Treatment decision-making for a post-traumatic malocclusion
An 81-year-old male was admitted to the authors’ department outpatient clinic with a history of facial trauma caused by an accidental fall that occurred 10 months before. Immediately after the trauma, the patient was admitted to another hospital emergency department where clinical examination and a CT scan confirmed bilateral condyle fractures. No surgical treatment was provided. Soft diet, non-specific rehabilitation therapy, and management with NSAIDs and a muscle relaxant were prescribed. Six weeks later, during a subsequent examination, a post-traumatic malocclusion was noted. Mandibular exercises and a dental examination were prescribed. The physical examination, conducted 10 months after the trauma, showed dentulous upper and lower arches, post-traumatic malocclusion with an increased overjet, and a slight anterior open bite without restrictions in the mandibular range of motion. The patient reported mild discomfort during mastication but no pain.

Given his characteristics of being elderly and almost fully dentulous, the patient was initially referred to his dentist for occlusal equilibration therapy. However, given its complexity due to the significant loss of mandible height, which would have implied extensive molar grinding, the dentist advised the patient against such treatment. In addition, occlusal equilibration would have not managed the mandibular retrusion and would not have restored the pre-trauma occlusion. Since the patient strongly demanded treatment to address the retruded appearance of his mandible, surgical correction of the malocclusion with orthognathic surgery involving the lower jaw was suggested. An orthopantomogram and a lateral cephalogram of the patient were obtained. Standard model planning was done, and supplemental calcium and vitamin D therapy was prescribed, starting from ten days prior to the surgical intervention.

A bilateral sagittal split osteotomy (BSSO) was performed to advance and rotate the mandible in order to restore the occlusion. Intermaxillary fixation (IMF) was accomplished with both tooth- and bone-borne appliances. Spino-mental fixation was applied with two trans-mucosally inserted self-drilling screws. Two S-shaped wire hooks were attached to the central IMF screws, and two IMF screws were applied on the left side. On the right side, fixation was achieved with an IMF screw in the mandibular bone and with a wire ligature on a maxillary premolar. A single 2.3 plate was applied to each mandibular side for internal fixation. Spino-mental hooks were left in place after the surgery for potential elastic fixation, in order to provide occlusal guidance and to lighten the condylar load consequent to mandibular advancement and rotation, thus avoiding condylar resorption. Besides persistent cervical bruising, there were no major postoperative complications and the patient was discharged from the hospital three days after the surgery. A non-steroidal anti-inflammatory drug was prescribed, along with continuing the supplemental calcium and vitamin D therapy for 2 months. Follow-up visits were scheduled up to 1 year after the intervention. The spino-mental screws were removed after two weeks. No further dental or prosthetic treatments were needed, and the occlusion remained stable over time.