A Comparison of Long-Term Stability and Satisfaction in Moderate Skeletal Class III Patients Treated with Orthodontic Camouflage versus Orthognathic
Surgery
1Dr. Animesh Barodiya, 2Dr Rishi Thukral, 3Dr Shikhar Pratap Chauhan, 4Dr Sanad Kumar Singh Solanki, 5Dr Tridib Goswami, 6Dr Thiyam Nickychandra Singh
1Reader, Department Of OMFS, Gurugovind Singh Dental College, Burhanpur
2Assistant Professor, Department Of Dentistry, Atal Bihari Vajpayee Government Medical College, Vidisha ( M.P.)
3Assistant Professor, Department of Pediatric & Preventive Dentistry, Government College of Dentistry,
Indore
4 BDS, MDS, Orthodontics
5BDS, Private Practioner
6 BDS, MDS, Orthodontics Corresponding Authors: Rishi Thukral
Abstract:
Objective- The aim of this study was to compare the long-term stability and satisfaction of orthodontic camouflage and orthognathic surgery in the treatment of adults with moderate skeletal Class III.
Methodology-A total of 25 adult females treated with orthodontic camouflage for Class III malocclusions were contacted at least three years after treatment to assess treatment stability and satisfaction. The results were compared to long-term outcomes in 21 patients who had bimaxillary surgical correction for the same Class III problems.
Results-Small mean improvements in skeletal landmark locations occurred in the camouflage patients over time, but the changes were much smaller than in the surgery patients. The surgery group's dental improvements were more serious than the camouflage group's. Patients who received camouflage had less functional or temporomandibular joint problems than those who had surgery. Both groups expressed equal levels of overall treatment satisfaction.
Conclusion-The findings indicate that in moderate skeletal Class III adults, both camouflage and surgical care can provide adequate results and long-term stability. Camouflage therapy can be an appropriate alternative treatment if patients are unable to accept surgery due to possible surgical complications or financial difficulties.
Keywords: Orthognathic Surgery, Camouflage, Moderate Skeletal Class III.
Introduction:
A structural deviation in the sagittal relationship between the maxillary and mandibular bony arches is known as Class III malocclusion [1-5]. The condition is marked by maxillary retrusion, mandibular protrusion, or a combination of the two. Anterior crossbite and increased or decreased divergence are often correlated with the disease. According to studies, skeletal malocclusion accounts for 63 percent to 73 percent of Class III malocclusion cases [3]. Prevalence varies by race [1], with Asian populations having a higher prevalence (ranging from 15% to 23%) and American, European, and African Caucasian populations having a lower prevalence (below 5%).
Just two treatment options are available when treating non-growing patients with skeletal Class III malocclusion [2]: 1) Orthognathic surgery combined with orthodontic treatment to conceal the underlying skeletal discrepancy, or 2) orthognathic surgery combined with orthodontic treatment.
Natural occlusion, enhanced facial and dental esthetics, and long-term recovery are the same treatment targets for all treatment choices. However, it is well recognized that the results of the two approaches for the same patient differ, especially in terms of jaw relation and incisor inclination. However, no one has looked at the disparities between the two approaches in terms of
patient long-term stabilization.
While several case studies have addressed Class III malocclusions that have been successfully treated with orthodontic camouflage [3-5], there has been little discussion of long-term stability (>3 years). Costa [6] studied the use of orthodontic camouflage in patients with skeletal Class III malocclusions and discovered relapses 18 months after successful treatment ended.
More research has been done on surgical patients' long-term stability. De Villa [7] studied at 20 surgical patients and found that the average long-term horizontal relapse was 2.3 mm (28.0%) at the B point and 3.0 mm (34.1%) at the Pogonion. Twelve of the twenty patients relapsed horizontally more than 2 mm at the B point and thirteen at the pogonion. Long-term relapse was between 14.9 percent and 28.0 percent at point B, and between 11.5 percent and 25.4 percent at Pogonion, according to Joss [8]. Kraft [9] looked at 12 patients and found that four of them (33%) experienced skeletal instability (follow-up 3 years 8 months).Busby [10] investigated the long- term stability of bimaxillary surgery (> or =5 years) and discovered that bimaxillary surgery in Class III patients is more stable than in Class II patients.
Patients treated with camouflage and those treated with orthognathic surgery have only been compared in a few studies. According to Mihalik [11], long-term stability for patients with Class II malocclusion tended to be the same if they were treated with camouflage or mixed care. The author did note, however, that patients who were treated with orthodontic camouflage had less serious problems than those who were treated surgically. These statistics, however, are inadequate to report on the results of alternative therapies for similar problems.
The aim of this study was to compare the long-term stability and satisfaction of patients who received orthodontic camouflage versus those who received orthognathic surgery.
Methodology:
A total of 25 camouflage (Group 1) and 21 surgical orthodontic (Group 2) Class III patients were chosen from different hospital's database of Bhopal district. The following conditions were met by all of the participants: 2) mild skeletal Class III (overjet of 1 mm to 4 mm, bilateral Angle Class III molar relationship, and ANB cephalometric measurement of 1° to 4°).The following is used as exclusion criteria: 1) a noticeable transversal difference, 2) a cleft, and/or 3) syndromic diseases. The straight wire technique was used on Group 1 with or without mini-plants. Group 2 underwent rigid fixation orthognathic surgery and bimaxillary surgery (maxillary advancement and mandibular setback surgery).
Both patients had pre-treatment (T1), post-treatment (T2), and long-term follow-up (T3) lateral cephalometric radiographs taken. The T2 cephalograms were taken less than two months after the removal of the orthodontic appliances. T3 lateral cephalometric radiographs (taken more than 3 years after orthodontic appliance removal) were collected from the database or by calling the patients.
Cephalometric analysis: The linear measures used in this analysis on the lateral cephalograms were the same as those recorded by Yoshioka [12]. A coordinate system was developed, with the x coordinate being a vertical line through the nasion and perpendicular to it, and the y coordinate being a line parallel to the Frankfort horizontal plane at the nasion. The positions of the U1, L1, point A, point B, and the pogonion were tracked over time. Changes of more than 2 mm or 2 degrees were deemed clinically meaningful because they were beyond the cephalometric method's inherent error [11].
A double determination by the same investigator, separated by at least a 10-day interval, was used to measure the accuracy of landmark recognition. The measurements' reproducibility was calculated by selecting 20 cephalograms at random from each of four classes, redigitizing points, and calculating the differences between all pairs. The mean difference was used as a criterion for the measurement's repeatability. There were no major variations between the measurements taken at different times (P > 0.05). The standard deviations for distances and angles were 0.20 to 0.32 mm and 0.150 to 0.250 mm, respectively.
Questionnaire analysis: Patients completed questionnaires about their attitudes, happiness, and current issues upon recall. The questionnaire was adapted from Uslu's [13], which measured satisfaction with orthodontic care outcomes.
The questionnaire was made up of ten statements, each of which could be answered positively or negatively. For scoring, it was divided into three subscales: teeth and profile concerns (5 items), temporomandibular joint (TMJ) concerns (3 items), and practical concerns (2 items) (2 items).
Statistical analysis: The statistical package program SPSS Version 23.0 was used to analyze the data. For each topic, descriptive statistics such as means and standard deviations were determined.
The cephalometric differences between the two groups were compared using a Student's t-test with a group configuration. The response frequency distributions were measured, and Chi-squared tests were used to see whether there were any variations between the two groups' responses.
Results:
Cephalograms: Table 1 indicates the demographic and cephalometric comparisons before treatment, with no substantial variations between the two groups on either of the products.
Table 1: Demographic and cephalometric comparison before treatment
Group 1 Group 2 P
Int age (y) 18.78±3.76 19.10±2.14 NS
Tx time (y) 1.96±0.87 2.12±0.45 NS
Follow-up (y) 5.86±1.78 5.12±0.79 NS
SNA (0) 82.24±1.63 82.13±1.12 NS
SNB (0) 84.79±1.87 85.25±1.34 NS
ANB (0) -2.55±1.91 -3.12±1.94 NS
PP-FH (0) 2.02±1.75 2.57±0.67 NS
OL-FH (0) 11.32±3.03 11.43±2.59 NS
FMA (0) 33.42±4.12 32.19±3.98 NS
U1-FH (0) 71.01±4.83 72.09±5.72 NS
IMPA (0) 80.18±4.29 81.56±6.12 NS
Overbite (mm) 1.08±0.25 1.28±0.56 NS
Overjet (mm) -2.08±0.18 -3.23±0.87 NS
NS: no significance.
The post-treatment results for the two groups are shown in Table 2. The incisor disposition was mostly affected by the camouflage treatment, with little improvement in the jaw relationship. In the surgery community, good dental and skeletal relationships were achieved. The surgery group had a higher success rate than the camouflage group in achieving natural occlusion.
Table 2: Cephalometric comparison post treatment
Group 1 Group 2 P
SNA (0) 82.67±3.24 84.13±3.12 *
SNB (0) 84.24±2.13 82.12±3.09 *
ANB (0) -1.67±1.23 2.01±1.34 *
PP-FH (0) 2.13±0.98 1.02±2.12 NS
OL-FH (0) 11.32±3.03 11.43±2.59 NS
FMA (0) 31.56±4.23 30.28±5.87 NS
U1-FH (0) 60.12±7.12 70.13±6.92 *
IMPA (0) 73.29±8.23 88.75±6.34 *
Overbite (mm) 1.43±1.56 1.54±1.84 NS
Overjet (mm) 1.01±1.39 2.24±1.87 NS
The shifts from post-treatment to long-term follow-up are shown in Table 3. For most things, the changes in Group 2 were substantially greater than those in Group 1, but the long-term changes in both groups were very tiny.
Table 3: Comparison of changes from post-treatment to long- term follow-up
Group 1 Group 2 P
x-coordinate (mm)
A B Pog
U1 L1
-0.02±0.81 -0.13±0.82 *
0.03±0.93 1.21±1.83 *
0.04±1.03 1.48±2.08 *
-0.42±0.81 0.55±1.25 NS
1.43±1.16 -1.89±1.31 *
y-coordinate (mm)
A B Pog
U1 L1
0.16±0.84 0.85±1.16 *
-0.26±1.21 0.99±1.67 *
0.52±1.45 1.71±1.43 *
0.31±0.72 0.58±0.94 NS
-1.31±0.89 1.85±1.23 *
Dimension changes
Overjet Overbite
0.43±1.32 0.86±1.12 NS
0.34±0.93 1.58±1.66 NS
x-axis: anterior movement was indicated as a positive value, and posterior movement as a negative value; y-axis: superior movement was indicated as a positive value while inferior movement as a negative value; Statistically significant difference among groups; *P < 0.05; NS:
no significant.
In clinical trials, a few patients are often responsible for the majority of the observed improvements, resulting in misleading descriptive statistics based on a normal distribution. Table 4 displays the numbers and percentages of changes greater than 2 mm in each category. There were no shifts of more than 2 mm in point A, point B, or the pogonion in either of the patients.
Except for overjet in one patient, the cephalometric data for the camouflage patients showed almost no long-term relapse improvements. In the surgery community, more than 15% of patients had a >2 mm improvement in point A, point B, or the pogonion.
Table 4: The number (percentage) in each group with changes of greater than 2 mm.
Group 1 Group 2
x-coordinate (mm) A
B Pog
0 4 (19%)
0 5 (23%)
0 4 (19%)
y-coordinate (mm) A
B Pog
0 4 (19%)
0 8 (38%)
0 7 (33%)
Dimension changes Overjet 6 (19%)
Overbite 1 (4%) 6 (19%)
0 8 (38%)
Questionnaire: After successful care, both groups were pleased with their teeth alignment and profiles, with the majority of subjects showing changes in their final esthetic profile and smiles.
Subjects who were disappointed with the final outcome (T3) (4 in Group 1 and 10 in Group 2) suggested that they had experienced a "relapse."
After surgery, 9 participants in Group 2 experienced discomfort or clicking in the temporomandibular joint (TMJ). Three patients had restrictions in their mouth opening. Just four of the patients who had camouflage had discomfort or clicking in their TMJ after treatment. No patients complained of difficulty opening their mouths. TMJ-related issues, pain, and discomfort were reported by 2 times (9 patients) more people in Group 1 than in Group 2, with a statistically significant difference (P< 0.05). The increase in chewing/biting capacity in Group 1 (92 %), which was higher than that in Group 2, was especially noteworthy (80 %).
Discussion:
When the skeletal difference is not extreme and an appropriate overbite occurs prior to treatment, camouflage treatment may be effective. Treatment objectives could be restricted to achieving a Class I incisor relationship with aligned anterior teeth and recognizing a less-than-ideal profile [3]. Although orthognathic surgery [4] produces the best relationship between the maxilla and mandible, it is also the most intrusive and costly procedure.There is still no strong consensus about whether to treat moderate skeletal Class III malocclusion with surgery or nonsurgical orthodontic approaches; some authors [3,4] have attempted to define threshold values for pretreatment recognition of patients who should undergo surgery. Proper patient selection, on the other hand, is neither easy nor straightforward. There are guidelines, but they are focused on occlusal considerations and do not consider variables like facial esthetics, primary chief complaint, or patient motivation.As a result, some patients with mild skeletal Class III occlusion may be unable to undergo surgery due to the risk of complications, opting instead for an orthodontic solution.
Since this was a retrospective analysis, the number and quality of subjects were critical. We found that the malocclusions and jaw differences in the camouflage patients were identical to those in the surgery patients (P > 0.05). This contrasted with a previous comparative study [11], which found that patients treated with orthodontic camouflage had less problems than those treated surgically. Our data may provide a more accurate picture of the results of a different procedure for similar problems.
In terms of cephalometric stability, patients in both groups demonstrated adequate long-term stability. The surgical group's higher rate of skeletal relapse is unsurprising, as those patients may have experienced a skeletal alteration that the orthodontic patients did not. Long-term relapse can be caused by a variety of factors, including the initial soft tissue profile, hard tissue remodeling processes, and muscular factors [14].
The maxillary incisors remained stable in both classes, while the mandibular incisors changed more and showed considerable variations between them. Furthermore, the mandibular incisors were oriented differently in the two classes. Camouflage patients' lower incisors displayed labial movement, while surgical patients' showed lingual movement. The different relapse directions may be due to the teeth moving in different directions during treatment. Since most relapses occur in mandibular anterior alignment, certain changes in the mandibular teeth were greater than those in the maxillary teeth [15].
Another critical factor in dental stability is the use of retainers. In both categories, 35 patients wore a retainer for more than two years, while 11 only wore it for one year. Patients who did not wear their retainer properly have a higher rate of dental relapse. Insufficient retainer time [11] is
often a potential cause for relapse, even if there is insufficient scientific evidence on which to base our clinical decisions about retainer and stability.
It's worth noting that the percentage of patients in the camouflage treatment group who were pleased with their profile changes was higher than in the surgery group, particularly because orthodontists believe camouflage treatment has little effect on the profile. This may be due to different treatment expectations [13]. The profile was the key source of concern for the surgical community, with patients typically assuming that their skeletal difference needed to be fixed.Patients in the camouflage community, on the other hand, may have placed a greater emphasis on their dental arch relationship and mastication capacity because they were warned before treatment that their profiles would not improve. As a result, even minor changes in the facial profile, which were primarily accomplished by tooth movement, resulted in patient satisfaction in the camouflage community. Patients' perceptions of the seriousness of their problems and their treatment expectations will affect whether they opt for surgery or camouflage treatment [11,16].
The majority of surgical patients had functional and TMJ problems after their operation [11], while the orthodontic community had these issues only occasionally. The proximal portion of the condyle can be pushed backward during jaw surgery, putting stress on the condylar surface.
Loading can cause changes to the disc, condyle, and disc-condyle relationship, and dislocating the condyle can cause degenerative changes in the articular cartilage. TMJ problems can result from these changes [17]. Orthodontic tooth movement has nothing to do with the disc, condyle, or disc- condyle relationship, which explains why Group 1 patients have a lower rate of TMJ problems.
Conclusion:
Despite their discrepancies in care, both modalities largely achieved their treatment goals. Patients who are properly selected for camouflage treatment are more likely to be pleased with the treatment's result than those who have surgery. The study's shortcomings were the unavoidable non-responders. This demonstrates the importance of meticulously maintaining and updating medical records over time in order to ensure the possibility of future review.
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