Upload
others
View
13
Download
0
Embed Size (px)
Citation preview
Presurgical Orthodontic Preparation for Optimal Outcome
Treatment Planning of Surgical Orthodontic Cases
AAO 119th Annual Session
©sylvainchamberland.com
Biography Sylvain Chamberland
• D.M.D. (Docteur en Médecine Dentaire), University Laval, 1983
• Private practice, general dentistry 1983-1988
• Certificate in Orthodontics, University of Montreal, 1990
• M.Sc. in Dental Science, University Laval, 2008
• Private practice in orthodontics since 1990
• Publications
✦ Closer look at SARPE, JOMS 2008
✦ Short-term and long-term stability of SARPE revisited, AJODO 2011
✦ Long-term dental and skeletal changes following SARPE, letter to editor, OOOO 2013
✦ Functional genioplasty in growing patients, AO 2015,
✦ Response to : Functional geniolasty in growing patients by Chamberland et al, AO 2015,;85, 6: p1083
✦ À la mémoire de William Robert Proffit, Orthod Fr 2018, 89: 323-326. https://doi.org/10.1051/orthodfr/2018038
✦ Progressive/Idiopathic Condylar Resorption: Three Case Reports, AJODO 2019, In Press
• Lecturer in several graduate program and scientific meeting in USA, Canada, Europe
Consensus Sequence: Pre- and Post-Surgical Orthodontics
©sylvainchamberland.com
Orthodontic plan Preliminary surgical plan (VTO + STO)
Pre-surgical Orthodontics
Final surgery plan
Orthognathic surgery
Minimal post-surgical orthodontics
Courtesy of Dr Bill Proffit ©sylvainchamberland.com
Goals of Pre-Surgical Treatment• Establish incisor position (A-P)
✦ Either exactly where they should be at completion, or slightly overcorrected
• Establish interincisal angle
✦ Dependant of 1/-SN and /1-MP
• The positioning of the incisors has a substantial effect on the aesthetic outcome
Sarver D., How to avoid surgical failure, Sem.Ortho 1999;5: 257-274
©sylvainchamberland.com
Incisors Inclination & ANB• Proclination of Mx incisors ➔ ANB decrease
• Proclination of Md incisors ➔ ANB increase
• Pre-surgical inclination has a direct impact on skeletal surgical correction
✦ Inadequate incisors decompensation likely decrease the skeletal AP changes
©sylvainchamberland.com
Advantage of Adequately Decompensated Incisors
• Adequate preoperative decompensation
✦ Permit optimal skeletal AP changes
• Normalizing incisor inclination only by surgical movement without appropriate preoperative decompensation can increase the surgical morbidity and compromise the facial aesthetics and stability
Sarver D., How to avoid surgical failure, Sem.Ortho 1999;5: 257-274 Kim, Do-Keun et al. Change in maxillary incisor inclination during surgical-orthodontic treatment of skeletal Class III malocclusion: Comparison of extraction and nonextraction of the maxillary first premolars, AJODO 2013;143:324-35
©sylvainchamberland.com
Problems Created by Inadequately Decompensated Incisors
• Inadequate incisor positioning
✦ Can compromise buccal interdigitation
✦ Can substantially affect the aesthetic outcome
• Class I buccal segments are not attainable
✦ Retroclination 1/ (or too much retraction)
✓ Insufficient room to provide for adequate Md advancement
✓ Increase the need to compensate by more genio advancement
✓Risk for limiting success in improving overall health (Tx of sleep apnea)
Sarver D., How to avoid surgical failure, Sem.Ortho 1999;5: 257-274 Kim, Do-Keun et al. Change in maxillary incisor inclination during surgical-orthodontic treatment of skeletal Class III malocclusion: Comparison of extraction and nonextraction of the maxillary first premolars, AJODO 2013;143:324-35
Feb 1994
©sylvainchamberland.com
Problems Created by Inadequately Decompensated Incisors
• Proclination of Md Incisors-Cl II
✦Decrease the amount of md advancement
✓Risk of limiting success in improving SAS
• Increase the chin advancement to compensate for the lack of Md advancement
©sylvainchamberland.com
Problems Created by Inadequately Decompensated Incisors
• Proclination of Md Incisors-Cl II
✦ Affect the aesthetic outcome
AuSan initial AuSan préop
AuSan final ©sylvainchamberland.com
Problems Created by Inadequately Decompensated Incisors
• Too much retraction of 1/
• Decrease the amplitude Md advancement
• Increase chin advancement to compensate
80728
8
24
622
-1
21
40
125
32
57
91
78718
2
21
519
2
25
43
133
32
63
85
80764
3
19
5256
20
37
132
28
93
Beginner’s error
©sylvainchamberland.com
AP Incisors Position- Cl III•Proclination of Mx incisors or Retroclination of Md incisors
✦ Insufficient negative overjet preparation for adequate Mx advancement or Md setback
✦Decrease the amplitude of surgical skeletal correction
✦ Inability to achieve Cl I buccal segment
©sylvainchamberland.com
Decompensation in Class III•Unraveling crowding of /1
•Use Cl II elastics
DyLa Sept 15 to Sept 17 StBrCa Apr16 to Aug 17
Case 1 Case 2
©sylvainchamberland.com
Decompensation in Class III• Extraction of premolar, 4s/ or 5s/ or 4s/5s or 5s/5s
PuCeJe Apr 2012 Sept 2012 May 2014 Kim, Do-Keun et al. Change in maxillary incisor inclination during surgical-orthodontic treatment of skeletal Class III malocclusion: Comparison of extraction and nonextraction of the maxillary first premolars, AJODO 2013;143:324-35 ©sylvainchamberland.com
Optimal Decompensation
Missing 14, 15, 24, 25, 35, 45
©sylvainchamberland.com
AP Incisors Position- Torque• Proclination of both Mx and Md incisors
✦ Incisors retraction (bimax reduction) facilitates obtaining positive overbite
✦ Conversely, iatrogenic proclination favor opening of the bite
©sylvainchamberland.com
Open Bite + Bimax Protrusion
•Extraction of all 2nd Pm
•Mx: Space closed on segmented arch
✦ Self leveling of Mx Curve of Spee
Initial Presurgical
©sylvainchamberland.com
Incisor Extrusion on Stability of Anterior Open bite
•Moderate extrusion or absence of pre-surgical extrusion has little effect on the long-term stability of open bite
•The decrease in overbite depends on the influence of several factors: dental, skeletal, soft tissues and condylar remodellingInitial
Progress 12 m
Lo FM, Shappiro PA, Effect of presurgical incisor extrusion on stability of anterior openbite malocclusion treated with orthognatic surgery. Int J Adult Ortho Orthognat Surg 1998;13:23-34
©sylvainchamberland.com
Incisor Extrusion on Stability of Anterior Open bite
• If the curve of Spee does not level by itself when closing extraction space in segmented approach
✦ No attempt was made to extrude anterior teeth
✦ Leveling was made surgically
ViLa 29-11-2015ViLa 24-01-2017
ViLa 21-09-2017
©sylvainchamberland.com
Skeletal Etiology of OpenBite
Distance apex-hard palateOcclusal plane Short ramus
Gui-Dev Ma26-05-14Ra-Ch-An14-09-17
VME No VME
©sylvainchamberland.com
Skeletal Etiology of OpenBite
Distance apex-hard palateOcclusal plane
Ra-Ch-An14-09-17Blo Ja 28-11-18 Mel Moris 25-10-17
©sylvainchamberland.com
Goals of Pre-Surgical Treatment•Obtain arch form compatibility
✦ Transverse relationship
✓ < 5 mm of expansion
✓ > 5 mm of expansion
•Maxillary midline
✦ Favor the coincidence with the facial midline
•Mandibular midline
✦ Achieve arch symmetry
©sylvainchamberland.com
Goals of Pre-Surgical Treatment
• Vertical
✦ Level or intrude lower 2nd molars
✦ Do not extrude upper 2nd molars
✓Often time lingual cusp is hanging down
©sylvainchamberland.com
Occlusal Plane Alteration• Clockwise rotation
✦ Decrease 1/ ∠ ° + chin projection
✦ Increase /1-MP ∠ °
• Counterclockwise rotation
✦ Increase 1/ ∠ ° + chin projection
✦ Decrease /1-MP ∠ °
Wolford LM, Chemello PD, AJODO 1994;106:304-16 ©sylvainchamberland.com
Occlusal Plane Alteration + CRot
• Clockwise rotation
✦ ↑ occlusal plane angle
✦ ↑ FMA
✦ Chin rotate posteriorly ↓ PFH
✦ Perinasal structures advance
✦ ↓ ∠1/
✦ ↑ ∠/1Wolford LM: J Oral Maxillofac Surg 1993
Reyneke JP: Essentials of orthognathic surgery 2003Courtesy Dr Dany Morais
CR at incisal edge CR at ANS CR at PNS
©sylvainchamberland.com
Change of Occlusal Plane
Counterclockwise rotation
LachSab
©sylvainchamberland.com
Change of Occlusal Plane
Clockwise rotation
Simulated Postoperative Occlusal Angle = 11.2ᵒ
Preoperative Occlusal Angle = 7.7ᵒ
Occ Plane -SN 13.5° to 17,8°
©sylvainchamberland.com
What do you Have to do Before Surgery?
• Obtain a flat occlusal plane ➜ Level the curve of Spee
✦ Dr Profit: "level / depress lower 2nd molars", it is like levelling the curve of Spee
©sylvainchamberland.com
What do you Have to do Before Surgery?
• Courbe de Spee = 0
• Levelled marginal ridges
• Extraction site closed
• Alignement of the cusp MD
• Grind the interferences on the models and repeat it in the mouth
©sylvainchamberland.com
What do you Have to do Before Surgery?
• Alignment
• A-P and vertical incisor positioning
• Everything to set it up finishing 4 to 6 months post-surgery
• Hand articulated models should fit in Class I
©sylvainchamberland.com
What Happen if the Curve of Spee is not Leveled?
• Final AP position of /1 is unknown
• Optimal surgical movement is difficult to estimates
• Post surgical ortho will take long
• Incisors AP will likely change, hence affecting surgical correction
©sylvainchamberland.com
What Happens at Surgery?
• Mandibular distal segment will rotate clockwise
• Proximal segment is maintained in the fossa
• No further AP movement of /1 will occur
Prior to surgeryPosturing into class I
JeAu02-04-2019JeAu20-03-2018
©sylvainchamberland.com
What is the Advantage of Presurgical Flat Curve of Spee
• Permits optimal occlusal outcome per-op
©sylvainchamberland.com
What is the Advantage of Optimal Orthodontic Decompensation?
• Per Op
✦ Permits maximum interdigitation
✦ Permits class I occlusion
• Please note
✦ To surgically close an anterior openbite do not create a posterior openbite
©sylvainchamberland.com
What Can be Done After Surgery?• Root parallelism
• Finishing and detailing posterior occlusion
• Minor transverse problems
• Closing residual space if any
©sylvainchamberland.com
Satisfaction and Self-Esteem Post Surgery
• Overall satisfaction and self-esteem increase during the first 4 months post surgery
• Decline at 9 mois
• Conclusion
✦ End treatment 4 to 6 months post surgery
Kiyak HA, Bell R. Psychosocial considerations in surgery and orthodontics. Chapter 3 in Proffit WR, White RP Jr, Surgical-Orthodontic Treatment . St-Louis, Mosby, 1993
Treatment Sequence Surgery 1st
©sylvainchamberland.com
3D imaging, Surgical plan chirurgicalPostsurg ortho plan, template-splint
Ortho appliance only, no AW or passive stabilizing wire
Orthognathic surgery (+dentoalveolar surgery, corticotomy), TADs / miniplates for anchorage
Extensive post surgical orthodontics (9-15 months). Increasingly difficult if incisors are not in correct vertical positionCourtesy of Dr Proffit
©sylvainchamberland.com
Surgery1st
• Is it a good idea?
• The idea behind its introduction: the biggest problem is addressed first, so the patients are more pleased with the treatment experience
✦ Minimal or no evidence to support this
✦ Kiyak et coll (Seattle1990s): > 6 months post-surg orthodontics becomes a problem for patients
✦ Compromise in occlusion and alignment post treatment?
©sylvainchamberland.com
Orthosurgical Tx vs Surgery 1st
• An orthosurgery tx requires orthodontic decompensation certainly, but the post surgery finishing is not that long.
• The deal is: Do the surgery at the right time.
©sylvainchamberland.com
Surgery 1st
• Perhaps easier now with 3D CAD/CAM planification
✦ Typically requires segmental jaw surgery and multiple splint fabricated from virtual models
✓Bone screws / miniplates added for orthodontic anchorage
✓Dentoalveolar corticotomy
✓ Increasingly difficult if the incisors are not in the correct vertical position
Courtesy of Dr Proffit©sylvainchamberland.com
Surgery 1st
• 45 of 230 ortho-surg patients selected for surgery 1st
✦Exclusion
✓Severe crowding requiring extraction
✓Severe asymmetry with dental compensation in the 3 planes of space
✓Cl II div 2 deep bite
✓Periodontal problems and TMJ dysfunction/symptoms
Hernandez-Alfaro F et al, Surgery first in orthodontics: what have we learned? J Oral Maxillofac Surg 72:376-390, 2014 (February).
Courtesy of Dr Proffit
©sylvainchamberland.com
Surgery 1st
•Outcome data
✦Patient satisfaction: high
✓But no comparison to other satisfaction reports in the literature
✦ Treatment time reduced
✓But corticotomy, more frequent orthodontic appointments and perhaps less precise orthodontic finishing may have affected this
✦No data
✓Complications
✓Quality of final occlusion
✓ StabilityHernandez-Alfaro F et al, Surgery first in orthodontics: what have we learned? J Oral Maxillofac Surg 72:376-390, 2014 (February). Courtoisie de Dr Proffit
©sylvainchamberland.com
• The absence of dental decompensation affects the quality of the dentoskeletal correction ...
• Should not an optimal skeletal correction be aimed at?
A, Preoperative, and C, final views A patient with Class III malocclusion treated with a surgery-first approach. Orthodontic preoperative axial correction of the inferior incisors was not performed to avoid exacerbating the anterior crossbite. The patient greatly valued the immediate esthetic improvement
©sylvainchamberland.com
Surgery 1st
• Technically difficult, but good results achievable
• Contre-indications: severe crowding, deep overbite
• Higher patient satisfaction?
• Faster treatment time?
The key question: For which patients is it cost-effective, with cost including effect on patient?
Merci de votre attentionAvez-vous des questions ?
©sylvainchamberland.com
Visual Surgical Treatment ObjectivesVTO
• Dental objectives
• Surgical objectives
©sylvainchamberland.com
Visual Surgical Treatment ObjectivesVTO
• Dental objectives
✦ Assessment of /1-MP
✦ Assessment of 1/-SN
• Surgical objectives
✦ Le Fort 1
✦ BSSO
✦ Genio
Hyperdivergent Cases
Pont de l’Île d’Orléans ©sylvainchamberland.com
Hyperdivergent Cases• Place /1-MP at or near 90°
• Obtain ideal 1/-SN or slightly higher
✦ Clockwise rotation of the occlusal plane decrease 1/-SN
✦ Counterclockwise rotation of the occlusal plane increase 1/-SN
• Undertorque 1/ or proclined /1-MP reduce the Md sagittal advancement
• Flattened curve of Spee
✦ Any modification after surgery may reopen the bite
©sylvainchamberland.com
Class II div 1• Constricted Mx
• Missing 46
• Md dental asymmetry
• Lower midline deviation to the right
LiDu19012011 56a ©sylvainchamberland.com
•Hyperdivergent, FMA = 42°
•Retrognathic Mx + Md (SNA=74°, SNB = 66°)
• Impacted 18, 28, 38. Mutilated 46
•Mx-Md transverse deficiency
✦ 85- 62= 23 (norm = 20)
•Sleep apnea syndrome
©sylvainchamberland.com
Tx Plan?•Presurgical goal
✦ Achieve normal transverse relationship
✦ Achieve symmetry of lower canines
✓Midline coordination
✦ Upright lower incisors (/1-MP)
•Exo LL4
•SARPE
•Bimax surgery
-15
79
96
71
37
90
13492
11
35
26
126
118
0
4
1
-1
19
3
83
48
8
Lower Arch: Right Left Change Changes: X Y Rot ALD -2.0 -2.0 mx at ANS 6.8 0.8 -7.7Incisors -0.1 -0.2 mx at A 5.3 0.41st Molar -0.0 -2.0 -2.0 mx at 1 crown -0.2 -0.5Extraction 6.0 6.0 mx at PNS 6.4 -5.1 -7.7Expansion mx at 6 crown 3.9 -4.1Stripping md6 Left ost. 8.3 -1.1 -5.2E-Space genioplasty 3.3 -0.2
md at 1 crown 9.2 3.1Net Change 1.8
©sylvainchamberland.com
End of distraction
• Note the position of the screw in line with 1st molars
©sylvainchamberland.com
Pre Phase 2 Surgery• Arch coordination
• Midline coincident
LiDu17102012
©sylvainchamberland.com
Dental Arch Symmetry
©sylvainchamberland.com
• Upright lower incisors, /1-PM = 84°
✦ Permit max md advancement
• Too upright upper incisors
✦ But Mx advancement is planned
©sylvainchamberland.com
• Class I occlusion achieved
• Coordinated arch form
LiDu06052013
©sylvainchamberland.com
• Uprighted lower incisors and counterclockwise rotation of the maxilla helped to achieve maximum Md advancement
• Genioplasty was not necessary, beside advancement of genial process
• Improved airways
©sylvainchamberland.com
• Counterclockwise rotation of occlusal plane +
• Full dimensional 21x25 finishing wire
✦Help to improve 1/-SN from 79° to 87°
©sylvainchamberland.com
• At 61, she feel younger and healthier than in her mid 50s
LiDu08092015
Follow up 2 years
©sylvainchamberland.com
Complication• Bruise post SARPE
• Infection cause by remnants of partial odontectomy
• Sequestra and plates was removed on the left.
Follow up 2 y
©sylvainchamberland.com Apple orchard, île d’Orleans ©sylvainchamberland.com
Class III Open Bite• Maxillary constriction/ Left posterior Xbite
• Moderate crowding
• Mandibular tori
LaVi20-10-2015
©sylvainchamberland.com
• Hyperdivergent, FMA = 41°
• Vertical excess: maxilla and lower facial 3rd
• Laterodeviation to the right
• Bimax dentoalveolar protrusion
©sylvainchamberland.com
• Left condylar hyperplasia (or right condylar hypoplasia)
• Impacted 3rd molars
©sylvainchamberland.com
Surgical Treatment Objective• Le Fort 1 superior repositioning 3 mm
• BSSO
• Genioplasty
✦ advance +5 mm, vertical - 4 mm
Lower Arch: Right Left Change Changes: X Y Rot ALD -7.0 -7.0 mx at ANS 0.2 -3.0Incisors -2.0 -3.9 mx at A 0.2 -3.01st Molar -2.3 -2.4 -4.7 mx at 1 crown -1.9 -2.4Extraction 7.5 7.5 15.0 mx at PNS 0.2 -3.0Expansion mx at 6 crown 6.3 -1.4Stripping md6 Left ost. 2.0 4.9 7.0E-Space genioplasty 5.0 -4.2
md at 1 crown 2.2 -10.0Net Change -0.6
ntation is a SIMULATION ONLY and is not intended to be a guarantee of the actual orthodon ©sylvainchamberland.com
At 30 weeks• Mx: 16X22 SS
• Md: 21x21x20 SS en masse retraction
• Mandibular tori were removed along with 3rd molars
LaVi31-05-2016
©sylvainchamberland.com
At 64 weeks• Mx: segment 21X25 TMA, distal root tip 14 & 24
• Md: 20X25 SS
LaVi24-01-2017 ©sylvainchamberland.com
• Loss of 1/ torque
• /1 retracted 5,4 mm
• Long left condylar neckLaVi24-01-2017
©sylvainchamberland.com
3D Planning
©sylvainchamberland.com
3D Planning
©sylvainchamberland.com
3D Planning
• Counterclockwise rotation of occlusal plane 2°
©sylvainchamberland.com
3 weeks post op•Arch change
•Finishing elastics
LaVi 17-05-2017
©sylvainchamberland.com
Tx time: 98 weeks•Improved smile display
•Finishing on the left side should have been improved but she was leaving for 3 months very far away
LaVi 21-09-2017 ©sylvainchamberland.com
• Improved profile
• Lip competency
• Normal LAFH
©sylvainchamberland.com
Condyles
•Right hypoplasia vs left hyperplasia?? Right antegonial notch deeper than the left
•Long term follow-up is necessary©sylvainchamberland.com
Follow up at 34 Weeks
• Left side…!!!
LaVi 14-05-2018
©sylvainchamberland.com
Hyperdivergent Cases• Place /1-MP at or near 90°
• Obtain ideal 1/-SN or slightly higher
✦ Clockwise rotation of the occlusal plane decrease 1/-SN
✦ Counterclockwise rotation of the occlusal plane increase 1/-SN
• Undertorque 1/ or proclined /1-MP reduce the Md sagittal advancement
• Flattened curve of Spee
✦ Any modification after surgery may reopen the bite
Normodivergent Cases
North shore of Ste-Laurence river + Mont Ste-Anne
©sylvainchamberland.com
Normodivergent case
• Aim for ideal 1/ -SN and /1-PM prior to surgery
• Assess the amount of retraction of incisors in extraction cases
• Flattened curve of Spee to obtain maximum intercuspation at surgery
©sylvainchamberland.com
Class II div 2• Moderate ALD
DaMo18012011
©sylvainchamberland.com
• FMA = 23°
• /1-PM = 98°
• 1/-SN = 100°
©sylvainchamberland.com
Tx Plan• Exo 15, 25, 35, 45
• Assess 1/ & /1
✦ /1:retract 1 mm; /1: retract 3 mm
• BSSO advancement ~ 4,7 mm
©sylvainchamberland.com
Prior to Surgery
• Full dimensional archwire
DaMo 22052013©sylvainchamberland.com
• 1/-SN = 104°
• /1-PM = 95°
DaMo 22052013 119 w
©sylvainchamberland.com
Post Surgery Orthodontics• Cl II elastics
• Finishing bend
DaMo 02072013 ©sylvainchamberland.com
Tx time 138 weeks• Class I occlusion
DaMo 02102013
©sylvainchamberland.com
• Ideal 1/ & /1 angulation
✦ /1-MP = 92°; 1/-SN = 105°; 1/1 = 129°
©sylvainchamberland.com
©sylvainchamberland.com
Class III• Excess of space
• Retroclines /1; proclined 1/
Br-Ca Ste 13-04-2016 16y 9m
©sylvainchamberland.com
• FMA = 26°
• /1-PM = 76°; 1/-SN = 116°
• Witts (ABOP) = -15 mm
• Cant of occlusal plane
Br-Ca Ste 13-04-2016 16y 9m
©sylvainchamberland.com
Visual Treatment Objective
Br-Ca Ste 13-04-2016 16y 9m
Dental objective
©sylvainchamberland.com
Progress at 36 weeks• TADs used as indirect anchorage
to assist molar protraction
• Friction will likely help proclining lower anteriors
Br-Ca Ste 07-02-2017 17y 7m
©sylvainchamberland.com
Progress at 44 weeks
Br-Ca Ste 07-02-2017 17y 7m
Br-Ca Ste 04-05-2017 17y 10m ©sylvainchamberland.com
Progress at 62 weeks
• 20x25 SS will be followed by 21x25 TMA/21x25SS
Br-Ca Ste 04-05-2017 17y 10m
Br-Ca Ste 08-08-2017 18y 1m
©sylvainchamberland.com
•1/-SN = 106°
• /1-MP = 82°
•OJ = -14 mm; witts = -18 mm
•Md growth did occur
Br-Ca Ste 08-08-2017 18y 1m
©sylvainchamberland.com
3D Surgical Planning ProPLan CMF
©sylvainchamberland.com
21 Days Post Op• Finishing box elastics
Br-Ca Ste 21-12-2017 18y 6m©sylvainchamberland.com
•Bone graft infraorbital (bone came from the chin)
•Bad split on the left side
©sylvainchamberland.com
Final
• Tx time: 92 weeks
Br-Ca Ste 05-08-2018 18y 10m
Witts = -6 mm
©sylvainchamberland.com
Improuved Self-Esteem
©sylvainchamberland.com
Follow up at 11 Months
©sylvainchamberland.com
Normodivergent case
• Aim for ideal 1/ -SN and /1-PM prior to surgery
• Assess the amount of retraction of incisors in extraction cases
• Flattened curve of Spee to obtain maximum intercuspation at surgery
Hypodivergent
Ste-FamilleÎle d’Orléans ©sylvainchamberland.com
Hypodivergent Cases• Accept non ideal proclined /1-PM prior to surgery because of chin
prominence or dentoalveolar retrusion at baseline
• Aim for ideal 1/-SN
• Flat curve of Spee prior to surgery
• Promote extrusion of mandibular teeth while leveling
• Clockwise rotation of the distal segment occur in Md advancement, hence help increasing facial height
©sylvainchamberland.com
• Hypodivergent, FMA = 16°
• Proclined: 1/-SN = 121°, /1-MP = 103°
• Vertical insufficiency of lower facial height
©sylvainchamberland.com
Class II div 1• Deep overbite impinging palate
• Mx spacing
• Light Md crowding
KaVe05052012
©sylvainchamberland.com
Tx goal
• Increase vertical dimension
• Place 1/-SN = 103° (upright incisors)
• Maintain (not procline) /1-PM
©sylvainchamberland.com
Tx Plan• Le Fort 1:
✦ Advancement 4,6 mm
✦ Downward at ANS
✦ Upward at PNS
• BSSO
✦ Advancement 6 mm
✦ Clockwise rotation of distal segment
©sylvainchamberland.com
Mecanotherapy
• Hawley anterior bite plane
• Md: tip back mechanism
✦ Alignement in 3 segments
✦ Intrusive arch attached to /3s
• Goal: promote maximum posterior eruption of md teeth
©sylvainchamberland.com
At 36 weeks • Presurgical reassessment
• 20x25SS U & L
KaVe05022013
©sylvainchamberland.com
•Reassessment of surgical plan: No need for mx surgery
•Curve of Spee is leveled without /1 proclination
•Uprighted: 1/-SN = 105°
•Uprighted: /1-PM = 99°
©sylvainchamberland.com
©sylvainchamberland.com
At 50 weeks
• Post Surgical Orthodontics
©sylvainchamberland.com
65 weeks
• Class I occlusion
©sylvainchamberland.com ©sylvainchamberland.com
©sylvainchamberland.com
Class II div 2• Cl II subdivision right
• Deep overbite
• Md midline deviated to the right
GeRo12042010©sylvainchamberland.com
• Short anterior face height
• Prominent chin
GeRo12-04-2010
©sylvainchamberland.com
Tx Plan
• Place 1/-SN = ~100°
• Level curve of Spee by posterior extrusion
• Maintain /1-MP
• BSSO advancement ~5 mm
• Génio: Elongation 2 mm (?)
©sylvainchamberland.com
Mechanotherapy• Mx anterior bite plan
• Align and level
GeRo21062010
©sylvainchamberland.com
• Follow up 3 months
✦Mx anterior torque improved
✓ 21x21Dwire
✦Md: 19x25 TMA reverse curve Andrews
GeRo21062010
GeRo20092010 ©sylvainchamberland.com
• Mx: bond 6s. Stop Anterior Bite plane
✦ Md curve of Spee leveled
GeRo20092010
GeRo01112010
©sylvainchamberland.com
• Mx: Anterior root torque auxiliary for 6 weeks
✦20x25 SS U & L.
• Preop at 65 weeks
GeRo01112010
GeRo08082011
©sylvainchamberland.com
• At 65 weeks
• 1/ to SN improved from 72° to 100°
• /1-MP proclined 99° to 107°
©sylvainchamberland.com
At 74 weeks• Post surgical orthodontics
• Class II elastics
GeRo08102011
©sylvainchamberland.com
Complication
©sylvainchamberland.com
Final Outcome• Tx time = 106 weeks
• Class I occlusion
GeRo23-05-2012©sylvainchamberland.com
• Improved profile
• Increased vertical dimension
GeRo23-05-2012
GeRo12-04-2010
©sylvainchamberland.com
Hypodivergent Cases• Accept non ideal proclined /1-PM prior to surgery because of chin
prominence or dentoalveolar retrusion at baseline
• Aim for ideal 1/-SN
• Flat curve of Spee prior to surgery
• Promote extrusion of mandibular teeth while leveling
• Clockwise rotation of the distal segment occur in Md advancement, hence help increasing facial height
©sylvainchamberland.com
©sylvainchamberland.com
What Happens if There is Lack of Communication with the Oral Surgeon?
• It is important for the orthodontist to understand the surgical tx planning
• Sometimes, the surgeon may not do what you had planned
• Some orthodontists don’t have a clue on surgical tx planning
©sylvainchamberland.com
Surgical Treatment Planning
•Exo 5s/4s
•BSSO: advancement ~6 mm
•Génio: advancement ~ 7 mm + vertical reduction ~ 1,5 mm
©sylvainchamberland.com
Presurgery
•Tips: note .016 niti root spring
✦Elastomeric chain to correct rotation of 4s & 6s
•Exo 15, 25, 44, missing 36
©sylvainchamberland.com
Outcome
• The surgeon did not perform the genioplasty as planned at baseline!
✦ Some lip incompetency persist
✦ Profile would have benefit from advancement of the chin
• It is important to reassess WITH the surgeon, the final surgical Tx plan.
✦ If I would have paid more attention to presurgical report of the surgeon, I would have pick the missing genio in the surgical plan
©sylvainchamberland.com
Surgical Treatment Planning
• Exo 5s
• BSSO: Advancement 5 mm
• Genio: Advancement 3 mm to obtain normal /1-APg & lip comptency
©sylvainchamberland.com
Presurgey
• Normodivergent
• 1/-SN = 100°
• /1-PM = 93°
©sylvainchamberland.com
Outcome
• Nice occlusal outcome
• Patient would have benefited from advancement genioplasty as it was planned
©sylvainchamberland.com
• Thanks for your attention
• Merci de votre attention
323
À la mémoire de William Robert Proffit
Sylvain CHAMBERLAND*
* Auteur pour correspondance : [email protected]
Orthod Fr 2018;89:323–326© EDP Sciences, SFODF, 2018https://doi.org/10.1051/orthodfr/2018038
Disponible en ligne sur :www.orthodfr.org
In Memoriam
C’est avec une très grande tristesse que j’ai appris, au lendemain du 30 septembre 2018, le décès du Dr William Robert Proffit, dit Bill ou Prof. J’aurais aimé le revoir dans d’autres circonstances que pour assister à son service commémoratif, le 6 octobre à la Carol Woods Retirement Community de Chapel Hill, NC.
J’ai fait la connaissance du Dr Proffit en 2001, lors d’un séminaire d’une semaine à l’université de Caroline du Nord. Cette rencontre a eu un impact déterminant et indélébile sur ma carrière professionnelle, comme sur celle de plusieurs autres et j’aimerais lui rendre hommage ici.
Je me rappelle encore très bien notre discussion à propos de l’expansion palatine assistée chirurgicalement. En applanissant nos divergences d’appréciation sur la stabilité après Le Fort 1, il m’avait jeté un regard particu-lier en proposant de m’aider à publier mes données de cas, qui étaient systématiquement consignées en vue de pouvoir éventuellement les analyser ultérieurement de façon rigoureuse. Ceux qui connaissent Prof se rappellent ce regard. J’ai pu comprendre, en discutant avec le Dr David Sarver, que j’avais alors goutté à la technique de motivation préférée du Dr Proffit, celle de la carotte et du bâton. La carotte était l’article à publier. Le bâton, lui, était la condition pour atteindre ce but : il faut travailler très dur. Une de ses qualités les plus merveilleuses était son aptitude extraordinaire à mobiliser, guider, encadrer et maintenir l’effort et l’action. William Proffit savait générer la motivation en créant des opportunités de coopération où vous appreniez la signification du mot travail. C’est ainsi que s’est établie une collaboration de 17 ans menant à la publication de trois articles et un quatrième « sous-presse » lorsqu’il nous a quitté.
L’impact de William R. Proffit sur l’Orthodontie dépasse son influence sur la pléthore d’orthodontistes ayant eu le privilège de collaborer avec lui de près ou de loin. Sa rigueur scientifique, dont ses pairs gardent un souvenir personnel, a contribué à établir les jalons de la recherche clinique en orthodontie. Plusieurs s’enten-dront pour dire qu’il a élevé la profession orthodontique en promouvant des standards scientifiques appuyés par les données probantes (evidence-based practice). Il prônait d’ailleurs la réserve et un ton posé dans l’écriture académique. Il disait souvent : « Si tu affirmes quelque chose, c’est soit un fait, soit une opinion. Si c’est un fait, tu dois être capable de citer la référence ; si c’est une opinion, dis que c’est une opinion ».
Ce ton était d’ailleurs combiné à un judicieux sens de l’observation. Lorsque je ressentais un doute quant à la validité des résultats d’une étude, je lui demandais souvent conseil. Il avait le don d’identifier correctement l’erreur dans un article. Voici un commentaire qui revenait régulièrement : « This study is an excellent example of misplaying soft variables in an attempt to support predetermined conclusions, which in fact were not supported by the data they reported » (cette étude est un excellent exemple de mauvaise utilisation de variables confondantes dans le but de soutenir des conclusions prédéterminées, qui en fait n’étaient pas corroborées par les données rapportées).
Merci, Dr Proffit
©sylvainchamberland.com
• Thanks for your attention
• Merci de votre attention
Church Ste-Famille Îles d’Orléans