Vertical Stability of Different Orthognathic
Vertical Stability of Different Orthognathic
Vertical Stability of Different Orthognathic
doi:10.1093/ejo/cjab011
Systematic Review
Systematic Review
Correspondence to: Fulan Wei, Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of Medi-
cine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory
for Dental Materials and Oral Tissue Regeneration, No. 44-1 Wenhua Road West, Jinan, Shandong 250012, China. E-mail:
[email protected]
Mengqiao Wang and Bowen Zhang contributed equally to this work and are cofirst authors.
#
Summary
Background: Several orthognathic procedures have been applied to correct skeletal anterior open
bites (SAOB). Which method is most stable has been debated and no consensus has been reached
and there is no conclusive evidence for clinicians to use.
Objective: To analyse whether maxillary, mandibular, or bimaxillary surgery provides a better stability.
Materials and methods: A systematic search was conducted up to December 2020 using PubMed, EMBASE,
Medline, Scopus, Web of Science, Cochrane CENTRAL, and Google Scholar. We made direct comparisons
among the controlled trials and also made indirect comparisons via subgroup analysis on the aspects of
occlusional, skeletal, and dento-alveolar stability to assess the overall stability of each method.
Results: Finally 16 cohort studies were identified. At the occlusional level, pooled change in overbite
was 0.21 mm in maxillary surgery, 0.37 mm in bimaxillary surgery, and −0.32 mm in mandibular
surgery. At the skeletal level, pooled sella–nasion–Point A angle (SNA) was −0.12 degrees in
bimaxillary surgery, −0.37 degrees in maxillary surgery and −0.20 degrees in mandibular surgery.
The sella–nasion to palatal plane angle (SNPP) relapsed to a statistically significant degree in all
samples received single maxillary surgery. Relapse of the sella–nasion–Point B angle (SNB) was
0.47 degrees in mandibular setback, −1.8 degrees in mandibular advancement, and −0.48 degrees
in maxillary surgery. The Sella–Nasion to mandibular plane angle (SNMP) relapsed more in
procedures involving bilateral sagittal split osteotomy than in other procedures. As for dento-
alveolar changes, intrusion of molars and extrusion of incisors took place in most patients.
Conclusions: Bimaxillary surgery produced the most beneficial post-operative increase in overbite,
maxillary surgery led to a lesser but still positive overbite change, and mandibular surgery correlated
with some extent of relapse. Skeletally, bimaxillary surgery was more stable than maxillary surgery
at both SNA and SNPP; SNB was more stable in mandibular setback than advancement; and
SNMP was unstable in both mandibular and bimaxillary surgeries versus maxillary surgery with
comparable surgical changes. Dento-alveolar compensation helped maintain a positive overbite.
Registration number: CRD42020198088.
© The Author(s) 2021. Published by Oxford University Press on behalf of the European Orthodontic Society.
1
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2 European Journal of Orthodontics, 2021
Table 1. Eligibility criteria for study selection. SNMP: the angle between sella–nasion and mandibular plane; U1PP: the distance from the
edge of upper incisor perpendicularly to palatal plane; U6PP: the distance from the mesial cusp tip of upper first molar perpendicularly to
the palatal plane; L1MP: the distance from the edge of lower incisor to mandibular plane; L6MP: the distance from the mesial cusp tip of
lower first molar perpendicularly to the mandibular line.
Study design Randomized controlled trials, controlled clinical trials, co- Case reports with ≤5 subjects, systematic reviews, opinion,
horts or philosophy articles without new data
Participants Patients after the stage of rapid growth with skeletal anterior Patients with systematic disease or craniofacial pathologies
open bite and in good general health requiring or anomalies potentially influencing stability or
surgical-orthodontic correction complicating treatment (periodontal disease, root
resorption, oral neoplasm, cleft lip or palate, trauma, and
of effect; and then classified it into four levels: high, moderate, low, Asia (China (25, 26), South Korea (12, 15)); 255 were from Europe
and very low. (Sweden (4), Finland (14), UK (33), Norway (18, 30), Italy (29),
Belgium (32)); and 71 were from the USA (21, 27, 28).
Summary measures and additional analysis The sample sizes of the studies ranged from 6 (13) to 72 (25)
of results participants, with mean age of included patients ranging from 19
(33) to 30.8 (16) years. Of all participants, 63.7 per cent were fe-
We conducted meta-analysis using Stata software version 15.1
male and 36.3 per cent were male. Initial mean open bite ranged
(StataCorp., College Station, Texas, USA). The pooled post-operative
from 1.9 (30) to 6.78 mm (12). Eight studies reported the type of
change (PC) was weighted by sample size. Forest plots and quantita-
antero-posterior relationship. Overall, 6.0 per cent of patients had
tive τ2, χ2, and I2 indices were used to indicate statistical heterogen-
eity. We applied the fixed-effects model if I2 <25 per cent; otherwise,
we applied the random-effects model. P < 0.05 was regarded to in-
dicate a statistically significant difference. When homogeneity was Records idenfied through
Identification
database searching
insufficient in the original data (I2 > 50 per cent), sensitivity analysis (n=1490)
was applied, and subgroup analyses of different orthognathic pro-
cedures (separated maxillary surgery, separated mandibular surgery,
and bimaxillary surgery) were performed to explain heterogeneity Records aer duplicates removed
(n=837)
and compare stability levels among these different procedures.
abstract (n=804)
Results Records screened
(n = 837)
6 months (n=3)
text reading and assessment of eligibility. All publications found by No outcome data about
manual search were also among in the electronic search results. stability (n=1)
Studies included in
quantave synthesis
Study characteristics (meta-analysis)
(n=12)
All 16 studies were retrospective cohort studies. Data extraction re-
vealed that they included a total of 506 patients who underwent
orthognathic correction of SAOB. Of all patients, 180 were from Figure 1. PRISMA diagram of the study identification process.
4 European Journal of Orthodontics, 2021
Class I malocclusion, 31.5 per cent had Class II malocclusion, and overbite changes in maxillary surgery (n = 114; PC = 0.21 degrees;
62.5 per cent had Class III malocclusion. 95 per cent CI, 0.06–0.37; I2 = 95.0 per cent, P = 0) (4, 14, 18,
In terms of surgical procedures, 29.7 per cent of cases received 28–30), and the relapse rate for mandibular surgery had no hetero-
bimaxillary treatment (12–14, 25, 26, 29, 32), all of which consisted geneity (n = 79; PC = −0.32 degrees; 95 per cent CI, −0.61 to −0.02;
of Le Fort I in combination with bilateral sagittal split osteotomy I2 = 0, P = 0.752) (13, 15, 21, 30, 31). One record was excluded by
(BSSO); 32.8 per cent of cases received a single mandibular oste- sensitivity analysis due to its high level of heterogeneity (27).
otomy (15, 21, 25, 27, 30, 31) performed via BSSO or modifications
thereof; and 36.3 per cent of subjects received a single maxillary Secondary outcomes
surgery (4, 13, 14, 18, 26, 28–30, 32) using Le Fort I osteotomy. For Figure 4 illustrates greater and lesser rates of relapse for each skel-
six cases in one study, specific surgical procedures were not reported etal measurement in all studies. Synthesized SNA had lower relapse
(1). Follow-up periods ranged from 8.3 (15) to 98 months (1); only in bimaxillary surgery (n = 61; PC = −0.12 degrees; 95 per cent CI,
Synthesis of results
Primary outcome Discussion
Figure 3 presents the pooled overbite relapse rates of different sur- This study explored the post-operative stability of SAOB across
geries. The most beneficial overbite increases were in bimaxillary sur- three aspects: occlusional, skeletal, and dento-alveolar stability. The
gery (n = 69; PC = 0.37 degrees; 95 per cent CI, 0.18–0.57; I2 = 98.5 most beneficial overbite increase was found in bimaxillary surgery,
per cent, P = 0) (12–14, 29). There were fewer but still positive there was less but still positive overbite change in maxillary surgery,
Table 2. Data on occlusional, skeletal, and dento-alveolar stability from the included studies. Le Fort I: Le Fort I Osteotomy; BSSO: bilateral sagittal split osteotomy; SNMP: the angle between
sella–nasion to mandibular plane; L1-Me: Distance between the edge of lower incisor and menton point; FNO: Frequency of people with No vertical Overlap; FsOBd: Frequency of people with
significant postsurgical overbite decrease (≥ 2mm); FsOBi: Frequency of people with significant postsurgical overbite increase (≥ 2mm); FsSNMPi: Frequency of people with significant post-
surgical SNMP increase (≥ 2mm); FsSNMPd: Frequency of people with significant post-surgical SNMP decrease (≥ 2mm); T1:Measurement before follow-up; T2: Value at the end of follow-up;
NR: None related Report; NR: None significance (P ≥ 0.05).
M. Wang et al.
T1 T2 Difference Significance
Author (year)/surgery Follow-up (months) Variables Measurements M ± (SD) M ± (SD) M ± (SD) P-value
Bisase et al. (31)/BSSO 12 Occlusional OB (mm) 1.42 (0.51) 1.0 (0.6) −0.42 (0.51) 0.045
Espeland et al. (18)/Le Fort I 36 Occlusional OB (mm) NR NR 0.1 (0.4) NS
Fontes et al. (21)/BSSO 54 Occlusional OB (mm) 0.6 (1.0) 1.0 (1.0) NR NR
FNO (%) 25.8 9.7 NR NR
Skeletal SNA (°) 80.3 79.9 NR NR
SNB (°) 78.1 77 NR NR
Dento-alveolar U1PP (mm) 32.6 32.8 NR NR
U6PP (mm) 26.1 25.8 NR NR
L1MP (mm) 44 43.8 NR NR
L6MP (mm) 32.5 32.2 NR NR
Hull et al. (28)/Le Fort I 25 Occlusional OB (mm) 1.7 (0.6) 1.5 (0.8) −0.1 (1.1) NR
Skeletal SNA (°) 81.9 (6.4) 81.2 (6.3) −0.7 (1.1) NR
SNB (°) 78.1 (5.0) 77.4 (5.0) −0.7 (1.3) NR
SNMP (°) 35.6 (6.2) 36.4 (6.6) 0.8 (2.1) NR
Dento-alveolar U1PP (mm) 29.5 (3.2) 29.7 (2.6) 0.2 (1.0) NR
L1MP (mm) 30.1 (2.0) 30.4 (2.0) 0.3 (0.9) NR
L6MP (mm) 37.0 (2.9) 37.6 (2.9) 0.6 (0.6) NR
Iannetti et al. (29) (Bi)/Le Fort I+BSSO 24 Occlusional OB (mm) NR NR 0.875 (0.141) NR
Skeletal SNA (°) NR NR 0.055 (0.051) NR
SNB (°) NR NR −0.54 (0.305) NR
Iannetti et al. (29) (Max)/Le Fort I 24 Occlusional OB (mm) NR NR 0.4 (0.152) NR
Skeletal SNA (°) NR NR 0.1 (0.117) NR
SNB (°) NR NR 0.025 (0.072) NR
Ismail et al. (26) (Bi)/Le Fort I+BSSO 24 Occlusional FNO (%) 20.8 12.5 −8.3 NR
Ismail et al. (26) (Max)/Le Fort I 24 Occlusional FNO (%) 11.1 11.1 0 NR
Kwon et al. (15)/BSSO 8.3 Occlusional OB (mm) NR NR −0.2 (1.6) 0.519
Skeletal SNA (°) NR NR −0.2 (1.2) 0.461
SNB (°) NR NR 0.2 (1.3) 0.533
SNMP (°) NR NR 3.6 (2.9) <0.001
Kor et al. (12) (Bi1)/Le Fort I+BSSO 12 Occlusional OB (mm) NR NR 0.75 (0.70) NR
Skeletal SNA (°) NR NR −0.11 (0.75) NR
SNB (°) NR NR 0.45 (0.66) NR
Kor et al. (12) (Bi2)/Le Fort I+ BSSO 12 Occlusional OB (mm) NR NR 0.06 (0.93) NR
Skeletal SNA (°) NR NR −0.14 (1.07) NR
SNB (°) NR NR 0.79 (1.05) NR
Liu et al. (25) (Bi)/Le Fort I+BSSO 24 Occlusional FsOBd (%) 10 NR
FsOBi (%) 8 NR
Skeletal FsSNMPi (%) 19 NR
FsSNMPd (%) 6 NR
5
T1 T2 Difference Significance
Author (year)/surgery Follow-up (months) Variables Measurements M ± (SD) M ± (SD) M ± (SD) P-value
Significance
P-value
0.046
0.022
0.206
0.293
0.088
0.864
0.197
0.159
0.359
0.111
0.709
0.175
0.276
−0.47 (1.41)
−2.14 (3.31)
−1.02 (1.33)
−0.77 (1.42)
−0.61 (1.54)
−0.24 (0.86)
0.84 (2.17)
0.40 (1.24)
0.12 (2.38)
0.44 (1.01)
0.38 (0.75)
0.18 (1.66)
0.59 (1.40)
Difference
M ± (SD)
overbite or less relapse; L1–Me: distance between edge of lower incisor and
M ± (SD)
0.05).
Measurements
L1MP (mm)
L6MP (mm)
L1MP (mm)
L6MP (mm)
U1PP (mm)
U6PP (mm)
U1PP (mm)
U6PP (mm)
SNMP (°)
OB (mm)
SNPP (°)
SNA (°)
SNB (°)
Dento-alveolar
Dento-alveolar
Occlusional
Variables
Skeletal
Follow-up (months)
Conclusions References
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