Case Reports Annals and Essences of Dentistry Vol. VII Issue 2 Apr– Jun 2015 37e 10.5368/aedj.2015.7.2.2.3 SURGICAL ORTHODONTIC TREATMENT OF SEVERE SKELETAL CLASS II WITH VERTICAL MAXILLARY EXCESS 1 Vivek Reddy Ganugapanta 1 Senior lecturer 2 Venkata Naidu Bavikati 2 Post graduate 3 Imran khan 3 Post graduate 4 Gowri sankar Singaraju 4 Professor 1-4 Department of Orthodontics, Narayana Dental College, Nellore, Andhra Pradesh, India. ABSTRACT: This paper describes an adult male patient who presented with a severe skeletal class II deformity with severe gummy smile. The case was managed with a combination of presurgical orthodontic treatment followed by a double jaw orthognathic surgery and then another phase of orthodontic treatment for final occlusal detailing. Extraction of the upper fives and lower first premolars was done during the presurgical orthodontic phase of treatment to decompensate upper and lower incisors and to give room for surgical setback of the maxillary anterior segment. Double jaw surgery was performed: bilateral sagittal split ramus osteotomy (BSSO) for 6mm mandibular advancement combined with Le Fort I maxillary osteotomy with 8mm impaction of the maxilla. Although the anteroposterior discrepancy and the facial convexity were so severe, highly acceptable results were obtained, both esthetically as well as occlusally. KEYWORDS: Orthognathic surgery , INTRODUCTION Orthognathic surgery is considered for the treatment of dentofacialskeletal deformities for more than 100 years. Interestingly, the first jaw deformity correction was performed without anesthesia in the United States by Simon Hullihen, anAmerican general surgeon, in the mid of the 19 th century. Dentofacialskeletal deformities always cause severe functional and esthetic problems to the patient. In adult severe cases, the combined approach, orthodontic and orthognathicsurgery, is always the treatment of choice, and the results obtained usually ensure a better esthetic, functional, andstable results. Class II skeletal deformity is characterized by an exaggeratedsagittal distance between the maxilla and the mandible, which could be the result of maxillary prognathism, mandibular retrognathism, or both. Presurgical orthodontic decompensation is essential toenable the surgeon tomake a considerable amount of surgical correction, otherwise the esthetic and functional outcome of the entire procedure will not be that ideal 1,2,3. Case Report A 20-year-old male was referred to the orthodontic department for the treatment of “Bothering anterior teeth.” At the first consultation visit, the patient expressed his great concerns about his anterior teeth in addition to his severely retruded chin. The clinical examination of the patient revealed a severe skeletal class II pattern with a severe mandibular retrognathism. The frontal facial view showed a dolichofacial pattern, an excessive lower face height, and an interlabial gap of 18 mm. the lips were incompetent at rest with the lower lip resting behind the upper incisors. At rest, there is a 10mm incisal show in addition to 4mm of the gum. The lips are incompetent at rest with a short upper lip, while the lower lip is resting behind the upper incisors. Upon smiling, there was a severe gingival show around 8 mm. The lateral view of the face revealed an average nose, a normal nasolabial angle, a convex profile,severe mandibular retrognathism, a severely deficient chin. Intraoral photographs reveal an end on molar and canine relation on both sides. The upper arch is V shaped, while the lower arch is U shaped.There is an excessive overjet, almost 12mm. Radiographically, the panoramic view revealed a normal bony trabeculation, the full number of permanent teeth. Cephalometric analysis revealed that the patient had a severe skeletal class II, and the ANB angle was 6∘which is more resorted to the lower jaw. Upper incisor position was proclined and protruded, while the lower incisors were more severely proclined and protruded. Vertically, the patient had an increased lower face height. The chin was markedly deficient. After a complete diagnosis of the case, the patient was informed the detailed treatment plan, and it was explained to the patient that the presurgical orthodontic preparation “decompensation” of the dentition will worsen the deformity and that the malocclusion, facial profile, and speech will be temporarily worsened. The patient was further informed that this presurgical treatment only improves the bony support for the teeth, and all the facial and profile changes will result after the upcoming surgical procedures.