What treatment options are available for a patient with mandibular deviation to the right and skeletal protrusion, potentially including orthodontic braces?

Treatment of Mandibular Deviation to the Right with Skeletal Protrusion

The treatment approach depends critically on skeletal maturity: skeletally immature patients should receive dentofacial orthopedic appliances (oral splints) combined with orthodontic treatment, while skeletally mature patients with significant deformity require orthognathic surgery after controlling any underlying inflammatory conditions. 1

Initial Assessment and Classification

Before determining treatment, you must systematically evaluate:

• Skeletal maturity status - this is the single most important factor determining whether orthopedic vs. surgical intervention is appropriate 1
• Severity of dentofacial deformity - assess mandibular asymmetry, degree of protrusion, and functional impairment 1
• Presence of active TMJ inflammation - any underlying arthritis must be controlled before definitive treatment 1
• Functional impairment - evaluate mastication, speech, and TMJ function 2

The mandibular deviation should be classified into one of three categories: positioning factors (dental compensation, habitual posturing), condylar defects (asymmetrical resorption/hyperplasia), or congenital jaw deformities 3

Treatment Algorithm by Skeletal Maturity

For Skeletally Immature Patients

Dentofacial orthopedic appliances (oral splints) are the primary treatment modality and should be initiated early in the development of deformity. 1

• These splints support normal mandibular growth and occlusal development when used in growing patients 1
• The optimal effect is achieved by initiating treatment early, as splints may normalize minor-to-moderate dentofacial deformities and prevent worsening 1
• Splints must be used in conjunction with anti-inflammatory therapies if active TMJ arthritis is present 1

Fixed orthodontic appliances (braces) play a secondary role in skeletally immature patients. 1

• Little is known about the effects of braces alone in patients with skeletal deformities 1
• Orthodontic treatment is mainly considered to establish dental occlusion after the use of orthopedic appliances 1
• Fixed appliances may be used to correct minor malocclusions separately from orthopedic treatment 1

For Skeletally Mature Patients

Orthognathic surgery is the definitive treatment for significant dentofacial deformities in skeletally mature patients, but only after TMJ inflammation is quiescent/controlled. 1, 4

The three general surgical approaches are:

1. Mandibular distraction osteogenesis 1
2. Orthognathic surgery with TMJ preservation (Le Fort I osteotomy for maxilla + bilateral sagittal split osteotomy for mandible) 1, 4, 2
3. TMJ reconstruction with autologous or alloplastic implants 1

For mandibular protrusion with deviation, the typical approach is Le Fort I osteotomy to advance the maxilla combined with bilateral sagittal split osteotomy to setback the mandible. 4, 2

• An advancement of 10-15mm of the maxilla and mandible is necessary when maxillomandibular abnormality exists 4
• Surgery is medically necessary only when skeletal deformities contribute to significant masticatory dysfunction that precludes adequate treatment through dental therapeutics and orthodontics alone 4

Orthodontic braces in skeletally mature patients are used primarily to establish dental occlusion after surgical correction or in conjunction with surgery. 1

Special Considerations for Borderline Cases

For adults with mild-to-moderate skeletal crossbite and mandibular deviation, orthodontic treatment with straight-wire appliance combined with occlusal plate may be effective without surgery. 5

• This approach uses elastics to correct mandibular deviation 5
• This is appropriate only for borderline skeletal cases, not severe deformities 5

Critical Pitfalls to Avoid

• Never proceed with orthognathic surgery if active TMJ inflammation is present - the TMJ arthritis must be quiescent/controlled first 1
• Do not use fixed orthodontic appliances (braces) as primary treatment for skeletal deformities in growing patients - orthopedic appliances should be used first 1
• Avoid delaying treatment in skeletally immature patients - early intervention with orthopedic appliances has the best outcomes 1
• Do not consider surgery for primarily aesthetic concerns without documented functional impairment - this is not medically necessary 4

Post-Treatment Management

After surgical correction:

• Perform full polysomnography between 2-6 months after surgery to assess effectiveness if sleep-disordered breathing was present 4
• Initiate orthodontic treatment 2 weeks post-surgery for final occlusal refinement 2
• Long-term follow-up with appropriate specialists is recommended after surgical treatment 4