Management of a severe skeletal Class II hyperdivergent patient with asymmetric missing teeth with lingual appliances and mandibular osteotomy: A case report

Abstract

Rationale: Orthognathic surgery cases are inherently challenging to treat with lingual appliances due to the complexities of orthodontic management and difficulties in achieving intermaxillary fixation during surgery. This challenge is further amplified in cases involving asymmetric space closure, such as those with a missing molar on one side and a premolar on the other, a scenario not yet documented in the literature. This case report presents the orthodontic–orthognathic management of an adult patient requiring space closure of asymmetric missing lower teeth. Patient concerns: A 30-year-old female patient presented with a severe skeletal Class II patient with a retruded mandible, hyperdivergent facial pattern, excessive overjet and overbite, and asymmetric missing lower teeth. Diagnosis: The patient was diagnosed with a Class II malocclusion and asymmetric missing mandibular posterior teeth on a skeletal hyperdivergent Class II relationship. Interventions and outcomes: The treatment involved orthodontic decompensation with fixed lingual appliances in combination with mandibular advancement osteotomy and genioplasty. Mini-screws were utilized for anchorage control during asymmetric space closure in the presurgical stage and entire lower arch distalization in the postsurgical stage. A significant facial esthetic and functional improvement was achieved posttreatment. Lessons: The combination of mini-screws and lingual appliances may offer effective anchorage management in both presurgical and postsurgical orthodontic stages for optimal orthodontic–orthognathic treatment outcomes. This approach allows for precise tooth movement and control during space closure in the presence of challenging asymmetric missing tooth patterns.