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CASE REPORT

Improvement of asymmetric stomatognathicfunctions, unilateral crossbite, and facial estheticsin a patient with skeletal Class III malocclusionand mandibular asymmetry, treated withorthognathic surgery

Nobuo Takeshita,a Masahiko Ishida,b Hisako Watanabe,c Takashi Hashimoto,c Takayoshi Daimaruya,c

Masakazu Hasegawa,d and Teruko Takano-Yamamotoe

Sendai, Japan

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Patients with a dentofacial skeletal deformity have not only esthetic and morphologic problems related to facialproportions and dentition, but also problems of stomatognathic functions. Therefore, in addition to morphologicanalysis, functional analysis is important for the diagnosis and evaluation of treatment in these patients. Howev-er, no reports have described longitudinal simultaneous evaluations of stomatognathic functions, and thecomprehensive effects of surgical orthodontics on the stomatognathic functions are unclear. A patient wasdiagnosed as having a skeletal Class III jaw-base relationship, mandibular asymmetry, unilateral crossbite,asymmetric stomatognathic functions, and a temporomandibular disorder. She was treated with a combinationof surgery and orthodontic therapy. As a result, facial proportions and occlusion improved; in particular,asymmetric stomatognathic functions, including masticatory muscle activity, condylar movement, and occlusalforce, became symmetric between the left and right sides. Moreover, after 2 years of retention, the activity ofthe masticatory muscles and the values of occlusal force and occlusal contact area exceeded those at pretreat-ment. These results suggest that improvement of asymmetric stomatognathic functions can be achieved bycorrection of dentofacial morphology by surgical orthodontic treatment in patients with mandibular asymmetry.(Am J Orthod Dentofacial Orthop 2013;144:441-54)

Patients with a dentofacial skeletal deformity havenot only esthetic and morphologic problemsrelated to facial proportions and the dentition,

but also problems of stomatognathic functions, suchas masticatory muscle activity, mandibular and condylarmovement, and occlusal force.1-7 Therefore, in addition

the Division of Orthodontics and Dentofacial Orthopedics, Graduate Schoolntistry, Tohoku University, Sendai, Japan.tant professor.graduate student.nct assistant professor.uctor.ssor and chair.thors have completed and submitted the ICMJE Form for Disclosure of Po-l Conflicts of Interest, and none were reported.t requests to: Teruko Takano-Yamamoto, Division of Orthodontics andfacial Orthopedics, Graduate School of Dentistry, Tohoku University, 4-1-machi, Aoba-ku, Sendai City, Miyagi 980-8575, Japan; e-mail,[email protected], revised and accepted, September 2012.5406/$36.00ight � 2013 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2012.09.024

to morphologic analysis, functional analysis is importantfor the diagnosis and evaluation of treatment results inthese patients. Some previous case reports presentedfindings of stomatognathic function. Maeda et al8 andNakajima et al9 reported improvement of electromyo-graphic activity of the masseter and temporalis musclesin surgical orthodontic cases with maxillary andmandib-ular prognathism, respectively. Furthermore, orthog-nathic surgery for patients with unilateral crossbiteand occlusal cant resulted in correction of asymmetricincisal and condylar paths using a 6 degrees of freedomjaw movement recording system.10,11 However,although masticatory muscle activity, occlusal force,and condylar movement are all important factors fornormal stomatognathic function, they were onlyindividually evaluated in previous case reports, and thecomprehensive effects of surgical orthodontics onstomatognathic function is unclear.

The prevalence of temporomandibular disorder(TMD) symptoms, such as joint sounds and pain, limited

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http://dx.doi.org/10.1016/j.ajodo.2012.09.024

Fig 1. Pretreatment facial and intraoral photographs.

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opening of the mouth, and articular disc displacement,was found to be higher in patients with mandibularprognathism and mandibular asymmetry than in thosewithout mandibular asymmetry.12,13 In contrast, Gotoet al14 reported that although the temporomandibularjoint (TMJ) on the deviated side showed a higher inci-dence of disc displacement in patients with mandibularasymmetry, clinical TMD symptoms showed no differ-ence between the deviated and nondeviated sides. Onthe other hand, it has been reported that TMD symptomscan be improved by orthognathic surgery in patientswith mandibular prognathism.10,15 Therefore,diagnosis and posttreatment evaluation of the TMJ areimportant for patients with mandibular asymmetry andprognathism treated by orthognathic surgery.

Magnetic resonance imaging is useful to make a diag-nosis of the TMJ because of its capacity to evaluate the

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soft and hard tissues without physical invasion. Antero-posterior and transverse disc displacements are diagnosedby sagittal and coronal magnetic resonance images,respectively. However, the transverse disc position in pa-tients with mandibular asymmetry is not well known.

This case report describes a skeletal Class III patientwith mandibular asymmetry and unilateral crossbitetreated by a combination of surgery and orthodontictherapy. For the first time, we longitudinally evaluatedchanges of occlusion, skeletal morphology, and stoma-tognathic functions such as masticatory muscle activity,occlusal force, condylar movement, and anteroposteriorand transverse disc positions. As a result, it was sug-gested that the improvement of asymmetric stomatog-nathic functions can be achieved by correction ofdentofacial morphology by surgical orthodontics in pa-tients with mandibular asymmetry.

Journal of Orthodontics and Dentofacial Orthopedics

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment cephalometric and panoramic radiographs.

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Table I. Cephalometric summary

Measurement

Japanese norm (adult)

Pretreatment Posttreatment PostretentionMean SDAngular (�)SNA 80.8 3.6 82.3 82.3 82.2SNB 77.9 4.5 82.9 80.8 80.6ANB 2.8 2.4 �0.6 1.6 1.6Mp-SN 37.1 4.6 34.6 37.4 37.1Gonial angle 122.1 5.3 130.1 132.2 132.6U1-SN 105.9 8.8 107.7 106.1 106.5L1-FH 56.0 8.1 61.3 60.0 60.0L1-Mp 93.4 6.8 90.4 89.2 89.0IIA 123.6 10.6 127.3 127.3 127.4

Linear (mm)S-N 67.9 3.7 75.0 74.7 74.6N-Me 125.8 5.0 130.6 129.4 129.6Me/NF 68.6 3.7 71.8 70.8 70.7Ans-Ptm/NF 52.1 3.0 59.3 59.6 59.7Go-Me 71.4 4.1 78.4 76.3 76.2Ar-Go 47.3 3.3 49.9 47.6 47.5Ar-Me 106.6 5.7 118.7 115.3 115.0Overjet 3.1 1.1 �2.6 1.7 1.5Overbite 3.3 1.9 1.2 1.2 1.3

Means and standard deviations from Wada et al.31

Fig 4. Electromyographic recordings of masticatory muscles. Ta, Anterior temporalis muscle; Mm,masseter muscle; Tp, posterior temporalis muscle.

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DIAGNOSIS AND ETIOLOGY

A young woman, age 18 years 8 months, came to theoutpatient clinic of Tohoku University Hospital in Japan.Her chief complaints were mandibular protrusion andfacial asymmetry. The facial photographs showed amandibular deviation toward the right and a concaveprofile (Fig 1). The mandibular dental midline was devi-ated 3.5 mm toward the right compared with the


maxilla, and she had anterior and right posterior cross-bites (Figs 1 and 2). The molar relationships were ClassIII on both sides. Overjet and overbite were –1.5 and 2mm, respectively (Figs 1 and 2). A panoramic radiographshowed that all third molars were impacted (Fig 3). Thecephalometric analysis showed a skeletal Class III jaw-base relationship, an average mandibular plane angle,and normal inclinations of the maxillary and mandibular


Table II. Occlusal force and occlusal contact area

Pretreatment Posttreatment Postretention

Total Right Left Total Right Left Total Right LeftOcclusal force (N) 735.2 475.7 259.5 518.2 263.4 254.8 837.3 422.0 415.3% 100 64.7 35.3 100 50.8 49.2 100 50.4 49.6

Occlusal contact area (mm2) 17.1 10.6 6.5 11.3 5.9 5.4 23.4 12.4 11.0% 100 62.0 38.0 100 51.9 48.1 100 52.9 47.1

Fig 6. Sagittal view of condylar movement during 6 degrees of freedom jaw movement recording.

Fig 5. Occlusal force and occlusal contact area recordings (1 represents the center of the occlusalforce): A, pretreatment; B, posttreatment; C, postretention. Rt, Right side; Lt, left side.

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anterior teeth (Fig 3, Table I). The posteroanterior ceph-alogram showed a mandibular deviation toward theright of 4 mm.

Electromyographic monitoring showed that activitiesof the masseter and anterior and posterior temporalismuscles were lower during unilateral chewing on the

American Journal of Orthodontics and Dentofacial Orthoped

left side than on the right side (Fig 4). During tapping,the masseter muscle was mainly activated on the rightside; in contrast, the posterior temporalis muscle wasmainly activated on the left side. An occlusal-forcerecording system showed higher values of occlusal forceand occlusal contact area on the right side than on the

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Table III. Condylar path length during jaw movements

Condylar path length (mm) Pretreatment Posttreatment PostretentionMaximum open-closeRight 12.8 16.4 17.2Left 11.5 11.2 15.6

LaterotrusionRight 11.2 8.5 9.8Left 6.9 9.0 9.7

ProtrusionRight 7.2 10.6 11.0Left 5.9 12.1 11.8

Fig 7. Magnetic resonance images: A-D, I-L, and Q-T, sagittal planes; E-H, M-P, and U-X, coronalplanes. Arrows show disc positions: a, Anterior side; p, posterior side; m, mesial side; l, lateral side.

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left (Fig 5,A; Table II). A 6 degrees of freedom jawmove-ment recording system showed that condylar pathlength was shorter on the left side than on the right dur-ing lateral and protrusive jaw movements (Fig 6, TableIII). Manipulation of the TMJ elicited clicking soundson the left side. The sagittal magnetic resonance imagesshowed anterior articular disc displacement with reduc-tion on the right TMJ (Fig 7, A and C). In contrast, anormal disc position was shown on the left side (Fig 7,B and D). The coronal magnetic resonance images didnot show a transverse displacement of the disc on theright side (Fig 7, E and G). On the left side, lateraldisplacement of the anterior band of the disc was shownin the closed-mouth position, but not in the open-mouth position (Fig 7, F and H).


TREATMENT OBJECTIVES

The patient was diagnosed as having a skeletal ClassIII jaw-base relationship, mandibular asymmetry, unilat-eral crossbite, asymmetric stomatognathic functions,and TMD.

The treatment objectives were to correct the skeletaldeformity, obtain an ideal occlusion, and improve theasymmetric stomatognathic functions by a combinationof surgery and orthodontic therapy. We planned toperform presurgical orthodontic treatment focused onmaintaining normal inclinations of the maxillary andmandibular incisors to obtain an ideal incisor relation-ship after surgery. A bilateral sagittal split ramus osteot-omy was planned to correct the mandibular asymmetry


Fig 8. Posttreatment facial and intraoral photographs.

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and the protrusion after the improvement of the asym-metric stomatognathic function. The impacted mandib-ular right and left third molars were to be extractedbefore surgery so as not to interfere with the surgicalprocedures.

TREATMENT ALTERNATIVES

Because it is possible to achieve a good treatmentoutcome using miniscrew anchorage in patients with askeletal discrepancy, orthodontic camouflage with mini-screw anchorage could be a treatment alternative tocorrect the anterior and unilateral crossbites in our pa-tient.16 However, it could not sufficiently correct themandibular protrusion and the facial asymmetry, whichwere the patient’s chief complaints. Furthermore, it was


expected that asymmetric stomatognathic functionscould be improved in patients with mandibular asymme-try by orthognathic surgery.17,18 Therefore, we decidedto perform a combination of surgery and orthodontictherapy to improve both dentofacial morphology andstomatognathic functions.

TREATMENT PROGRESS

After checking the oral hygiene status and givingtoothbrushing instructions, we placed 0.018 3 0.025-inpreadjusted edgewise appliances on the maxillary andmandibular dental arches, and leveling and alignmentwere started with 0.016-in and 0.014-in nickel-titaniumarchwires for the maxilla andmandible, respectively. Sub-sequently, tooth alignment proceeded by changing the


Fig 9. Posttreatment dental casts.

Fig 10. Posttreatment cephalometric and panoramic radiographs.

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Fig 11. Superimposed pretreatment (solid line) and posttreatment (dotted line) cephalometric tracings:A, on the sella-nasion plane at sella; B, on the palatal plane at ANS; C, on the mandibular plane atmenton.

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archwires sequentially, and 0.016 3 0.022-in stainlesssteel archwires were used to adjust the tooth positionsjust before surgery. Both mandibular third molars wereextracted 5 months before surgery, and the extractionsockets were cured by bone formation at the time of sur-gery. After presurgical orthodontic treatment for 1 year 4months, a sagittal split ramus osteotomy was performed.Themandible was set back 2mmon the right side and 5.5mm on the left side. Postsurgical orthodontic treatmentwas performed for 7 months. The occlusion was detailedusing 0.017 3 0.025-in beta-titanium archwires, andthen the edgewise appliances were removed. The durationof active treatment was 2 years 1 month. Retention wasstarted with Begg-type retainers, and the patient was fol-lowed for 2 years.

TREATMENT RESULTS

As a result of the setback and the transverse rotationof the mandible by the sagittal split ramus osteotomy,the mandibular protrusion and the asymmetry were cor-rected, and facial esthetics were improved (Fig 8). Theanterior and right posterior crossbites were corrected,and the mandibular midline was coincident with themaxillary midline (Figs 8 and 9). Class I canine and molarrelationships were obtained. The posttreatment pano-ramic radiograph showed no remarkable apical root


resorption or alveolar bone loss (Fig 10). The posttreat-ment cephalometric analysis showed that a skeletal ClassI jaw relationship had been achieved (Figs 10 and 11,Table I). Clear changes of the maxillary and mandibularincisor inclinations were not shown, indicating that thenormal incisor inclinations were maintained (Figs 10and 11, Table I). A posteroanterior cephalogram showedthat the mandibular midline coincided with the facialmidline (Fig 10).

A posttreatment electromyographic recordingshowed no remarkable differences of the activity of themasseter and the anterior and posterior temporalis mus-cles during unilateral chewing on the left and right sides(Fig 4). During tapping, activities of these masticatorymuscles were balanced on the 2 sides (Fig 4). However,activity of the masticatory muscles decreased duringclenching (Fig 4). Occlusal force and occlusal contactarea showed almost the same values on the left and rightsides, although each value decreased compared with thevalues before treatment (Fig 5, B; Table II). The 6 degreesof freedom jaw movement recording system showed anincrease of the right condylar path length duringmaximum mouth opening and closing (Fig 6, TableIII). The asymmetric condylar path lengths during lateraland protrusive jaw movements were improved (Fig 6,Table III). In addition, the condylar path lengths on


Fig 12. Postretention facial and intraoral photographs.

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both sides increased during protrusive jaw movements(Fig 6, Table III). The clicking sounds still remained,and the sagittal and coronal magnetic resonance imagesshowed no clear changes of articular disc positions (Fig7, I-P).

After 2 years of retention, an acceptable facial profileand occlusion were maintained (Figs 12-15, Table I). Thesymmetric masticatory muscle activities were also main-tained (Fig 4). Moreover, they were increased during tap-ping and clenching compared with those atposttreatment. The occlusal force and occlusal contactarea increased during the retention phase, and theyshowed higher values than before treatment (Fig 5, C;Table II). The left condylar path length during maximummouth opening and closing increased; consequently, thedifference of condylar path length between the right and


left sides shown just after active treatment was corrected(Fig 6, Table III). The symmetric condylar path lengthsduring lateral and protrusive jaw movements were main-tained. Although the disc displacement and the clickingsounds still remained in the TMJ, they have not wors-ened (Fig 7, Q-X).

DISCUSSION

Patients with mandibular asymmetry and unilateralcrossbite have asymmetric activity of masticatory mus-cles.3,19 Asymmetry of muscle size and orientation, anda difference of myosin heavy chain compositionbetween the right and left sides might be associatedwith the asymmetric activity of the masticatorymuscles in these patients.20,21 Sforza et al17 reportedthat orthognathic surgery for a mandibular


Fig 13. Postretention dental casts.

Fig 14. Postretention cephalometric and panoramic radiographs.

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American Journal of Orthodontics and Dentofacial Orthopedics September 2013 � Vol 144 � Issue 3

Fig 15. Superimposed posttreatment (solid line) and postretention (dotted line) cephalometric trac-ings: A, on the sella-nasion plane at sella; B, on the palatal plane at ANS; C, on the mandibular planeat menton.

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prognathism patient with mandibular asymmetry re-sulted in improvement of the asymmetric activity ofthe masticatory muscles. In our patient, activities ofthe masseter and anterior and posterior temporalismuscles were lower during unilateral chewing on theleft side than on the right side before treatment.Furthermore, the masseter muscle and the posteriortemporalis muscle were mainly activated on the rightand the left sides during tapping, respectively. Theseresults indicated asymmetric activity of the masticatorymuscles in this patient. On the other hand, the post-treatment electromyographic recording showed sym-metric activities of the masticatory muscles duringunilateral chewing and tapping, and these results sug-gest that this patient obtained balanced masticatorymuscle activity by surgical orthodontics. It is knownthat occlusal force and occlusal contact area are greateron the deviated side than on the nondeviated side inpatients with mandibular asymmetry.7 However, the ef-fects of surgical orthodontics on the asymmetry ofocclusal force and occlusal contact area are unclear.In this patient, occlusal force and occlusal contactarea were greater on the deviated side than on the non-deviated side before treatment. On the other hand, theywere balanced between the 2 sides after postsurgicalorthodontic therapy. These results suggest the possibil-ity of correcting the asymmetry of occlusal force and


occlusal contact area by surgical orthodontics in pa-tients with mandibular asymmetry.

The effects of orthognathic surgery on masticatorymuscle activity and occlusal force have been individu-ally reported.22,23 However, there have been no reportsregarding simultaneous longitudinal assessments ofmasticatory muscle activity, occlusal force, andocclusal contact area in a surgical orthodonticpatient. In our patient, asymmetric masticatorymuscle activity, occlusal force, and occlusal contactarea were corrected after active treatment, and theobtained symmetric stomatognathic functions weremaintained during the retention phase. Moreover,although the activity of the masticatory muscles andthe values of occlusal force and occlusal contact areadecreased after active treatment, they increasedduring retention and showed higher activity andvalues than before treatment. These results indicatethe long-term stability of balanced stomatognathicfunction obtained by orthognathic surgery in a patientwith mandibular asymmetry. Furthermore, it is sug-gested that stomatognathic function decreases just af-ter active treatment, but it recovers and subsequentlyexceeds the pretreatment values during the retentionphase, possibly in correlation with masticatory muscleactivity, occlusal force, and occlusal contact area insurgical orthodontic patients.


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In patients with mandibular deviation, condylar pathlength on the deviated side was longer than on the non-deviated side during mouth opening and closing, andlateral and protrusive jaw movements.5,6 Not onlyskeletal discrepancy but also asymmetric condylarmovement can be corrected by orthognathic surgeryfor patients with mandibular asymmetry.11,18 In thispatient, condylar path length on the nondeviated sidewas shorter than on the deviated side during lateraland protrusive jaw movements before treatment. Theasymmetric condylar path length was corrected afteractive treatment, mainly because of an increase ofcondylar path length on the nondeviated side. Theseresults are consistent with previous reports.5,6,11,18

However, the relationships between condylarmovement and masticatory muscle activity have beenunclear. In this patient, improvements of asymmetriccondylar movement and masticatory muscle activitywere shown after active treatment. Because jawmovement is directly regulated by the contraction ofthe masticatory muscles, it is speculated that skeletalcorrection by orthognathic surgery resulted inimprovement of asymmetric masticatory muscleactivity, followed by improvement of asymmetriccondylar movement.24 Moreover, little is known aboutthe change of the condylar path length during the reten-tion phase in patients who undergo orthognathic sur-gery. In this patient, condylar path length on bothsides during maximum mouth opening and closingincreased during the retention phase. The inferior headof the lateral pterygoid muscle regulates the anteriormovement of the condyle during mouth opening.25

Because activities of the masseter muscle and the ante-rior and posterior temporalis muscles increased duringthe retention phase in this patient, it is possible that ac-tivity of the lateral pterygoid muscle also increased andcontributed to the increase of the condylar path length.

It has been reported that there is a close relationshipbetween mandibular asymmetry and TMD.12,13,26 It isimportant to make a diagnosis of TMD beforeorthodontic treatment of patients with mandibularasymmetry. Disc displacement, which is a form ofTMD, is often diagnosed by analysis of theanteroposterior disc position with sagittal magneticresonance images. However, coronal magneticresonance images are needed to diagnose transversedisplacement and rotation of the disc.27 In this patient,the coronal magnetic resonance images showed lateraldisplacement of the anterior band of the disc on thenondeviated side in the closed-mouth position, but nodisplacement in the open-mouth position. These resultssuggest lateral disc displacement with reduction on thenondeviated side. A common cause of clicking in the


TMJ is disc displacement with reduction.28 Therefore,the clicking sound on the nondeviated side in this pa-tient might have been due to the reduction of the lateraldisc displacement. In addition, anterior disc displace-ment is frequently seen on the deviated side in patientswith mandibular asymmetry.12,29 Anterior discdisplacement with reduction was observed on thedeviated side in our patient. Because overload of theTMJ can be a cause of disc displacement, it issuggested that asymmetric occlusal force andmasticatory muscle activity lead to overload of theTMJ on the deviated side and then cause anterior discdisplacement.30 It has been reported that an intraoralramus osteotomy can improve anterior disc displace-ment.10 However, little is known about the effect of or-thognathic surgery on transverse disc displacement.Although there were no clear changes of the lateraldisc displacement after the sagittal split ramus osteot-omy in this patient, further study is needed to clarifythe effect of orthognathic surgery on transverse disc po-sition by evaluating coronal magnetic resonance images.

CONCLUSIONS

Longitudinal simultaneous evaluation of stomatog-nathic function was performed as well as analysis of den-tofacial morphology for a skeletal Class III patient withmandibular asymmetry. As a result of the evaluation, itwas indicated for the first time that surgical orthodonticscould comprehensively improve asymmetric stomatog-nathic functions including masticatory muscle activity,condylar movement, and occlusal force. In addition,with sagittal and coronal magnetic resonance images,we could evaluate the 3-dimensional position of thearticular disc, and it was shown that although the artic-ular disc displacements were not corrected, at least noworsening of these displacements occurred after surgeryin this patient. This case report demonstrates the impor-tance of analysis of stomatognathic function and theTMJ as well as dentofacial morphology to make adiagnosis and to evaluate the treatment outcome in apatient with a dentofacial skeletal deformity.

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