be corrected with growthmodifying appliances. But in adults Class II malocclusion, surgical intervention to reposition the jaws and dentoalveolar segments becomes the only option to treat such patients where growth modulation is not possible using fixed functional appliances (FFA), headgear, camouflage to mask the underlying skeletal discrepancy [10]. This cases can be treated by a combination of maxillary and mandibular surgeries, maxillary surgery alone or by mandible surgery solely depending on the underlying skeletal disepancyMaxillary Le Fort I (superior repositioning) with autorotation of mandible, Bi-jaw surgery-bilateral sagittal split osteotomy (BSSO) along with maxillary Le Fort I superior positioning., Genioplasty-advancement of chin. The results obtained by surgical as well as orthodontic management of such cases usually ensure a better esthetic, functional stability.
10 patients of skeletal class II have been treated surgically and results evaluated were: Out of 10 cases 3 patients underwent Bijaw surgery. And 7 patients underwent Single jaw surgery. In the cases of vertical maxillary excess cases single jaw surgery was planned in most of the cases. "Careful diagnosis and treatment planning is required for successful outcome of any Skeletal class II patient-Hanumath et al [8]. It is Sometimes difficult to improve labially inclined teeth, particularly in patients with mandibular retrognathia, because symphysis menti is often thin. Insufficient space therefore is available to permit sagittal rotation of the teeth without root exposure from the alveolar bone. And so 3 staged method for correction of skeletal discrepancy is advised (Kazuhiro Matsushita). Genioplasty for retruded chin and constructing infrastructure for subsequent le fort 1 osteotomy and then lefort 1 osteotomy itself is carried, finally a two-jaw surgery.

Conclusion
Overall Class II malocclusions require careful diagnosis and treatment planning for a successful outcome [12]. Treatment planning according to the level of discrepancy ensures stability and good outcome [8,9]. Orthodontics play a crucial role in management and patient satisfaction. Surgical superior repositioning of the maxilla for aesthetic and functional correction of selected dentofacial deformities, especially open bite deformity, produces an optimum aesthetic correction of the deformity with excellent stability [13]. Mandibular sagittal split osteotomy in combination with pre-and postsurgical orthodontics is an efficient approach in the therapy of adult Class II, division 1 malocclusion. Sagittal occlusal malrelationships are corrected and the hardand soft tissue profiles straightened in a consistent way [14]. According to the outcomes of the cases it provided a reliable esthetic and functional enhancement of the patient when maxilla was superiorly positioned, with mandibular advancement, genioplasty for retruded chin according to the treatment planned for each patient.
Result: the different surgeries done in 10 different patients accordingly are summarised in Table 1.