Điều trị liên chuyên khoa cho bệnh nhân sai lệch xương hàm sau chỉnh nha ngụy trang và phục hình toàn hàm Multidisciplinary management of severe skeletal malocclusion following previous orthodontic camouflage and full-mouth prosthodontic treatment

This was one of the most complex and memorable cases in my practice, requiring close collaboration between Endodontics, Periodontics, Prosthodontics, and Oral and Maxillofacial Surgery.

Initial presentation

The patient presented with a severe skeletal Class III malocclusion, associated with significant facial asymmetry and deviation of the mandible to the left.

Prior to presenting to us, the patient had undergone orthodontic camouflage treatment. However, because the primary problem was skeletal rather than dentoalveolar, orthodontic treatment alone was unable to correct the underlying maxillomandibular discrepancy.

The patient subsequently underwent full-mouth crown restoration in an attempt to improve the occlusion and dental appearance. Despite this treatment, the skeletal Class III relationship and mandibular deviation remained.

At the time of our initial assessment, the problem extended beyond the skeletal discrepancy. Multiple restored teeth demonstrated periapical pathology, while the periodontal tissues showed chronic inflammation and frequent bleeding during mastication. The morphology and shade of the existing restorations were also aesthetically unsatisfactory.

The case therefore could not be addressed by orthodontics, prosthodontics, or surgery alone. A comprehensive multidisciplinary treatment strategy was required, with each stage carefully sequenced before definitive orthognathic correction could be undertaken.

Multidisciplinary treatment planning

In July 2021, our team established a coordinated treatment plan involving Endodontics, Periodontics, Prosthodontics, and Oral and Maxillofacial Surgery.

Stage 1 – Endodontic and periodontal stabilization

The existing inadequate restorations were removed. Teeth requiring further treatment underwent endodontic retreatment, while periodontal therapy was performed to control chronic inflammation and establish a healthy and stable periodontal environment.

Only after the endodontic and periodontal conditions had been adequately stabilized did we proceed to definitive surgical and prosthodontic planning.

Stage 2 – Integrated surgical and prosthodontic planning

The patient underwent a comprehensive clinical examination and cone-beam computed tomography (CBCT) as part of the orthognathic surgical assessment.

Using virtual surgical planning, the maxilla and mandible were repositioned digitally to establish a skeletal Class I relationship and correct the facial asymmetry.

An important aspect of this case was that the final skeletal position was not planned independently from the prosthodontic reconstruction.

The proposed postoperative jaw relationship was transferred to the prosthodontist. Based on this new skeletal relationship, provisional restorations for both arches were digitally designed to establish the intended tooth morphology and final occlusal relationship.

The provisional restorations were then 3D printed and transferred to the patient.

Stage 3 – Translating the digital plan into surgery

Once the relationship between the skeletal position, dental morphology, and final occlusion had been established, the data were used to design and 3D print patient-specific surgical guides.

The patient subsequently underwent bimaxillary orthognathic surgery to correct the severe skeletal Class III discrepancy and facial asymmetry.

Because the prosthodontic outcome had already been incorporated into the preoperative planning process, the surgical position of the jaws was determined not only by skeletal anatomy, but also by the intended occlusion, dental morphology, function, and final prosthodontic outcome.

Stage 4 – Definitive prosthodontic rehabilitation

Following stabilization of the postoperative skeletal and occlusal relationships, definitive ceramic restorations were completed by the prosthodontic team.

The main course of treatment was completed in October 2022, excluding subsequent plate removal and secondary genioplasty.

Outcome

• After more than one year of multidisciplinary treatment, the patient achieved:
• A skeletal Class I maxillomandibular relationship

Correction of the skeletal Class III malocclusion

Improvement of facial asymmetry and mandibular deviation

Stable occlusion

Stable periodontal health

Restoration of masticatory function

Improved dental and facial aesthetics

The patient remains in good general health with a stable oral condition.

This case illustrates an important principle in the management of complex dentofacial deformities: when the primary problem is skeletal, changing tooth position or tooth morphology alone cannot substitute for correction of the underlying skeletal discrepancy.

In patients who simultaneously present with endodontic, periodontal, prosthodontic, and skeletal problems, successful rehabilitation does not depend on a single procedure or specialty. Instead, it requires an integrated treatment strategy in which dental and periodontal health, skeletal position, occlusion, and the definitive prosthodontic reconstruction are planned as interconnected components of the same treatment.

My sincere thanks to our colleagues in Endodontics, Periodontics, and Prosthodontics for their close collaboration and invaluable contribution throughout this challenging case.