Expert consensus on orthodontic treatment of protrusive facial deformities

Abstract

Protrusive facial deformities, characterized by the forward displacement of the teeth and/or jaws beyond the normal range, affect a considerable portion of the population. The manifestations and morphological mechanisms of protrusive facial deformities are complex and diverse, requiring orthodontists to possess a high level of theoretical knowledge and practical experience in the relevant orthodontic field. To further optimize the correction of protrusive facial deformities, this consensus proposes that the morphological mechanisms and diagnosis of protrusive facial deformities should be analyzed and judged from multiple dimensions and factors to accurately formulate treatment plans. It emphasizes the use of orthodontic strategies, including jaw growth modification, tooth extraction or non-extraction for anterior teeth retraction, and maxillofacial vertical control. These strategies aim to reduce anterior teeth and lip protrusion, increase chin prominence, harmonize nasolabial and chin-lip relationships, and improve the facial profile of patients with protrusive facial deformities. For severe skeletal protrusive facial deformities, orthodontic-orthognathic combined treatment may be suggested. This consensus summarizes the theoretical knowledge and clinical experience of numerous renowned oral experts nationwide, offering reference strategies for the correction of protrusive facial deformities.

References

[1.] Bills DA, Handelman CS, BeGole EA. Bimaxillary dentoalveolar protrusion: traits and orthodontic correction. Angle Orthod., 2005, 75: 333-339

[2.] Jayaratne YS, Zwahlen RA, Lo J, Cheung LK. Facial soft tissue response to anterior segmental osteotomies: a systematic review. Int. J. Oral. Maxillofac. Surg., 2010, 39: 1050-1058.

[3.] Kamel AM, et al.. Dentofacial effects of miniscrew-anchored maxillary protraction on prepubertal children with maxillary deficiency: a randomized controlled trial. Prog. Orthod., 2023, 24. 22

[4.] Hoyte T, Ali A, Bearn D. Prevalence of bimaxillary protrusion: a systematic review. Open J. Epidemiol., 2021, 11: 37-46.

[5.] Alhammadi MS, Halboub E, Fayed MS, Labib A, El-Saaidi C. Global distribution of malocclusion traits: a systematic review. Dent. Press J. Orthod., 2018, 23: 40.e41-40.e10.

[6.] Ito A, et al.. Three-dimensional morphologic analysis of the maxillary alveolar bone after anterior tooth retraction with temporary anchorage devices. Angle Orthod., 2023, 93: 667-674.

[7.] Zhao T, et al.. Impact of pediatric obstructive sleep apnea on the development of class II hyperdivergent patients receiving orthodontic treatment: (a pilot study). Angle Orthod., 2018, 88: 560-566.

[8.] Rajandram RK, Ponnuthurai L, Mugunam K, Chan YS. Management of bimaxillary protrusion. Oral. Maxillofac. Surg. Clin. North Am., 2023, 35: 23-35.

[9.] Guo R, et al.. Long-term bone remodeling of maxillary anterior teeth with post-treatment alveolar bone defect in adult patients with maxillary protrusion: a prospective follow-up study. Prog. Orthod., 2023, 24. 36

[10.] Tawfik MGY, Izzat Bakhit D, El Sharaby FA, Moustafa YA, Dehis HM. Evaluation of the rate of anterior segment retraction in orthodontic patients with bimaxillary protrusion using friction vs frictionless mechanics: a single-center, single-blind randomized clinical trial. Angle Orthod., 2022, 92: 738-745.

[11.] Vaida, L. L., Negrutiu, B. M., Zetu, I. N., Moca, A. E. & Bran, S. Substantial improvements in facial morphology through surgical-orthodontic treatment: a case report and literature review. Medicina (Kaunas) 58 (2022).

[12.] Al-Rokhami RK, et al.. Proximity of upper central incisors to incisive canal among subjects with maxillary dentoalveolar protrusion in various facial growth patterns. Angle Orthod., 2022, 92: 529-536.

[13.] Singh SP, Verma S. Orthodontics: current principles and techniques. J. Indian Orthod. Soc., 2019, 51: 141-142.

[14.] Liu R, et al.. Severe skeletal bimaxillary protrusion treated with micro-implants and a self-made four-curvature torquing auxiliary: a case report. World J. Clin. Cases, 2021, 9: 722-735.

[15.] Alhammadi MS, et al.. Orthodontic camouflage versus orthodontic-orthognathic surgical treatment in borderline class III malocclusion: a systematic review. Clin. Oral. Investig., 2022, 26: 6443-6455.

[16.] Chen L, et al.. Beyond smiles: static expressions in maxillary protrusion and associated positivity. Front. Psychol., 2021, 12: 514016.

[17.] Alkan O, Kaya Y, Tunca M, Keskin S. Changes in the gingival thickness and keratinized gingival width of maxillary and mandibular anterior teeth after orthodontic treatment. Angle Orthod., 2021, 91: 459-467.

[18.] Luo X, Huang H, Yin X, Shi B, Li J. Functional stability analyses of maxillofacial skeleton bearing cleft deformities. Sci. Rep., 2019, 9. 4261

[19.] Villela HM. Treatment of bimaxillary protrusion using intra- and extra-alveolar miniscrews associated to self-ligating brackets system. Dent. Press J. Orthod., 2020, 25: 66-84.

[20.] Hong SY, et al.. Alveolar bone remodeling during maxillary incisor intrusion and retraction. Prog. Orthod., 2019, 20. 47

[21.] Ackerman JL, Proffit WR. The characteristics of malocclusion: a modern approach to classification and diagnosis. Am. J. Orthod., 1969, 56: 443-454.

[22.] Lee RW, et al.. Relationship between surface facial dimensions and upper airway structures in obstructive sleep apnea. Sleep, 2010, 33: 1249-1254.

[23.] Moss ML, Salentijn L. The primary role of functional matrices in facial growth. Am. J. Orthod., 1969, 55: 566-577.

[24.] Moss ML. The functional matrix hypothesis revisited. 1. The role of mechanotransduction. Am. J. Orthod. Dentofac. Orthop., 1997, 112: 8-11.

[25.] Fernandes P, Pinto J, Ustrell-Torrent J. Relationship between oro and nasopharynx permeability and the direction of facial growth. Eur. J. Paediatr. Dent., 2017, 18: 37-40

[26.] Ghorbanyjavadpour F, Rakhshan V. Factors associated with the beauty of soft-tissue profile. Am. J. Orthod. Dentofac. Orthop., 2019, 155: 832-843.

[27.] Hansen C, Markstrom A, Sonnesen L. Specific dento-craniofacial characteristics in non-syndromic children can predispose to sleep-disordered breathing. Acta Paediatr., 2022, 111: 473-477.

[28.] Yoon, A. et al. A roadmap of craniofacial growth modification for children with sleep-disordered breathing: a multidisciplinary proposal. Sleep 46, zsad095 (2023).

[29.] Grubb J, Evans C. Orthodontic management of dentofacial skeletal deformities. Clin. Plast. Surg., 2007, 34: 403-415.

[30.] Xiong X, et al.. Distribution of various maxilla-mandibular positions and cephalometric comparison in chinese skeletal class II malocclusions. J. Contemp. Dent. Pract., 2020, 21: 822-828.

[31.] Mah M, Tan WC, Ong SH, Chan YH, Foong K. Three-dimensional analysis of the change in the curvature of the smiling line following orthodontic treatment in incisor class II division 1 malocclusion. Eur. J. Orthod., 2014, 36: 657-664.

[32.] Oueis R, Waite PD, Wang J, Kau CH. Orthodontic-orthognathic management of a patient with skeletal class II with bimaxillary protrusion, complicated by vertical maxillary excess: a multi-faceted case report of difficult treatment management issues. Int. Orthod., 2020, 18: 178-190.

[33.] Chung CH, Wong WW. Craniofacial growth in untreated skeletal class II subjects: a longitudinal study. Am. J. Orthod. Dentofac. Orthop., 2002, 122: 619-626.

[34.] Liu Y, et al.. The effect of orthodontic vertical control on the changes in the upper airway size and tongue and hyoid position in adult patients with hyperdivergent skeletal class II. BMC Oral. Health, 2022, 22. 532

[35.] Hourfar J, Kinzinger GSM, Frye L, Lisson JA. Outcome differences after orthodontic camouflage treatment in hypo- and hyperdivergent patients - a retrospective cephalometric investigation. Clin. Oral. Investig., 2023, 27: 7307-7318.

[36.] Liaw JJL, Park JH. Orthodontic considerations in hypodivergent craniofacial patterns. J. World Fed. Orthod., 2024, 13: 18-24

[37.] Ning R, Guo J, Li Q, Martin D. Maxillary width and hard palate thickness in men and women with different vertical and sagittal skeletal patterns. Am. J. Orthod. Dentofac. Orthop., 2021, 159: 564-573.

[38.] Ciavarella D, et al.. Correlation between dental arch form and OSA severity in adult patients: an observational study. Prog. Orthod., 2023, 24. 19

[39.] Winiarska, N. et al. Anthropometry and current aesthetic concept of the lower third of the face and lips in caucasian adult population: a systematic review and meta-analysis. Aesthetic Plast. Surg. 48, 2353–2364 (2024).

[40.] Perinetti G, Rosso L, Riatti R, Contardo L. Sagittal and vertical craniofacial growth pattern and timing of circumpubertal skeletal maturation: a multiple regression study. Biomed. Res. Int., 2016, 2016: 1728712.

[41.] Shakr S, Negm I, Saifeldin H. Evaluation of digital and manual orthodontic diagnostic setups in non-extraction cases using ABO model grading system: an in-vitro study. BMC Oral. Health, 2024, 24. 207

[42.] Glass TR, Tremont T, Martin CA, Ngan PW. A CBCT evaluation of root position in bone, long axis inclination and relationship to the WALA Ridge. Semin. Orthod., 2019, 25: 24-35.

[43.] Raposo R, Peleteiro B, Paco M, Pinho T. Orthodontic camouflage versus orthodontic-orthognathic surgical treatment in class II malocclusion: a systematic review and meta-analysis. Int. J. Oral. Maxillofac. Surg., 2018, 47: 445-455.

[44.] Formosa J, Zou M, Chung CH, Boucher NS, Li C. Mandibular alveolar bone thickness in untreated Class I subjects with different vertical skeletal patterns: a cone-beam computed tomography study. Angle Orthod., 2023, 93: 683-694.

[45.] Kostic, M. et al. Correlation theory of the maxillary central incisor, face and dental arch shape in the serbian population. Medicina (Kaunas) 59, 2142 (2023).

[46.] Akyalcin S, Erdinc AE, Dincer B, Nanda RS. Do long-term changes in relative maxillary arch width affect buccal-corridor ratios in extraction and nonextraction treatment?. Am. J. Orthod. Dentofac. Orthop., 2011, 139: 356-361.

[47.] Moon CH, Park HK, Nam JS, Im JS, Baek SH. Relationship between vertical skeletal pattern and success rate of orthodontic mini-implants. Am. J. Orthod. Dentofac. Orthop., 2010, 138: 51-57.

[48.] Sangalli L, et al.. Proposed parameters of optimal central incisor positioning in orthodontic treatment planning: a systematic review. Korean J. Orthod., 2022, 52: 53-65.

[49.] Islam ZU, Shaikh AJ, Fida M. Dentoalveolar heights in vertical and sagittal facial patterns. J. Coll. Physicians Surg. Pak., 2016, 26: 753-757

[50.] Linjawi AI, Afify AR, Baeshen HA, Birkhed D, Zawawi KH. Mandibular symphysis dimensions in different sagittal and vertical skeletal relationships. Saudi J. Biol. Sci., 2021, 28: 280-285.

[51.] Yan, X., Zhang, X., Chen, Y., Long, H. & Lai, W. Association of upper lip morphology characteristics with sagittal and vertical skeletal patterns: a cross sectional study. Diagnostics (Basel) 11, 1713 (2021).

[52.] Krishnan, V. & Davidovitch, Z. E. In: Biological mechanisms of tooth movement, 1–15 (2021).

[53.] Turley PK. Evolution of esthetic considerations in orthodontics. Am. J. Orthod. Dentofac. Orthop., 2015, 148: 374-379.

[54.] Zhou Q, et al.. Three dimensional quantitative study of soft tissue changes in nasolabial folds after orthodontic treatment in female adults. BMC Oral. Health, 2023, 23. 31

[55.] Alsowaidan MA, et al.. Airway obstruction as a cause of malocclusion: a systematic review. Pharmacophore, 2021, 12: 92-97.

[56.] Wang Q, Jia P, Anderson NK, Wang L, Lin J. Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of Class I bimaxillary protrusion. Angle Orthod., 2012, 82: 115-121.

[57.] Zhang J, Chen G, Li W, Xu T, Gao X. Upper airway changes after orthodontic extraction treatment in adults: a preliminary study using cone beam computed tomography. PLoS One, 2015, 10. e0143233

[58.] Rojo-Sanchis C, Almerich-Silla JM, Paredes-Gallardo V, Montiel-Company JM, Bellot-Arcis C. Impact of bimaxillary advancement surgery on the upper airway and on obstructive sleep apnea syndrome: a meta-analysis. Sci. Rep., 2018, 8. 5756

[59.] Grippaudo C, et al.. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol. Ital., 2016, 36: 386-394.

[60.] Koletsi D, Makou M, Pandis N. Effect of orthodontic management and orofacial muscle training protocols on the correction of myofunctional and myoskeletal problems in developing dentition. A systematic review and meta-analysis. Orthod. Craniofac. Res., 2018, 21: 202-215.

[61.] List T, Jensen RH. Temporomandibular disorders: old ideas and new concepts. Cephalalgia, 2017, 37: 692-704.

[62.] Miao MZ, et al.. Temporomandibular joint positional change accompanies post-surgical mandibular relapse-a long-term retrospective study among patients who underwent mandibular advancement. Orthod. Craniofac. Res., 2018, 21: 33-40.

[63.] Lai YC, Yap AU, Turp JC. Prevalence of temporomandibular disorders in patients seeking orthodontic treatment: a systematic review. J. Oral. Rehabil., 2020, 47: 270-280.

[64.] Wang M, et al.. Impact of occlusal contact pattern on dental stability and oromandibular system after orthodontic tooth movement in rats. Sci. Rep., 2023, 13. 22276

[65.] Alstad S, Zachrisson BU. Longitudinal study of periodontal condition associated with orthodontic treatment in adolescents. Am. J. Orthod., 1979, 76: 277-286.

[66.] Han S, et al.. Dehiscence and fenestration of skeletal Class III malocclusions with different vertical growth patterns in the anterior region: a cone-beam computed tomography study. Am. J. Orthod. Dentofac. Orthop., 2024, 165: 423-433.

[67.] Jepsen K, Sculean A, Jepsen S. Complications and treatment errors involving periodontal tissues related to orthodontic therapy. Periodontol 2000, 2023, 92: 135-158.

[68.] Xiang M, Hu B, Liu Y, Sun J, Song J. Changes in airway dimensions following functional appliances in growing patients with skeletal class II malocclusion: a systematic review and meta-analysis. Int. J. Pediatr. Otorhinolaryngol., 2017, 97: 170-180.

[69.] Huo B, Che X, Li X. Timing of early correction of mandibular hypoplasia in skeletal class II malocclusion: a review. J. Clin. Pediatr. Dent., 2023, 47: 11-20

[70.] Tausche E, Luck O, Harzer W. Prevalence of malocclusions in the early mixed dentition and orthodontic treatment need. Eur. J. Orthod., 2004, 26: 237-244.

[71.] Elfeky HY, Fayed MS, Alhammadi MS, Soliman SAZ, El Boghdadi DM. Three-dimensional skeletal, dentoalveolar and temporomandibular joint changes produced by twin block functional appliance. J. Orofac. Orthop., 2018, 79: 245-258.

[72.] Mohamed AS, et al.. Three-dimensional evaluation of hyoid bone position in nasal and mouth breathing subjects with skeletal Class I, and Class II. BMC Oral. Health, 2022, 22. 228

[73.] Cha JY, et al.. Outcomes of early versus late treatment of severe class II high-angle patients. Am. J. Orthod. Dentofac. Orthop., 2019, 156: 375-382.

[74.] Gkantidis N, Halazonetis DJ, Alexandropoulos E, Haralabakis NB. Treatment strategies for patients with hyperdivergent class II division 1 malocclusion: is vertical dimension affected?. Am. J. Orthod. Dentofac. Orthop., 2011, 140: 346-355.

[75.] Galluccio, G. et al. Comparative evaluation of esthetic and structural aspects in class II functional therapy. A case-control retrospective study. Int. J. Environ. Res. Public Health 18, 6978 (2021).

[76.] Sambataro S, et al.. Comparison of cephalometric changes in Class II growing patients with increased vertical dimension after high-pull and cervical headgear treatment. Eur. J. Paediatr. Dent., 2023, 24: 36-41

[77.] Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope, 2010, 120: 2089-2093.

[78.] Han SH, Park YS. Growth patterns and overbite depth indicators of long and short faces in Korean adolescents: revisited through mixed-effects analysis. Orthod. Craniofac. Res., 2019, 22: 38-45.

[79.] Hourfar J, Kinzinger GSM, Frye L, Lisson JA. Effects of fixed functional orthodontic treatment in hypodivergent and hyperdivergent class II patients-a retrospective cephalometric investigation. Clin. Oral. Investig., 2023, 27: 4773-4784.

[80.] Wang H, Jiang L, Yi Y, Li H, Lan T. Camouflage treatment guided by facial improvement in hyperdivergent skeletal class II malocclusion. Ann. Transl. Med, 2022, 10: 163.

[81.] Moresca AHK, et al.. Esthetic perception of facial profile changes in Class II patients treated with Herbst or Forsus appliances. Angle Orthod., 2020, 90: 571-577.

[82.] Liu A, et al.. Efficacy of a modified twin block appliance compared with the traditional twin block appliance in children with hyperdivergent mandibular retrognathia: protocol for a single-centre, single-blind, randomised controlled trial. BMJ Open, 2023, 13. e071959

[83.] Cai J, Min Z, Deng Y, Jing D, Zhao Z. Assessing the impact of occlusal plane rotation on facial aesthetics in orthodontic treatment: a machine learning approach. BMC Oral. Health, 2024, 24. 30

[84.] Sambataro S, et al.. Changes of occlusal plane in growing patients with increased vertical dimension during class II correction by using cervical headgear. J. Craniofac. Surg., 2020, 31: 172-177.

[85.] Picchi Comar L, Salomão PMA, Martines de Souza B, Magalhães AC. Dental erosion: an overview on definition, prevalence, diagnosis and therapy. Braz. Dent. Sci., 2013, 16: 6-17.

[86.] Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am. J. Orthod., 1981, 79: 359-372.

[87.] Ishihara Y, Kuroda S, Sumiyoshi K, Takano-Yamamoto T, Yamashiro T. Extraction of the lateral incisors to treat maxillary protrusion: quantitative evaluation of the stomatognathic functions. Angle Orthod., 2013, 83: 341-354.

[88.] Perinetti G, Contardo L. Reliability of growth indicators and efficiency of functional treatment for skeletal class II malocclusion: current evidence and controversies. Biomed. Res. Int., 2017, 2017: 1367691.

[89.] Lee YJ, Park JT, Cha JY. Perioral soft tissue evaluation of skeletal class II division 1: a lateral cephalometric study. Am. J. Orthod. Dentofac. Orthop., 2015, 148: 405-413.

[90.] Talass MF, Talass L, Baker RC. Soft-tissue profile changes resulting from retraction of maxillary incisors. Am. J. Orthod. Dentofac. Orthop., 1987, 91: 385-394.

[91.] Alkadhi RM, Finkelman MD, Trotman CA, Kanavakis G. The role of lip thickness in upper lip response to sagittal change of incisor position. Orthod. Craniofac. Res., 2019, 22: 53-57.

[92.] Sun Q, et al.. Morphological changes of the anterior alveolar bone due to retraction of anterior teeth: a retrospective study. Head. Face Med., 2021, 17: 30.

[93.] Hatami A, Dreyer C. The extraction of first, second or third permanent molar teeth and its effect on the dentofacial complex. Aust. Dent. J., 2019, 64: 302-311.

[94.] Haque S, Sandler J, Cobourne MT, Bassett P, DiBiase AT. A retrospective study comparing the loss of anchorage following the extraction of maxillary first or second premolars during orthodontic treatment with fixed appliances in adolescent patients. J. Orthod., 2017, 44: 268-276.

[95.] Changsiripun C, Phusantisampan P. Attitudes of orthodontists and laypersons towards tooth extractions and additional anchorage devices. Prog. Orthod., 2017, 18. 19

[96.] Kinzinger GS, Diedrich PR. Biomechanics of a modified Pendulum appliance-theoretical considerations and in vitro analysis of the force systems. Eur. J. Orthod., 2007, 29: 1-7.

[97.] Byloff FK, Darendeliler MA, Clar E, Darendeliler A. Distal molar movement using the pendulum appliance. Part 2: the effects of maxillary molar root uprighting bends. Angle Orthod., 1997, 67: 261-270

[98.] Antonarakis GS, Kiliaridis S. Maxillary molar distalization with noncompliance intramaxillary appliances in class II malocclusion. A systematic review. Angle Orthod., 2008, 78: 1133-1140.

[99.] Alyami B. Full single arch distalization in class II malocclusion using subzygomatic temporary anchorage devices: a case report. Saudi J. Oral. Sci., 2023, 10: 184-188.

[100.] Guo YN, et al.. Quantitative evaluation of vertical control in orthodontic camouflage treatment for skeletal class II with hyperdivergent facial type. Head. Face Med., 2024, 20: 31.

[101.] Deng JR, et al.. Evaluation of long-term stability of vertical control in hyperdivergent patients treated with temporary anchorage devices. Curr. Med. Sci., 2018, 38: 914-919.

[102.] Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H. Skeletal anchorage system for open-bite correction. Am. J. Orthod. Dentofac. Orthop., 1999, 115: 166-174.

[103.] Sarver DM. Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic diagnosis and treatment planning. Am. J. Orthod. Dentofac. Orthop., 2015, 148: 380-386.

[104.] Freeman CS, McNamara JA Jr., Baccetti T, Franchi L, Graff TW. Treatment effects of the bionator and high-pull facebow combination followed by fixed appliances in patients with increased vertical dimensions. Am. J. Orthod. Dentofac. Orthop., 2007, 131: 184-195.

[105.] Kuhn RJ. Control of anterior vertical dimension and proper selection of extraoral anchorage. Angle Orthod., 1968, 38: 340-349

[106.] LaHaye MB, Buschang PH, Alexander RG, Boley JC. Orthodontic treatment changes of chin position in Class II division 1 patients. Am. J. Orthod. Dentofac. Orthop., 2006, 130: 732-741.

[107.] Ruslin M, et al.. One-year stability of the mandibular advancement and counterclockwise rotation for correction of the skeletal class II malocclusion and high mandibular plane angle: dental and skeletal aspect. Biomed. J., 2022, 45: 206-214.

[108.] Liou EJ, Chang PM. Apical root resorption in orthodontic patients with en-masse maxillary anterior retraction and intrusion with miniscrews. Am. J. Orthod. Dentofac. Orthop., 2010, 137: 207-212.

[109.] Peng J, Lei Y, Liu Y, Zhang B, Chen J. Effectiveness of micro-implant in vertical control during orthodontic extraction treatment in class II adults and adolescents after pubertal growth peak: a systematic review and meta-analysis. Clin. Oral. Investig., 2023, 27: 2149-2162.

[110.] Sendyk M, et al.. Three-dimensional evaluation of dental decompensation and mandibular symphysis remodeling on orthodontic-surgical treatment of class III malocclusion. Am. J. Orthod. Dentofac. Orthop., 2021, 159: 175-183.e173.

[111.] Möhlhenrich SC, et al.. Effects of different surgical techniques and displacement distances on the soft tissue profile via orthodontic-orthognathic treatment of class II and class III malocclusions. Head. Face Med., 2021, 17: 13.

[112.] Tanikawa C, Yamashiro T. Development of novel artificial intelligence systems to predict facial morphology after orthognathic surgery and orthodontic treatment in Japanese patients. Sci. Rep., 2021, 11. 15853

[113.] Kaplan PA, Tu HK, Koment MA, Bennion JW, Ruskin JD. Radiography after orthognathic surgery. Part I. Normal appearance. Radiology, 1988, 167: 191-194.

[114.] Prinsell JR. Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest, 1999, 116: 1519-1529.

[115.] Nachmani A, et al.. Differences in craniofacial morphology between platybasic and nonplatybasic patients with velopharyngeal dysfunction and control subjects. Am. J. Orthod. Dentofac. Orthop., 2022, 162: e5-e16.

[116.] Cao J, et al.. Reconstruction of dentomaxillofacial deformity secondary to mandibular defect using concomitant orthognathic surgery and fibula free flap. Plast. Reconstr. Surg., 2023, 151: 179-183

[117.] Muftuoglu O, et al.. Long-term evaluation of masseter muscle activity, dimensions, and elasticity after orthognathic surgery in skeletal class III patients. Clin. Oral. Investig., 2023, 27: 3855-3861.

[118.] Lee JY, Hung TY, Rieko Y, Fang CY. Correcting protruding maxillary appearance through one-piece Le fort I osteotomy without premolar extraction. J. Dent. Sci., 2023, 18: 1926-1928.

[119.] van Bakelen NB, et al.. Comparison of biodegradable and titanium fixation systems in maxillofacial surgery: a two-year multi-center randomized controlled trial. J. Dent. Res, 2013, 92: 1100-1105.

[120.] Rohner D, Yeow V, Hammer B. Endoscopically assisted Le Fort I osteotomy. J. Craniomaxillofac. Surg., 2001, 29: 360-365.

[121.] Chen, C. M. et al. Changes in facial profile after modified anterior maxillary subapical osteotomy. J. Pers. Med. 12, 508 (2022).

[122.] Arnett GW, Trevisiol L, Grendene E, McLaughlin RP, D’Agostino A. Combined orthodontic and surgical open bite correction. Angle Orthod., 2022, 92: 161-172.

[123.] Abdel-Moniem Barakat A, Abou-ElFetouh A, Hakam MM, El-Hawary H, Abdel-Ghany KM. Clinical and radiographic evaluation of a computer-generated guiding device in bilateral sagittal split osteotomies. J. Craniomaxillofac. Surg., 2014, 42: e195-e203.

[124.] Yoshioka I, et al.. Criteria and limitations for selecting a sagittal split ramus osteotomy for patients with skeletal mandibular prognathism and open bite. Oral. Surg. Oral. Med Oral. Pathol. Oral. Radio., 2013, 115: 455-465.

[125.] Suda N, Tominaga N, Niinaka Y, Amagasa T, Moriyama K. Orthognathic treatment for a patient with facial asymmetry associated with unilateral scissors-bite and a collapsed mandibular arch. Am. J. Orthod. Dentofac. Orthop., 2012, 141: 94-104.

[126.] Seo YJ, Lin L, Kim SH, Chung KR, Nelson G. Strategic camouflage treatment of skeletal Class III malocclusion (mandibular prognathism) using bone-borne rapid maxillary expansion and mandibular anterior subapical osteotomy. Am. J. Orthod. Dentofac. Orthop., 2016, 149: 114-126.

[127.] Foushee DG, Moriarty JD, Simpson DM. Effects of mandibular orthognathic treatment on mucogingival tissues. J. Periodontol., 1985, 56: 727-733.

[128.] Burk JL, Newby NW, Branham GB, Provencher RF. Surgical correction of pseudoankylosis and microgenia: report of case. J. Am. Dent. Assoc., 1977, 94: 1173-1177.

[129.] Yao K, et al.. Effect of surgery-first orthognathic approach on oral health-related quality of life. Angle Orthod., 2020, 90: 723-733.

[130.] Bichu YM, et al.. Insights into concepts, protocols, and evidence of surgery-first orthognathic approach– the journey so far. Semin. Orthod., 2022, 28: 247-257.

[131.] Wei H, Liu Z, Zang J, Wang X. Surgery-first/early-orthognathic approach may yield poorer postoperative stability than conventional orthodontics-first approach: a systematic review and meta-analysis. Oral. Surg. Oral. Med. Oral. Pathol. Oral. Radiol., 2018, 126: 107-116.

[132.] Barone S, Morice A, Picard A, Giudice A. Surgery-first orthognathic approach vs conventional orthognathic approach: a systematic review of systematic reviews. J. Stomatol. Oral Maxillofac. Surg., 2021, 122: 162-172.

[133.] Shathi FF, et al.. Evaluation of mandibular positional changes after orthognathic surgery in skeletal class II and class III surgery-first approach patients. J. Stomatol Oral. Maxillofac. Surg., 2022, 123: 677-684.

Funding

National Clinical Key Specialty Project of China Nos. GJLCZDZK-2023-01, Shanghai Top Priority Research Center Project Nos. 2023ZZ02009, National Natural Science Foundations of China Nos. 82230030, Clinical Innovation Project of Shanghai Shenkang Hospital Development Center Nos. SHDC12021108 and Angelalign Scientific Research Fund No. EARD20220725046,