Editorial Type:
Article Category: Research Article
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Online Publication Date: 20 May 2014

Long-term surgical versus functional Class II correction: A comparison of identical twins

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Page Range: 142 – 156
DOI: 10.2319/011314-46.1
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ABSTRACT

The purpose of this twin case comparison was to assess the short- and long-term effects of nonsurgical treatment vs orthognathic surgical treatment for Class II correction. Two identical twins (age 13 years 3 months) were treated for Class II correction where one patient was treated nonsurgically using a fixed functional appliance, while the other was treated using orthognathic mandibular advancement surgery. The patients were recalled and evaluated 5 years in retention. Comparing changes in the short and long term, surgical treatment led to superior skeletal results compared to the nonsurgical twin. However, the soft tissue profile was remarkably similar for both patients suggesting that soft tissue profile changes may not necessarily follow similar changes in the bony skeletal structures.

Keywords: Long term; Class II; Fixed functional; Surgical

INTRODUCTION

Morphogenesis and development of the face is one of the most complex processes in an individual's development. Facial appearance has a strong genetic component with monozygotic or dizygotic twins appearing more similar than unrelated individuals.1 The size, shape, and position of craniofacial structures are a combination of being genetically determined and influenced by external environmental factors. Certain craniofacial characteristics such as facial height and mandibular position appear to be more heritable than other structures.1,2 Even though it is reported that both Class II and Class III malocclusion have strong familial tendency,3,4 it is difficult to estimate the influence of environmental factors in modifying craniofacial growth because heritability studies of occlusion are typically based on twins and siblings who did not receive orthodontic treatment. While some5 suggest that malocclusion is a trait that can be greatly influenced by environmental factors, others believe that the cause is more multifactorial.1

Based on the growth status treatment, options for Class II correction commonly include use of functional/fixed functional appliances (FFA), headgear, camouflage by extractions of premolars, or surgical correction of the underlying skeletal discrepancy when growth has completed.6 The use of functional/FFAs to enhance mandibular growth has been questionable.7 Class II correction with such devices is usually a combination of skeletal and dental changes, including restraining maxillary growth, mild mandibular growth, proclination of mandibular and retroclination of maxillary incisors often called “side effects” of using such appliances.8 Orthognathic surgery, on the other hand, is aimed at correction of the underlying skeletal discrepancy without the “side effects” associated with FFAs. In comparing the outcome of orthognathic surgery in adults to functional appliances in growing children, no significant differences have been observed by some studies,9,10 while others have reported conversely claiming surgery to lead to greater skeletal correction.11

Treatment options for adolescents are particularly difficult due to uncertainty regarding the magnitude of remaining mandibular growth,12,13 and therefore may be treated by either camouflage/growth modification or orthognathic surgery. Twin studies in general would be advantageous in such situations because they would help understand the contribution of genetics as opposed to the effect of the environment (functional appliance or surgery). It is unclear if the long-term outcome with either method would be different. The key question is “Are there esthetic differences when Class II correction is achieved with surgical intervention in comparison to camouflage using a fixed functional appliance, both in the short and long term?” This twin case report allowed us to elucidate some answers.

CASE REPORT

Diagnosis

The patients who were identical twins 13 years 3 months at the start of treatment (Figures 1 and 2) reported to our division at the University of Connecticut Health Center with a chief complaint of an increased overjet. Both sisters were assessed to be at cervical vertebral maturation stage III.14 Not surprisingly, both twins had similar skeletal discrepancies (Figure 3), with skeletal Class II relation due to a retrognathic mandible and average to vertical growth pattern.15 Even though the patients were identical twins, they had slightly different dental representations. It has been reported that variation in occlusal relationships has little or no genetic association.16 Patient 1 had a congenitally missing mandibular right second premolar, while patient 2 had bilaterally missing mandibular second premolars with retained deciduous second molars and transposed mandibular right canine. The overjet was more pronounced in patient 2 due to slightly more proclined maxillary incisors.

Figure 1. Patient 1 (nonsurgical) pretreatment records.Figure 1. Patient 1 (nonsurgical) pretreatment records.Figure 1. Patient 1 (nonsurgical) pretreatment records.
Figure 1. Patient 1 (nonsurgical) pretreatment records.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 2. Patient 2 (surgical) pretreatment records.Figure 2. Patient 2 (surgical) pretreatment records.Figure 2. Patient 2 (surgical) pretreatment records.
Figure 2. Patient 2 (surgical) pretreatment records.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 3. The twins superimposed on each other at pretreatment. Their skeletal profiles were almost identical.Figure 3. The twins superimposed on each other at pretreatment. Their skeletal profiles were almost identical.Figure 3. The twins superimposed on each other at pretreatment. Their skeletal profiles were almost identical.
Figure 3. The twins superimposed on each other at pretreatment. Their skeletal profiles were almost identical.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Treatment Objectives

The primary treatment objective for both patients was to correct the underlying skeletal discrepancy. Therefore, orthognathic surgical treatment was initially the treatment of choice presented to both patients. While patient 1 declined the surgical option due to apprehension of the surgical procedure, patient 2 agreed to it. Informed consent was obtained from the parents for both patients, explaining the differences in the treatment approach and expected differences in outcome.

Patient 1 was thus treated nonsurgically with a FFA. The treatment objectives for patient 1 were: attempt to maximize the differential jaw growth by nonsurgical correction of the malocclusion, control the vertical dimension and space maintenance for the missing mandibular premolar for subsequent implant replacement, retention, and follow up.

Patient 2 was treated with orthognathic surgery for Class II correction. For patient 2, the treatment objectives were: to surgically correct the underlying skeletal discrepancy, correct the vertical dimension by surgically impacting the maxilla, space maintenance for the missing mandibular second premolars and subsequent implant placement, retention, and follow up. Based on the unfavorable position of the transposed mandibular right canine, it was decided not to attempt to correct the transposition and mesially move the mandibular right first premolar into the canine region.

Treatment Alternatives

As an alternative treatment plan, extraction of maxillary premolars was considered for both patients. This would camouflage the underlying skeletal discrepancy by reducing the overjet primarily by maxillary anterior teeth retraction. However, this approach could potentially worsen the soft tissue profile.

Treatment Progress

For patient 1, initial leveling and alignment was achieved with a 0.016-inch nickel–titanium archwire. The archwires were gradually built up to maxillary 0.019 × 0.025-inch stainless steel and mandibular 0.021 × 0.025-inch stainless steel. A closed coil spring was placed to maintain the space for the missing mandibular right second premolar. To minimize the mandibular incisor proclination during the fixed functional appliance phase, mandibular incisor brackets with −6° torque were used. The Twin Force Bite Corrector (TFBC) appliance17–19 was used for 10 months for Class II correction (Figure 4). The patient was in a super Class I molar relation with anterior edge-to-edge incisal relationship to compensate for mild relapse after removal of the TFBC appliance. Class II elastics were used to maintain the corrections that were achieved. Finishing and detailing were done, and the patient was debonded after 30 months of active treatment at the age of 16 years (Figure 5).

Figure 4. Prefunctional appliance photographs for patient 1.Figure 4. Prefunctional appliance photographs for patient 1.Figure 4. Prefunctional appliance photographs for patient 1.
Figure 4. Prefunctional appliance photographs for patient 1.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 5. Patient 1 posttreatment records.Figure 5. Patient 1 posttreatment records.Figure 5. Patient 1 posttreatment records.
Figure 5. Patient 1 posttreatment records.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Patient 2 had bilateral missing mandibular second premolars. There was severe loss of arch length on the mandibular right side due to mesial migration of the entire posterior segment into the canine space. Since the erupting canine was transposed with the first premolar in an unfavorable manner (Figure 2), it was decided not to correct the transposition. On the left side, space was maintained for subsequent implant placement for the missing mandibular second premolar. Thus, the occlusion was planned to be finished in a Class III molar relation on the right and Class I on the left side.

After the alignment phase, mandibular anterior teeth were retracted into the edentulous space of the missing second premolars to maximize the mandibular surgical advancement (Figure 6). After assessing completion of growth by serial lateral cephalograms, surgery was planned when the patient was age 18 years and 2 months. To correct the vertical maxillary excess and excessive gingival display, LeFort I maxillary impaction along with mandibular advancement using bilateral sagittal split osteotomy technique was performed. The patient was subsequently debonded at the age of 18 years and 8 months after an active treatment time of 5 years and 2 months (Figure 7). Similar observations of an increased treatment time in surgical cases compared to nonsurgical cases have been reported.20

Figure 6. Presurgical photographs for patient 2.Figure 6. Presurgical photographs for patient 2.Figure 6. Presurgical photographs for patient 2.
Figure 6. Presurgical photographs for patient 2.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 7. Patient 2 posttreatment records.Figure 7. Patient 2 posttreatment records.Figure 7. Patient 2 posttreatment records.
Figure 7. Patient 2 posttreatment records.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Treatment Results

Overall, cephalometric superimpositions were done using the Björk and Skieller method.21 For regional superimpositions, the maxilla was superimposed along the palatal cortex by registering on the bony internal details and superior and inferior surfaces of the hard palate. The mandible was superimposed posteriorly over the outline of the mandibular canal and anteriorly over the anterior contour of the chin and internal bony structures of the symphysis.

In patient 1, the TFBC appliance phase superimpositions (Figure 8) revealed that overjet correction was due to proclination of mandibular incisors, and molar correction was a combination of differential jaw growth and mesial movement of mandibular molars. The patient was recalled 5 years in retention and showed stable correction of the treatment results (Figure 9). Overall and regional superimpositions at pretreatment, posttreatment, and retention (Figure 10) depicted mesial movement of the molars along with incisor proclination for both arches. During the retention phase, there was mild relapse of the mandibular incisor proclination leading to an increase in overjet with stable results for molar correction that were achieved.

Figure 8. Overall and regional superimpositions depicting fixed functional appliance (FFA) outcome: before FFA (solid black), after FFA (dashed grey).Figure 8. Overall and regional superimpositions depicting fixed functional appliance (FFA) outcome: before FFA (solid black), after FFA (dashed grey).Figure 8. Overall and regional superimpositions depicting fixed functional appliance (FFA) outcome: before FFA (solid black), after FFA (dashed grey).
Figure 8. Overall and regional superimpositions depicting fixed functional appliance (FFA) outcome: before FFA (solid black), after FFA (dashed grey).

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 9. Five years retention evaluation for patient 1 (nonsurgical twin).Figure 9. Five years retention evaluation for patient 1 (nonsurgical twin).Figure 9. Five years retention evaluation for patient 1 (nonsurgical twin).
Figure 9. Five years retention evaluation for patient 1 (nonsurgical twin).

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 10. Nonsurgical case overall and regional superimpositions: pretreatment (solid black), post treatment (dashed grey), and retention (dashed black).Figure 10. Nonsurgical case overall and regional superimpositions: pretreatment (solid black), post treatment (dashed grey), and retention (dashed black).Figure 10. Nonsurgical case overall and regional superimpositions: pretreatment (solid black), post treatment (dashed grey), and retention (dashed black).
Figure 10. Nonsurgical case overall and regional superimpositions: pretreatment (solid black), post treatment (dashed grey), and retention (dashed black).

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

For patient 2, the surgical phase superimpositions (Figure 11) showed the maxilla was impacted 4–5 mm posteriorly and 2–3 mm anteriorly. The mandible was advanced by 4–5 mm. The patient was recalled 4 years in retention and showed slight improvement of the occlusal relationship (Figure 12). Overall and regional superimpositions at pretreatment, posttreatment, and retention time points (Figure 13) showed that the overjet and molar correction was essentially due to the surgical advancement of the mandible. In the retention phase, the skeletal corrections achieved were remarkably stable with mild relapse of the mandibular incisor inclination, which led to slight increase in overjet.

Figure 11. Overall and regional superimpositions depicting surgery outcome: before surgery (solid black), after surgery (dashed grey).Figure 11. Overall and regional superimpositions depicting surgery outcome: before surgery (solid black), after surgery (dashed grey).Figure 11. Overall and regional superimpositions depicting surgery outcome: before surgery (solid black), after surgery (dashed grey).
Figure 11. Overall and regional superimpositions depicting surgery outcome: before surgery (solid black), after surgery (dashed grey).

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 12. Four-year retention evaluation for patient 2 (surgical twin).Figure 12. Four-year retention evaluation for patient 2 (surgical twin).Figure 12. Four-year retention evaluation for patient 2 (surgical twin).
Figure 12. Four-year retention evaluation for patient 2 (surgical twin).

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 13. Surgical case overall and regional superimpositions: pretreatment (solid black), posttreatment (dashed grey), and retention (dashed black).Figure 13. Surgical case overall and regional superimpositions: pretreatment (solid black), posttreatment (dashed grey), and retention (dashed black).Figure 13. Surgical case overall and regional superimpositions: pretreatment (solid black), posttreatment (dashed grey), and retention (dashed black).
Figure 13. Surgical case overall and regional superimpositions: pretreatment (solid black), posttreatment (dashed grey), and retention (dashed black).

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Comparison of Treatment Progress, Results, and Long-term Retention

The cephalometric and clinical comparison of the twin sisters took place at three time points: pretreatment, posttreatment, and long-term retention (Figures 3, 14, and 15; Table 1).

Figure 14. The twins superimposed on each other after treatment.Figure 14. The twins superimposed on each other after treatment.Figure 14. The twins superimposed on each other after treatment.
Figure 14. The twins superimposed on each other after treatment.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Figure 15. The twins superimposed on each other at retention.Figure 15. The twins superimposed on each other at retention.Figure 15. The twins superimposed on each other at retention.
Figure 15. The twins superimposed on each other at retention.

Citation: The Angle Orthodontist 85, 1; 10.2319/011314-46.1

Table 1. Cephalometric Values for Patients 1 and 2
Table 1.

  1. At the initial examination (13 years 3 months). Even though the skeletal A and B points were slightly backwardly positioned in patient 2 compared to patient 1, the underlying skeletal discrepancy associated with mandibular retrognathia and vertically maxillary excess was similar in both. The overjet was slightly more pronounced in patient 2 due to proclined maxillary incisors (Figure 3). Dentally there were minor differences, with patient 1 having her mandibular second premolar missing, while patient 2 had bilateral missing second premolars with a transposed mandibular right canine.

  2. At the posttreatment level (age 16 years, 5 months for patient 1 and 18 years, 8 months for patient 2). The overall skeletal outcome was superior for patient 2. She showed greater skeletal Class II correction with good vertical control, while her twin had dental compensations. However, the esthetic outcome was similar in both patients (Figure 14).

  3. At the retention level (22 years and 9 months). Interestingly, even though the skeletal outcome of patient 2 remained superior, the soft tissue profile was still remarkably similar even though they underwent different procedures for Class II correction (Figure 15).

DISCUSSION

When comparing different treatment options, their efficacy is determined based on achievement of good occlusion, acceptable skeletal, dentofacial esthetics, and long-term stability.14 The risks and cost/benefit ratio of treatment approaches must be understood when a treatment decision is being made for an individual patient. The advantage of using twins for such comparisons is that the difference in outcome can be assumed to be epigenetic and thus directly the result of the intervention provided, ie, surgery or FFA. Because the treatment approaches were so drastically different, different outcomes would be expected in both of the twins, and were observed at the end of treatment.

It may be argued that in the surgical patient the occlusion was not established perfectly on the right side; however, the transposition between the canine and the first premolar along with the missing second premolar made space management complicated, and further surgical advancement of the mandible on the right side to achieve a Class III molar relation might have shifted the skeletal midline to the patient's left side and created facial asymmetry. In addition, it could also be argued that the mandibular anterior teeth were not retracted enough in the surgical case to create a greater overjet to advance the mandible. However, presurgically the occlusion was set to a Class II relation bilaterally, and any further retraction was not possible without consideration of interproximal reduction of lower anterior teeth or extraction of additional teeth. It has been reported that often in surgical cases there is not adequate decompensation of the dentition for greater surgical correction.22,23 Additionally, since the surgical plan entailed maxillary impaction, it was thought that the maxillary impaction would cause an autorotation of the mandible allowing greater mandibular advancement.

Studies comparing surgery to camouflage for Class II correction have indicated that that surgical skeletal correction generally results in better esthetic outcome compared to camouflage,20 while others comparing surgery to growth modification have reported that the soft tissue profile outcome was similar with either method.24 Moreover, Ibitayo et al.10 compared the outcome of growing hyperdivergent Class II patients treated with functional appliances to adults with surgical maxillary impaction and mandibular advancement and found similar dentoskeletal outcomes with either method hypothesizing that residual growth played an important contributing factor in normalization of the malocclusion in the growing functional group. In comparative studies of mandibular advancement surgery to camouflage by extractions or fixed functional appliances,25,26 it has been reported that while the skeletal profile outcome showed greatest improvement with mandibular advancement surgery, no significant differences was observed for soft tissue profile improvement, suggesting that soft-tissue remodeling does not follow changes in skeletal structures in a predictable manner similar to observations made by Park and Burstone.27 Here with the twins, even though the vertical control and skeletal correction was better in the surgical case compared to the nonsurgical twin, the long-term profile outcome were remarkably similar.

The benefits of superior skeletal outcome with orthognathic surgery should be outweighed against the risks/complications and costs associated. The most common short-term complications include pain, swelling, and intraoperative or postoperative bleeding. The most common long-term complication is postoperative neurosensory loss of the inferior alveolar nerve with up to 35% for subjective reporting and 33% for objective testing.28 Other long-term complications such as neurosensory abnormality, nonunion, mal union, postoperative malocclusion, and relapse have also been reported.29 Orthodontic treatment with functional appliances involves frequent short visits to a clinician for a long duration. While the orthodontic armamentarium is relatively inexpensive compared to those used in a surgical setup, the frequent visits over a long time period could possibly increase the overall treatment cost to the patient. Kumar et al.30 compared the cost of orthodontics to orthognathic surgery and reported that the overall cost of orthodontics was relatively inexpensive and accounted for only 25% of overall treatment cost. Venugoplan et al.31 using the nationwide inpatient sample database for the year 2008 analyzed 10,345 orthognathic surgical procedures in the United States and reported that the mean charge per hospitalization was $47,348, and the total hospitalization charge for the entire United States was approximately $466.8 million. However, they did not have a breakdown on the type of surgery related to the cost associated. Nevertheless, it may therefore seem justifiable to question the cost, affordability, need, want, and effects of orthognathic surgery compared to other nonsurgical methods in patients with residual mandibular growth.

CONCLUSIONS

Two identical twins were treated with two different treatment methods for Class II correction. In the long term, even though the skeletal outcome with orthognathic surgery was superior compared to her nonsurgical twin, the soft tissue profiles were remarkably similar. The increased treatment time and cost may call to question the use of such surgical intervention compared to other nonsurgical methods if done prior to the completion of growth.

ACKNOWLEDGMENT

We thank Drs Erin Kazmierski, Jill Danaher, Allen Yaghoubzadeh, and Shyam Desai for their contribution to the treatment of these two patients.

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Copyright: The EH Angle Education and Research Foundation, Inc.
Figure 1.
Figure 1.

Patient 1 (nonsurgical) pretreatment records.

Figure 2.
Figure 2.

Patient 2 (surgical) pretreatment records.

Figure 3.
Figure 3.

The twins superimposed on each other at pretreatment. Their skeletal profiles were almost identical.

Figure 4.
Figure 4.

Prefunctional appliance photographs for patient 1.

Figure 5.
Figure 5.

Patient 1 posttreatment records.

Figure 6.
Figure 6.

Presurgical photographs for patient 2.

Figure 7.
Figure 7.

Patient 2 posttreatment records.

Figure 8.
Figure 8.

Overall and regional superimpositions depicting fixed functional appliance (FFA) outcome: before FFA (solid black), after FFA (dashed grey).

Figure 9.
Figure 9.

Five years retention evaluation for patient 1 (nonsurgical twin).

Figure 10.
Figure 10.

Nonsurgical case overall and regional superimpositions: pretreatment (solid black), post treatment (dashed grey), and retention (dashed black).

Figure 11.
Figure 11.

Overall and regional superimpositions depicting surgery outcome: before surgery (solid black), after surgery (dashed grey).

Figure 12.
Figure 12.

Four-year retention evaluation for patient 2 (surgical twin).

Figure 13.
Figure 13.

Surgical case overall and regional superimpositions: pretreatment (solid black), posttreatment (dashed grey), and retention (dashed black).

Figure 14.
Figure 14.

The twins superimposed on each other after treatment.

Figure 15.
Figure 15.

The twins superimposed on each other at retention.

Contributor Notes

Corresponding author: Dr Aditya Chhibber, Division of Orthodontics, Section of Growth & Development, Columbia University College of Dental Medicine, 630 West 168th Street, P&S Box 20, VC9-218, New York, NY 10032 (e-mail: adityachhibber14@gmail.com) (e-mail: ac3674@columbia.edu)
Received: 01 Jan 2014
Accepted: 01 Mar 2014
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