We read with interest the case report, “Miniscrew-assisted nonsurgical palatal expansion before orthognathic surgery for a patient with severe mandibular prognathism” (Lee KJ, Park YC, Park JY, Hwang WS. Am J Orthod Dentofacial Orthop 2010;137:830-9). Although the result achieved was excellent, we wonder whether the treatment protocol was more involved than necessary.
The title referred to “severe mandibular prognathism.” The lateral cephalogram and facial photographs illustrate that the description should more accurately include severe maxillary retrusion as well. The authors referred, in the diagnosis, to excessive buccal tipping of the maxillary second molars. In looking closely at the occlusal view of the diagnostic models, we noticed that the second molars were possibly in acceptable positions, and the maxillary first molars were actually tipped palatally.
The treatment alternatives discussed in the article included maxillary segmental osteotomy for bilateral expansion of the maxillary posterior segments. They decided against this because “lateral movements of the maxillary segment have been shown to be considerably unstable.” The literature reference for this statement is an article published in 1992 in the International Journal of Adult Orthodontics and Orthognathic Surgery . Eighteen years ago, that might have been accurate, but, with contemporary orthognathic surgical techniques and rigid internal fixation, that statement is no longer valid. It is now as predictable as any form of skeletal expansion (RPE or SARPE).
The use of MARPE rather than SARPE was an interesting choice. The use of TADS has gained acceptance as a valid means of using skeletal anchorage. The conclusion that the incorporation of miniscrews for transverse correction eliminates the need for multiple surgeries in patients with complex craniofacial discrepancies remains to be seen. We would propose just the opposite. The treatment subjected the patient to the additional procedure of MARPE that also extended the treatment time.
Our treatment plan for this patient would have included (1) ENT evaluation for probable intranasal issues; (2) bracketing all teeth from second molar to second molar, leveling and aligning with archwires, and no expansion of the maxillary arch; (3) orthognathic surgery including 2-piece LeFort I with expansion, vertical adjustment, occlusal plane change, and advancement, BSSO with minimum setback, intranasal surgery to reduce enlarged turbinates, extracting the third molars, and possible genioplasty; (4) final detailing; and (5) retention.
Performing all required procedures at one time eliminates the need for staged orthodontics. Opening the nasal airway during surgery corrects baseline chronic obstructive nasal breathing, when present. The total treatment time for a patient such as this is approximately 12 months (5-6 months for leveling and aligning, 5 weeks for postsurgical healing, and 5 months for postsurgical detailing).
We thank the authors for illustrating their excellent result for this complex case. Applying state-of-the-art orthodontic and orthognathic procedures could have achieved the same result with a shorter, less-invasive treatment time.