The Usage of Reversed Köle-Type Mandibular Anterior Segmental Subapical Osteotomy: Radiological, Clinical, and Surgical Considerations

The currently common procedures in orthognathic surgery are widely used. Different forms of skeletal malocclusion can be treated with great outcomes in terms of bite, bone harmony, function, improved mastication, esthetics, and even decreased problems with breathing. Each type and intensity of malocclusion may affect decision-making in terms of distraction, selection of osteotomy design, or even guide clinical and surgical decisions to use a less popular osteotomy protocol. CBCT (cone-beam computed tomography) is currently a milestone in the establishment of the condition of jaw bones, bone structure, temporomandibular joints, and central relation (CR), as well as the scope of maxilla–mandibular and tooth relations. When establishing all of the following in a clinical and radiological (CBCT-based) evaluation, it becomes possible to measure the occlusal plane, height, length, and three-dimensional position of each dental segment, as well as other dentoalveolar features. In the present case, CBCT helped distinguish a localized vertical anterior mandibular dentoalveolar discrepancy from generalized mandibular malposition and supported the planning of a mandibular anterior segmental subapical osteotomy (MASSO) by mapping the osteotomy corridor in relation to the dental roots, cortical bone, periapical bone height, and neurovascular structures. Significant therapeutic complexity emerges when severe skeletal Class III malocclusion (mandibular prognathism) is compounded by transverse maxillary discrepancies and a markedly elevated mandibular anterior segment. This constellation of deformities leads to profound disturbances in the anterior facial height, a disrupted maxillomandibular interincisal relationship, and the loss of a level occlusal plane. The presented case highlights how the patient’s clinical evaluation should be carefully compared with radiological data, status of both cortices in the mandible, the height of the mandibular anterior segment, presence of gum recessions and poor bone status that may affect healing, osteotomies, and occurrence of some unwanted events. Therefore, CBCT was useful not only for diagnosis and planning, but also for understanding the biological limits of movement and the risk of postoperative periodontal complications in this uncommon reversed Köle-type MASSO.