A. Ihde¹, A. Chakranarayan², O. Sipic³, P. Soni², S. Ihde⁴, Y. Vares⁵

¹International Implant Foundation, Munich, Germany

²Dental Centre, INHS Kalyani, Eastern Naval Command

³International Implant Foundation, Department of Evidence and Research, Munich, Germany

⁴International Implant Foundation, Department of Evidence and Research, Munich, Germany

⁵Danylo Halytsky Lviv National Medical University, Department of Maxillofacial Surgery

Introduction. Vertical maxillary excess is traditionally treated using Le Fort 1 horizontal osteotomy with the removal of an intermediate maxilla fragment of a particular height. This treatment was so far applied to patients at all ages. Since the technology of the Strategic Implant® had become available, patient in advanced age with compromised dental status have a faster and safer alternative to the orthognathic approach.

The aim of the study. To demonstrate on the example of two clinical cases the effectiveness of differential (depending on patient’s age and dental status) treatment of vertical maxillary excess by means of orthognathic surgery and Strategic implantation®.

Materials and methods. Two clinical cases of vertical maxillary excess are shown, one of which was treated with orthognathic surgery, and the other – with Strategic Implant® technology. The evaluation criteria taken into account were visual results of treatment of vertical maxillary excess and mandibular deficiency, tooth and gum show at rest and smile, time spent on rehabilitation of the treated patients, total chair time, duration of pain etc.

Results. The dynamics of intra- and extraoral change in patient S., 14 years old, who underwent complex orthodontic and orthognathic treatment, show improvement of both the face appearance, which has changed to mesofacial with balanced thirds in the vertical plane and profile, and the occlusion, which has acquired signs of normognathic. As a result of the orthognathic surgery, a “gummy” smile and excessive visibility of the teeth, both at rest and smile, were eliminated to become aesthetically acceptable. The total rehabilitation period of the patient was approximately 15 months! The total time spent in the orthodontic chair / operating room was approximately 11 hours. The duration of taking painkillers after orthodontic sessions and orthognathic surgery was a total of 33 days.

In case of patient G., 47 years old, treated by using the Strategic Implant® technology, the normalization of the functional and aesthetic status of the maxillofacial area took place in a much shorter time. Already on the 3^rd day after multiple tooth extraction and implantation on the upper and lower jaws, the permanent cement metal-plastic bridges were installed and fixed, and on the 4^th and 5^th postoperative day, correction of chewing surfaces was made. A reduction of »0.9 cm in height of the alveolar process of the upper jaw eliminated the problem of a “gummy” smile and achieved a shortening of the middle third of the face, which had a positive effect on the aesthetic appearance of the face. Radiographically, the correct placement of the implants in the “strategic” areas of the upper jaw – the pterygoid process, the cortical plate of the maxillary sinus and the bottom of the nasal cavity – was ascertained. The total rehabilitation period of the patient in this case was 5 days! The total chair time was 4 hours. The duration of painkillers intake was 2 days in total.

Conclusions. Вoth orthognathic surgery and Strategic Implant® technology are universal surgical interventions recommended for the correction of vertical maxillary excess, but the key to their successful employment is differential approach based, primarily, on patient‘s age and dental status. Thus, in young patients with healthy teeth and periodontium orthognathic surgery is advantageous despite the long-term treatment period and surgical invasiveness per se. Instead, the extent of surgical intervention, the time it takes to complete treatment, the invasiveness, and the potential risks are much lower for Strategic Implant® technology with excellent functional and aesthetic results, justifying extraction therapy combined with the early transition to Strategic Implant® technology in adult patients with vertical maxillary excess and compromised periodontium.

References

1. Vares YaE, Got’ ІМ, Filipski AV, Filipska TA. Application of the DDS PRO software for planning of bilateral sagittal split osteotomy of the mandible: clinical case description. Acta Medica Leopoliencia. 2017;23(4):40-45 (Ukrainian).
2. Nehra K, Sharma M, Sharma V, Sinha R. An Interdisciplinary Approach to the Management of Long-Face Syndrome and Bilateral Microtia. Modern Orthodontics. 2015;39(1):26-29 (Russian).
3. Angelillo JC, Dolan EA. The surgical correction of vertical maxillary excess (long face syndrome). Ann Plast Surg. 1982;8(1):64-70.
4. Fish LC, Woolford LM, Epker  Surgical-orthodontic correction of vertical maxillary excess. Am J Orthodontics. 1978;73(3):241-257.
5. Gupta R, Dahane T, Godbole SR, Shukla A. Esthetic correction: a case report. Intern J Contemp Med Res. 2017;4(4):809-811.
6. Henderson D. The vertical dimension in Orthognathic Surgery. Br J Oral Surg. 1981;19:237.
7. Humayun N, Kolhatkar S, Souiyas J, Monish. Mucosal Coronally Positioned Flap for the Management of Excessive Gingival Display in the Presence of Hypermobility of the Upper Lip and Vertical Maxillary Excess: A Case Report. J Periodontol. 2010;81:1858-1863.
8. Jananni M, Sivaramakrishnan M, Libby TJ. Surgical correction of excessive gingival display in class I vertical maxillary excess: Mucosal strip technique. J Nat Sci Biol Med. 2014;5(2):494-498.
9. Ihde S. Indications and treatment modalities with corticobasal jaw implants. Ann Maxillofac Surg. 2019;9:379‐3
10. Ihde S, Sipic O. Dental implant treatment and immediate functional loading (1). Case report and considerations: Extended treatment options using the strategic implant® and indications and objectives for comprehensive dental implant treatment. Ann Maxillofac Surg 2019;9:465-469.
11. Ihde S, Sipic O. Functional and esthetic indication for dental implant treatment and immediate loading (2) Case report and considerations: Typical attitudes of dentists (and their unions) toward tooth extractions and the prevention of early, effective, and helpful dental implant treatment in the European union. Ann Maxillofac Surg. 2019;9:470‐47
12. Ihde S, Ihde A, Lysenko V, Konstantinovic V, Palka L. New Systematic Terminology of cortical Bone areals for osseo-fixated Implants in Strategic Oral Implantology. J J Anatomy. 2016;1(2):007.
13. Lazarov A. Trans-and intra-sinus BCS implants: clinical alternative in advanced maxillary bone atrophy. Statistical analysis of maxillary sinus complications. Stomatological World. P. 8.
14. Osman M, Abdelnasir GA, Awadalkreem A Novel Approach for Rehabilitation of a Subtotal Maxillectomy Patient with Immediately Loaded Basal Implant-Supported Prosthesis: 4 Years Follow-Up. Hindawi Case Reports in Dentistry. 2020;2020.
15. Paik CH, Park HS, Ahn HW. Treatment of vertical maxillary excess without open bite in a skeletal Class II hyperdivergent patient. Angle Orthod. 2017;87:625-633.
16. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ. The long face syndrome: Vertical maxillary excess. Am J Orthodontics. 1976;70(4):398-408.
17. Sthapak U, Kataria S, Chandrashekar K, Mishra R, Tripathi VD. Management of excessive gingival display: Lip repositioning technique. J Intern Clin Den Res Org. 2015;7(2):151-154.
18. Tabrizi R, Nili M, Aliabadi E, Pourdanesh F. Skeletal stability following mandibular advancement: is it influenced by the magnitude of advancement or changes of the mandibular plane angle? J Korean Assoc Oral Maxillofac Surg. 2017;43(3):152-159.