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Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 577-580

Orthognathic surgery with two-segment le fort i and sagittal split ramus osteotomies of open bite deformity in an amelogenesis imperfecta patient via virtual planning: A case report

1 Department of Oral and Maxillofacial Surgery, Ataturk University Faculty of Dentistry, Erzurum, Turkey
2 Clinical Specialist on Oral and Maxillofacial Surgery, College of Health Sciences, Ankara Medipol University, Ankara, Turkey
3 Department of Orthodontics, Ataturk University Faculty of Dentistry, Erzurum, Turkey
4 Department of Orthodontics, Osmangazi University Faculty of Dentistry, Eskisehir, Turkey

Date of Submission14-Jun-2019
Date of Acceptance20-Dec-2019
Date of Web Publication4-Apr-2020

Correspondence Address:
Dr. M Ataol
Clin. Dent. Mert ATAOL, College of Health Sciences, Ankara Medipol University, Altindag, 06050, Ankara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_316_19

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Amelogenesis imperfecta (AI) is an enamel defect and is often associated with the anterior open bite (AOB) and transverse maxillary deficiency. It is known that in such cases when AI and AOB appeared together, posterior maxillary impaction with or without bilateral mandibular ramus osteotomies is a frequently preferred treatment option. Virtual planning is more reliable rather than the conventional model surgery planning, especially for complicated cases. Usage area of virtual 3D anatomical models reconstructed from Cone Beam Computed Tomography (CBCT) data is expanding day by day for both diagnosis and surgical planning. The aim of this study is to present a patient with AI and AOB and transverse maxillary deficiency and management of this case with virtually planned two-segment Le fort I and sagittal split ramus osteotomies followed by prosthetic rehabilitation.

Keywords: Amelogenesis imperfecta, anterior open bite, orthognathic surgery, segmental Le Fort I

How to cite this article:
Ertas U, Ataol M, Kiki A, Uğurlu M. Orthognathic surgery with two-segment le fort i and sagittal split ramus osteotomies of open bite deformity in an amelogenesis imperfecta patient via virtual planning: A case report. Niger J Clin Pract 2020;23:577-80

How to cite this URL:
Ertas U, Ataol M, Kiki A, Uğurlu M. Orthognathic surgery with two-segment le fort i and sagittal split ramus osteotomies of open bite deformity in an amelogenesis imperfecta patient via virtual planning: A case report. Niger J Clin Pract [serial online] 2020 [cited 2021 Sep 18];23:577-80. Available from:

   Introduction Top

Amelogenesis imperfecta (AI) is an inherited disease group characterized by enamel defects.[1] The frequency of AI varies from 1/700 to 1/14,000 people, based on the study group and the diagnostic criteria.[1] On the other hand, patients with AI, especially at younger ages, have also a psychosocial influence comparable with the impact of systemic health conditions.[2] AI is typically found in association with another problem: anterior open bite (AOB) ranges from 24% to 60%.[3],[4] It is known to be more difficult and less predictable than other dentofacial deformities in terms of surgical and/or orthodontic management of AOB.[1],[5] AOB deformities have some skeletal morphologic features such lower anterior facial height and mandibular plane angle increased; occlusal planes are divergent and maxillary dental height was increased with dentoalveolar hyperplasia.[5] It is recommended for AOB patients with maxillary posterior dentoalveolar hyperplasia that Le Fort I impaction (segmental or not) and advancement with mandibular bilateral sagittal split ramus osteotomy (BSSRO) if necessary.[1],[4]

Procedures involving a Le Fort I osteotomy present more predictable and stable results, comparing with nonsurgical orthodontic methods or only mandibular ramus osteotomies.[6] Presurgical orthodontic treatment is frequently not applicable because of the absence or defect of the enamel and insufficient crown height.[3] If there is a accompanied transverse maxillary deficiency, one of the frequently chosen treatment methods is multi-segment Le Fort I impaction osteotomy with or without BSSRO whether or not followed by prosthetic rehabilitation is usually the treatment of choice.[3],[5],[7] The aim of this study is to present and discuss a patient with AI and AOB and management with two-segment le fort I osteotomy and BSSRO.

   Case Report Top

A 21-year-old female patient was referred to our clinic with the esthetical complaints. Clinical and radiographic evaluations were carefully made. Intraoral examination showed AI, 4 mm AOB, long face and transverse maxillary skeletal deficiency with posterior bilateral cross-bite [Figure 1] and [Figure 2]. In addition, there were some accompanying problems such as short crowns, multiple diastema, and occlusal wear with exposed dentin and discoloration. The lengths and forms of roots are sufficient and oral care was acceptable. For radiographic examination, cone-beam computed tomography (CBCT) was obtained and evaluated on Dolphin3D Software Version 11.9 (Dolphin Imaging and Management Solutions, CA, USA) 2- and 3-dimensionally.
Figure 1: Preoperative intraoral view

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Figure 2: Preoperative orthopantomograph

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One of the treatment options was conventional orthodontic therapy and anterior tooth extrusion by intermaxillary elastics with maxillary expansion. Because this may cause a gummy smile, this option was discarded. Another option was to intrude both maxillary and mandibular posterior teeth by using miniscrew or miniplate anchorage and to take advantage of the autorotation of the mandible to close the AOB. However, because of the possibility of relapse, this alternative was not also chosen. A written informed consent for surgical treatment planning and possibility of publication was obtained from patient.

With all these findings and completion of facial growth, orthognathic surgery was recommended for the patient. After the approval of the patient, the virtual planning stage was started. It was decided that orthognathic surgery followed by fixed prosthetic treatment would be necessary to accomplish both dental and facial results.

First of all, the smiling line was determined and the current line was appropriate. Therefore, it was decided that the position of the anterior tooth segment should not be disturbed. Virtual surgical planning was performed with Dolphin3D (Chatsworth, CA, USA). Considered of counterclockwise rotational movement of mandible, posterior maxillary impaction with 5 mm at the line of the first upper molar tooth and 6 mm mandibular advancement and for compensating the transversal deficiency of maxilla, two-segment Le Fort I osteotomy with 6 mm divergence at the line of first upper molar tooth was planned [Figure 3]. The surgical splint was designed virtually and prepared with 3D printer (Digital Wax Systems 020D, DWS, Thiene, Italy). Before surgery, an arch bar was applied for intraoperatively surgical guide stabilization because orthodontic braces could not be applied due to AI. Then, surgical splint was checked.
Figure 3: Three.dimensional virtual surgery

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Under general anesthesia, posterior maxillary impaction with two-segment Le Fort I osteotomy was performed [Figure 4]. Midpalatal osteotomy line supported with bone fragments removed during impaction and covered by bichat fat pad and maxillary segments fixated with miniplates and miniscrews. Then, mandibular advancement with BSSRO was done and also fixated with miniplates and miniscrews [Figure 5] and [Figure 6]. The patient was followed at hospital for 3 days and then discharged without any problems.
Figure 4: Two.segmentLe Fort I osteotomy with midline osteotomy

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Figure 5: Postoperative intraoral view

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Figure 6: Postoperative orthopantomograph

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After 1-month healing period, full-mouth metal-ceramic fixed partial dentures were planned and fabricated. At 1 year follow-up, there was no complication or complaint and the situation was sufficient esthetically, clinically, and radiologically.

   Discussion Top

There were a lot of studies have been used to manage AOB with nonsurgical orthodontic treatments with miniscrews and elastics; however, majority of AOB cases, especially in adults, need orthognathic surgery for functionally effective, more stable, and esthetically acceptable treatment.[1],[4] In addition, the surgical posterior impaction of the maxilla can provide a counter-clockwise rotation of the mandible, thereby the height of the lower anterior face can be reduced.[1],[8]

The segmental Le Fort I osteotomies are recommended for the single-stage correction of transverse maxillary deficiencies up to 6–7 mm, the correction of AOB when there is a difference in the occlusal planes between the posterior and anterior segments of the maxilla, and the correction of severe proclination of the anterior teeth.[7] For the present case report, because of the transverse deficiency, it is decided to two-segment Le fort I surgery.

The conventional model surgery planning method for segmental Le Fort I osteotomies is very difficult and can lead to functional and esthetic problems because of dimensional change and iatrogenic errors during obtaining plaster models and face-bow transfer. Otherwise, virtual 3D planning reconstructed from CT data is more reliable.[9] Various types of software have been used to evaluate the maxillofacial structures and to plan orthognathic surgery in three dimensions. Dolphin 3D program is a comprehensive and widely-preferred software that can be used for three-dimensional imaging, airway evaluation, cephalometric drawing and analysis, simulation of treatment, and surgical treatment planning purposes.[10]

   Conclusion Top

The condition of the enamel and insufficient crown height could restrict the surgical orthodontic treatment in AI patients. In such cases when AI and AOB appeared together, multi-segment Le Fort I impaction osteotomy followed by prosthetic rehabilitation is a reliable and advantageous treatment of choice.

   List of Abbreviations Top

3D: Three-dimensional; AI: Amelogenesis Imperfecta; AOB: Anterior Open Bite; BSSRO: Bilateral Sagittal Split Ramus Osteotomy; CBCT: Cone Beam Computed Tomography; CT: Computed Tomography.

   Declarations Top

Ethics approval and consent to participate

This study was carried out at the Department of the Oral and MaxillofacialSurgery of the Ataturk University Faculty of Dentistry (Erzurum, Turkey). This study followed the Declaration of Helsinki on medical protocol and ethics and informed consent was obtained from patient.

Availability of data and materials

The datasets obtained and/or analyzed during the current study are available from the corresponding author on reasonable request.


This study was supported by the Scientific Research Project Fund of Ataturk University (BAP 2016/091).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Marsan G, Aksu IS, Kurt H, Kuvat SV, Cura N. Interdisciplinary treatment of a patient with amelogenesis imperfecta, a skeletal class III relationship, and an anterior open bite. World J Orthod 2010;11:284-90.  Back to cited text no. 1
Coffield KD, Phillips C, Brady M, Roberts MW, Strauss RP, Wright JT. The psychosocial impact of developmental dental defects in people with hereditary amelogenesis imperfecta. J Am Dent Assoc 2005;136:620-30.  Back to cited text no. 2
Hoppenreijs TJ, Voorsmit RA, Freihofer HP, van't Hof MA. Open bite deformity in amelogenesis imperfecta Part 2: Le Fort I osteotomies and treatment results. J Craniomaxillofac Surg 1998;26:286-93.  Back to cited text no. 3
Ramos A, Pascotto R, Filho L, Hayacibara R, Boselli G. Interdisciplinary treatment for a patient with open-bite malocclusion and amelogenesis imperfecta. Am J Orthod Dentofac Orthop 2011;139:145-53.  Back to cited text no. 4
Hoppenreijs TJ, Freihofer HP, Stoelinga PJ, Tuinzing DB, Freihofer HP, Paul JW, et al. Skeletal and dento-alveolar stability of Le Fort I intrusion osteotomies and bimaxillary osteotomies in anterior open bite deformities. A retrospective three-centre study. Int J Oral Maxillofac Surg 1997;26:161-75.  Back to cited text no. 5
Silva I, Suska F, Cardemil C, Rasmusson L. Stability after maxillary segmentation for correction of anterior open bite: A cohort study of 33 cases. J Cranio-Maxillofacial Surg 2013;41:3-7.  Back to cited text no. 6
Haas Junior OL, Guijarro-Martínez R, de Sousa Gil AP, da Silva Meirelles L, de Oliveira RB, Hernández-Alfaro F. Stability and surgical complications in segmental Le Fort I osteotomy: A systematic review. Int J Oral Maxillofac Surg 2017;46:1071-87.  Back to cited text no. 7
Ertas Ü, Saruhan N, Yalçin E. Surgical treatment of class III malocclusion: Monozygotic twin. J Craniofac Surg 2016;27:e471-3.  Back to cited text no. 8
Xia J, Ip HH, Samman N, Wang D, Kot CS, Yeung RW, et al. Computer-assisted three-dimensional surgical planning and simulation: 3D virtual osteotomy. Int J Oral Maxillofac Surg 2000;29:11-7.  Back to cited text no. 9
Glupker L, Kula K, Parks E, Babler W, Stewart K, Ghoneima A. Three-dimensional computed tomography analysis of airway volume changes between open and closed jaw positions. Am J Orthod Dentofac Orthop 2015;147:426-34.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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