Orthodontic-orthognathic treatment is a combined approach to correct Class III malocclusion with laterognathia, addressing both dental and skeletal discrepancies. 1, 2, 3, 4, 5 This typically involves a combination of orthodontic treatment (braces or aligners) to align the teeth, followed by orthognathic surgery to reposition the jaws and correct facial asymmetry, ultimately improving both function and aesthetics. Characterized by a misaligned bite where the lower jaw (mandible) is positioned too far forward or the upper jaw (maxilla) is too far back, or both. A type of facial asymmetry where one side of the lower jaw is more prominent or shifted to one side, leading to a crooked or off-center jawline. Class III malocclusion with laterognathia presents a more complex challenge, requiring a coordinated approach to address both the sagittal (forward/backward) and transverse (side-to-side) discrepancies in jaw position. 5, 1, 2, 3, 4

Patients seeking orthodontic treatment have a wide range of functional and esthetic needs and can be divided into three groups:

Group 1: Those with normal skeletal relationship and malocclusions that can be treated using routine orthodontic techniques.

Group 2: Those with mild to moderate skeletal discrepancies. The malocclusions of many of the patients in this group can be corrected by dental compensation and growth management.

Group 3: Those with moderate to severe skeletal discrepancy and noticeable facial imbalance. The negative effects of compromised orthodontic treatment for patients in the third group would be unacceptable, making combined surgery and orthodontics the treatment of choice.

Skeletal Class III malocclusion are complex skeletal relationships that have abnormalities and are difficult to correct. The incidence of this malocclusion in the Caucasoid race is around 5 percent. Etiology is generally influenced by genetic factors. Treatment made to improve function and aesthetics. This requires a combination of orthodontic treatment and orthognathic surgery. 3, 4, 5

The oldest theory of beauty can be found in the work of the Greeks of the pre-Socratic period. Pythagoras found a strong connection between mathematics and beauty, noticed that the objects that had a perfect proportion were more appealing. Ancient Greek architecture is based on this definition of symmetry and proportion. 3, 4, 5

Skeletal class III malocclusion is characterized by upper incisor proclination and retroclination of the lower incisors to compensate for the sagittal skeletal discrepancy. 3 The etiology of skeletal class III is multifactorial involving hereditary factors (race), environmental influences (normal position of the jaw or mouth breathing which stimulates mandibular growth) and pathologies (pituitary tumors such as acromegaly). 1, 2, 3, 4, 5

Dysgnathia is the medical term for jaw misalignment, which is often accompanied by dental misalignment. It can not only affect appearance but also cause health issues such as snoring, sleep apnea, and impaired chewing function. 5.

The treatment typically involves the repositioning of the upper and/or lower jaw, following an orthodontic pre-treatment. A personalized treatment plan is created for each patient, taking both functional and aesthetic aspects into account. 6.

The surgery is performed under general anesthesia and lasts between three and six hours, depending on the complexity. An inpatient stay of about three days is required to monitor the healing process. . 7.

After dysgnathia surgery, you can expect a harmonious facial profile and an optimally functional jaw alignment. The treatment is tailored to your individual needs to achieve both functional and aesthetic improvements. . 1.

Whether a dysgnathia treatment is the right choice for you depends on your individual needs and preferences. Schedule a consultation at Sailer Clinic to clarify any open questions and develop a personalized treatment plan. 1, 2, 3, 4, 5, 6

Laterognathia ,this term describes a lateral bite in the lower jaw and is often associated with an unilateral crossbite in the posterior teeth and asymmetry in the whole of the lower face. Treatment of laterognathia is either possible with orthodontic tooth movement or a surgical relocation of the lower jaw. 1, 2, 3, 4, 5, 6

In orthodontics, three main categories of problems or dysgnathias can be distinguished, which may develop in all three spatial dimensions. These dysgnathias can occur either individually or in combination (Figure 1):

The impact of the three types of dysgnathias on facial appearance and the aesthetic axis varies. Skeletal dysgnathias (affecting the hard tissues) have the most pronounced effect, particularly due to the malposition of the maxilla, mandible, or both jaws. This misalignment leads to significant disturbances in facial harmony and causes deviations in the aesthetic axis (Figure 2, Figure 3). 1, 2, 3, 4, 5, 6

Figure 1 depicts the classification of malocclusions based on their etiological origin, distinguishing between dysgnathias caused by neuromuscular dysfunction, skeletal discrepancies, and dentoalveolar compensations.

Figure 2 illustrates how skeletal discrepancies associated with Class III malocclusion—such as mandibular prognathism or maxillary (midfacial) hypoplasia—alter the alignment and balance of the facial aesthetic axis.

Figure 3 illustrates how skeletal Class II malocclusion, characterized by mandibular retrognathia, affects the alignment and harmony of the facial aesthetic axis, often resulting in an imbalanced profile.

It is generally well known that, in cases of dentoalveolar treatment, the therapeutic goals—defined as the individual functional and aesthetic optimum for the patient— can often be achieved with today’s modern treatment methods and appropriate appliances 1.

While minor dysgnathias can be compensated for through purely dentoalveolar measures, in cases of pronounced skeletal discrepancies—such as Class II and Class III dysgnathias, skeletal open bite, or laterognathia—the question arises as to which treatment approaches can lead to successful outcomes. If the jaw relationship is correct and the dysgnathia is purely dentoalveolar, it can be corrected through dental treatment involving appropriate tooth movements. 10

However, due to anatomical limitations, dental movements are only possible to a certain extent. Thus, correction or stable dental compensation of a skeletal dysgnathia—such as the elimination of an anterior crossbite in Class III cases, correction of a severely increased overjet in Class II, or closure of a skeletal open bite—is questionable in certain situations. In most cases, such approaches represent compromise treatments with regard to both aesthetics and function, and their long- term stability is also uncertain. 11, 12

To determine which treatment options are suitable for managing skeletal dysgnathias, it is essential to assess the patient's remaining growth potential 13. One therapeutic approach considered causal in growing patients is functional orthopedic treatment—such as stimulating mandibular growth and inhibiting maxillary growth in Class II dysgnathia or promoting maxillary growth and restraining mandibular growth using a facemask in Class III dysgnathia. Both treatment methods aim to influence growth patterns. 12, 14, 15, 16

If growth is no longer therapeutically available, orthognathic surgery remains the only causal treatment option to correct the positional discrepancies between the jaws in all three spatial dimensions 1, 2, 3, 4, 5, 6.

The relationship between the facial width and vertical height has a strong influence on facial harmony. Facial form and harmony should also be correlated with the patient’s overall body build. When correcting facial form, the overall body build of the individual (corporofacial relationship) should be considered (i.e., short and stocky versus long and thin). The height-to-width proportion is 1.3:1 for females and 1.35:1 for males. The bigonial width should be approximately 30% less than the bizygomatic dimension . Short, square facial types are often associated with a Class II deep bite malocclusion, vertical maxillary deficiency, masseteric hyperplasia, and macrogenia whereas long, narrow facial types are often associated with vertical maxillary excess, a narrow nose, mandibular anteroposterior deficiency, microgenia, a high palatal vault, and an anterior open bite malocclusion. 17, 18, 19, 20, 21

A prerequisite for successfully performing combined orthodontic-surgical therapy is that less invasive treatment approaches (such as the aforementioned growth modification) are no longer applicable, do not lead to the intended treatment objectives, or may even worsen the condition—for example, tooth extractions in patients with a flat facial profile, or distalization in cases with limited overjet.

This article discusses the causal treatment of a skeletal dysgnathia—specifically, a Class III case with laterognathia—through a combined orthodontic and orthognathic surgical approach. 17, 18, 19, 20, 21

In the context of interdisciplinary dysgnathia surgery aimed at improving the facial profile, it is important to emphasize that functionally and orthodontically motivated interventions are always accompanied by improvements in facial aesthetics. This reflects the principle: “Form goes with function” or, more precisely, the “correlation between form and function.”

Profile-enhancing interventions include repositioning procedures of the maxilla and mandible (orthognathic surgery) and, in a broader sense, repositioning procedures of the orbital and (frontal) cranial regions (craniofacial surgery). Due to its narrow operative indications and the higher surgical risk involved, craniofacial surgery has no place in aesthetic-oriented procedures and will not be further discussed here.

It must therefore be emphasized that the profile line connecting the nose, maxilla, mandible, and chin is of particular significance for overall facial aesthetics. We refer to this as the “aesthetic axis” (Figure 2, Figure 3) 17, 18, 19, 20, 21, 22, 23.

The beauty of the human face depends largely on the balance of the three prominent profile features—mouth, chin, and nose—collectively forming what we describe as the facial aesthetic triad. Within this framework, the prominence or convexity of the mouth plays a key role in conveying youthfulness and facial attractiveness.9 Orthodontic treatments—whether skeletal, functional, or dentoalveolar—can influence this axis by improving or harmonizing it (Figure 4 a–d, Figure 5 a–d, Figure 6 a–d, Figure 7 a–d, Figure 8 a–d).

Orthognathic surgery often has profound effects on the external appearance of the face. In adults, where morphological structures are typically well established, the facial appearance constitutes an integral component of personal identity and thus plays a significant role in self-image.7, 8, 9, 10, 24, 25 Furthermore, individuals are socially perceived and recognized primarily through their face, which significantly influences the quality of social interactions. Consequently, such invasive procedures require careful indication and psychological evaluation.

The patient’s perception of the treatment outcome—regarding both dental and general facial aesthetics, the subjective cost-benefit ratio (in terms of pain and effort), and the “social success” of the treatment—must therefore be regarded as evaluation criteria of paramount importance. For this reason, beyond functional outcomes (e.g., temporomandibular joint health, masticatory function), consideration of the psycho- aesthetic dimension—i.e., skeletal and soft tissue changes along with the patient’s self-perception—constitutes an essential factor in the indication process. 2, 26

It is important to emphasize that in the context of interdisciplinary planning of dysgnathia surgery aimed at profile enhancement, functionally oriented orthodontic procedures always go hand in hand with improvements in facial aesthetics. This reflects the principle: “Form goes with function.” 17, 18, 19, 20, 21, 22, 23

Profile-enhancing procedures become necessary when a purely orthodontic correction is no longer feasible due to individual anatomical limitations. In such cases, a paradigm shift must occur in orthodontic treatment planning compared to orthodontics alone. This includes, first and foremost, preoperative decompensation of skeletal-related dental malpositions in order to align each dental arch independently, without regard to the opposing arch. The harmonization of both arches is then achieved surgically. 17, 18, 19, 20, 21, 22, 23, 27

Although combined orthodontic-orthognathic procedures are often elective in nature, they are subject to strict indication criteria—despite the high level of treatment standardization and low risk profile. 14, 15, 16, 17, 18, 19

It is the responsibility of the maxillofacial surgeon and the orthodontist to assess whether contraindications are present that would preclude surgical intervention.

The main contraindications include 21, 22, 23, 27, 28, 13, 29, 30, 31, 24, 32:

These factors must be carefully evaluated to ensure the safety and appropriateness of combined orthodontic-orthognathic treatment .

Class III malocclusion, which was first described by Angle 3 1, is considered a clinical challenge for orthodontists even today 2, as anterior open bite 3, 4, 5, 6. The treatment of Class III malocclusion with concomitant anterior open bite by orthodontics alone may not achieve satisfactory functional and aesthetic results if the underlying causes of the deformity are not addressed 7, 8.

Thus, the orthodontic-surgical approach is indicated for such cases 9. In the present case report, the patient presented with an increased vertical dimension, skeletal Class III malocclusion and skeletal anterior open bite, suggesting the need for orthodontic-surgical intervention to achieve satisfactory functional and aesthetic results.

Regarding the surgical technique, rotation of the occlusal plane in the clockwise direction can generate a more stable result for the correction of the anterior open bite compared to the upward repositioning of the maxilla as a whole together with mandibular rotation in the counterclockwise direction 10, 11. In the present clinical case, clockwise rotation on the palatal plane was performed, favouring the stability of the correction of the anterior open bite. Moreover, conventional presurgical orthodontic preparation was chosen in this case due to the need for leveling the curve of Spee and creating space for the positioning of teeth 35 and 45, which could generate important premature contacts if surgery has been performed first. Obviously, such a decision was made jointly between the orthodontist and oral-maxillofacial surgeon.

The intraoral images demonstrate the post-treatment outcome (Figure 15 a–e). Bilateral neutral occlusal relationships were achieved, along with well-aligned and coordinated dental arches 17, 18, 19, 20, 21, 22, 23. The extraoral photographs reveal a balanced vertical facial proportion, attained through surgical shortening of the lower face, and a harmonious sagittal profile. The gummy smile on the left side and the occlusal cant were successfully corrected by the asymmetrical maxillary impaction on the right and left sides. The oral profile appears balanced with passive lip closure (Figure 16 a, b). From a functional standpoint, mandibular mobility remained unrestricted 17, 18, 19, 20, 21, 22, 23, 27, 28, 13, 29, 30, 31.

The panoramic radiograph at the end of treatment shows no pathological findings (Figure 17). The lateral cephalometric radiograph demonstrates the changes in skeletal parameters (Figure 18, Table 1). Due to the surgical impaction and posterior rotation of the maxilla, the inclination of the maxillary base increased by 3°. This posterior rotation led to a steeper angulation of the maxillary anterior segment—referred to as “surgically induced retrusion.” For this reason, the orthodontic preparation included controlled protrusion and torque of the maxillary incisors.

The combined effects of maxillary impaction and mandibular autorotation resulted in a reduction of the anterior facial height, thereby improving the vertical facial proportions and achieving greater harmony (Figure 19 a, b).

An evaluation of the vertical segmentation of the skeletal and soft tissue profiles shows improved proportional balance. Specifically, the relationship between the bony upper and lower facial thirds has become more harmonious.

Within the presented treatment protocol, a second application of an occlusal splint was implemented 3–4 weeks prior to final treatment planning and surgical scheduling in order to accurately determine the centric condylar position. Positioning the temporomandibular joints in an incorrect condylar position would have resulted in erroneous planning of the surgical displacement vectors in both jaws.

In agreement with the findings of Radney & Jacobs concerning the cranial displacement of the pronasale, as well as with the follow-up studies of Epker 5 and Rosen regarding the elevation of the nasal tip following maxillary impaction, both effects were observed in the presented patient. These results have been independently confirmed by other authors 16, particularly by De Assis et al. and Lee et al.

Figure 19

Cranial repositioning of the maxilla induces mandibular autorotation, whereby the mandible shifts ventrally in the sagittal plane and cranially in the vertical dimension. As a result of this impaction and subsequent mandibular autorotation, changes occur in both anterior (AFH) and posterior (PFH) facial height, leading to an increased PFH/AFH ratio 8, 28. A new skeletal jaw relationship is thereby established in both sagittal and vertical planes. The extent of this autorotation is proportional to the magnitude of the maxillary impaction (Figure 19 a), with the rotational center of the impaction playing a critical role. Depending on the center of rotation, maxillary impaction also influences the axial inclination of the anterior teeth (Figure 19 b).

The significance and extent of these movements must be assessed and integrated into the cephalometric surgical planning to ensure accurate prediction and execution of the desired outcome 17, 18, 19, 20, 21, 22, 23.

The extent of maxillary impaction is determined not only based on functional considerations, but also from an aesthetic perspective. Several key aspects are evaluated in this context:

These parameters play a critical role in defining the vertical position of the maxilla and contribute significantly to achieving both functional rehabilitation and facial harmony. 17, 18, 19, 20, 21, 22, 23, 27, 28, 13, 29

It is of great importance to the analysis of soft tissues and the correct clinical examination of the patient, to determine the precise diagnosis and type of facial deformity. Also the cephalometric will be only used as a method of diagnostic support and not as standard surgical. Another important point is to achieve an optimal occlusion and finally mention that the harmony between clinic-facial aesthetics are specific to each patient and they depend on the surgical correction 18, 19, 20, 21, 22, 23.

It is very important to make a correct assessment and an appropriate interdisciplinary diagnosis to be able to implement a correct treatment plan for the patient and try to cover all the objectives, besides obtaining correct integral health for the patient.

Retention is necessary after orthodontic treatment as there is a tendency for relapse. Although efforts are made to prevent relapse by wearing retainers, the patient's biological changes may cause relapse. Vacuum-formed retainers were used in these patients to maintain tooth alignment and arch width stability 31, 24, 32, 25, 26.

More clinical studies should be carried out to clarify the prevalence of bone dehiscence in patients after orthognathic surgery.

We believe the future digital medical student will require the following five core skill competencies:

A selection of key digital technologies that are impacting surgical training and education today include surgical robots, next generation minimally invasive surgery, and artificial intelligence 21. Surgical robots and minimally invasive approaches via advanced laparoscopy are changing surgery globally by reducing morbidity and mortality of operations that were once performed with traditional open methods. As a result, surgery is becoming more dependent on technology, and accordingly, the surgeon’s skill set is expanding to accommodate these new techniques. In accordance with this transition, the technical and nontechnical skills of surgeons must be adaptive. Surgeons will have to learn new technical skill approaches such as new robotic platforms and minimally invasive techniques that are incorporated into the surgeons’ workflow, as well as more specialized nontechnical digital communication skills for online and virtual provision of care. 8, 15, 21

This case analysis clearly demonstrates the effectiveness of a combined orthodontic– orthognathic treatment approach for managing complex Class III dysgnathia with laterognathia. Through individualized surgical planning, including maxillary impaction and mandibular segmental rotation both functional and aesthetic objectives were successfully achieved. In particular, the harmonization of the aesthetic axis and the restoration of vertical facial balance significantly contributed to the patient-centered quality of the outcome.

The importance of precise diagnostics, including skeletal scintigraphy and functional centric relation analysis, is emphasized as a critical component of interdisciplinary planning. The presented treatment concept highlights the necessity of a holistic approach that equally prioritizes aesthetics, function, and long-term stability.

Funding: This article received no external funding.Conflicts of interest: The authors declare no conflicts of interest.