Implantation before orthognathic surgery in a case of facial
This 29-year-old female patient wished to restore her left side chewing function and to improve her facial appearance. She had facial asymmetry with the mandible deviated to the right side, maxillary arch left-side-down, and mandibular arch left-side-up occlusal plane canting. Maxillary anterior teeth were tipped towards the right side and mandibular dental midline deviated towards the right side for approximately 4 mm, deep overbite from the right maxillary central incisor to the left maxillary first premolar. There was a minor crowding on both maxillary and mandibular arches, with Class II molar and canine relations. The left mandibular molars were missing with opposing arch teeth elongation that jeopardized spaces for prosthetic reconstruction. A prominent difference in bilateral condylar height was noted from the panoramic radiography, with the right condylar head mild flattening without any symptoms. Treatment objectives were to relieve crowding, create space for implant prosthesis, and correct facial asymmetry with OGS.

Two weeks after full mouth fixed appliance bonding, temporary anchorage devices (TADs) were placed between the left lateral incisor and canine of both arches for the regional intrusion to open the deep overbite. A TAD was also placed on the left mandibular edentulous area, and a single tube was bonded onto the built-up composite resin. It helped to relieve crowding, improve arch form symmetry, and intrude mandibular anterior teeth. Improvement of the canting and deep bite could be seen after four months of treatment. Wires were progressively changed to the rectangular stainless wire, at the eleventh month, two more TADs were placed on the buccal and palatal sides of the left maxillary molars for posterior intrusion, meanwhile, anterior TADs were retrieved. In the eighteenth month, decompensation was almost done, the patient received implantation of the left mandibular first and second molars, and the soft tissue healing was fine after a 3-month follow-up. Provisional crowns were delivered, and loading began 5 months after implantation, patient underwent OGS after 30 months of orthodontic treatment. Maxillary LeFort I left side vertical impaction, mandibular bilateral sagittal split osteotomy with the left-side shift, and genioplasty was performed. Post-surgical occlusion was very stable, fixed appliances were removed 4 months after intermaxillary fixation, and final prosthesis were fabricated. The total treatment period was 36 months. Panoramic radiography showed good root parallelism and stable peri-implant bone height. Comparison of initial and final posterior-anterior cephalometry showed good skeletal symmetry after OGS.