mulitidisciplinary orthodontic treatment case report

Multidisciplinary Orthodontic treatment

Case report Dr Sylvain Chamberland

D.M.D., Cert. Ortho. M.Sc.

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©sylvainchamberland.com

•Class III

•Mutilated dentition

HeAr030909

http://sylvainchamberland.com


•Tx Plan?



At baseline•Vector TAS mesio buccal + Palatal of 26

✦ Intrusion of 26

•Melsen TAD at #36 site

✦ Protraction of 38

HeAr280909



At 21 weeks

•Mx: .016 cnt. #26 engaged

•Md: .020 x .020 cnt. Passive elastomeric chain 38-TAD

HeAr280909

HeAr230210



At 44 weeks•Reassessment of bracket position, arch coordination

•Models to assess fitting of the occlusion for the surgery

HeAr050810



At 68 weeks•Prior to surgery

(planned in April)

•Dental arches are coordinatedHeAr050810

HeAr170111



•Prior to surgery and bone grafting

• #38 protracted + uprighted

•Orthodontic decompensation achieved

HeAr170111



At 85 weeks

•2-3 weeks post-surgery

•Autogenous bone graft from right oblique mandibular line to the upper right & left mx edentulous site + resorbable collagen membrane Bio-Guide

• Le Fort 1

✦ Advancement 4 mm

✦ Inferior repositioning 2 mm

•Genioplasty: chin to the right 4 mm

HeAr160511



•At 111 weeks, Strauman implant

✓ #14: 4,1 X 12 mm bone level



✓ #36: 4,8 X 8 mm tissu level WNI

•Debonding Jan 2012

HeAr061211 115 weeks



At 125 weeks

•Debonding

✦ Mx removable retainer

HeAr061211 115 weeks

HeAr210112



•Final restauration in place

• Total tx time 128 weeks

HeAr120312



•Forward + downward mvt of the maxilla

•Posterior rotation of md



Follow up at 2 years post tx

HeAr 080514



•Se.Ca



•Class II mutilated dentition

•Vertical bite collapse

• Impacted 33, 35

SeCa2111-8



•Tx Plan?



•Diagnostic wax set up



•TAD site 46 and 36

•Wire is engage into TAD

SeCa020609



At 34 weeks•Mx: .020 xé-25 niti

•Md: .016 cnt attached to TADs

• 17x25 Niti intrusive arch attached to 33, 43, 31-41

SeCa051009



At 116 weeks•Oh! By the way I have to use a CPAP.

✦ Hein! You didn’t tell.

• I thought it was not important

•Ms: 20x25 SS reverse curve

✦ 19x15 TMA root spring

SeCa260411



•Class I relationship is achieved!

•Vertical dimension was maintained

SeCa140812



•Prior to surgery

•Root parallelism is fair

• 33 & 35 are erupted

• #47 is uprighted

SeCa1003

SeCa140812

183 weeks



•Le Fort 1

✦ Mx advancement 10 mm

✦ Bone graft form iliac crest

•BSSO

✦ Advancement 12 mm

✦ Advancement of genial process



•Bone graft from iliac crest to increase thickness of the edentulous ridge

SeCa141112



•Brackets are bonded to partial denture

SeCa190312



•Strauman implant

✦ #12-22: Bone level 4,1 X 10 mm Zirconium type

✦ #37: 4,8 X 6 mm WNI

✦ #44: 3,3 X 6 mm Zirconium

• Implant 44 failed and has been replaced

SeCa220513



•Temporary bridge....

SeCa150717



•The patient delayed the restoration 46, 44

•Will likely be done in 2015…

SeCa041213



•Ma. He.



•Class II div 2

MaHe220611



• Internal root resorption of #46



•Hopeless #46



At 61 weeks•Removal of RPE

•End of Twin Force Bite Corrector

• #47 is protracted

MaHe031012



At 96 weeks

•Class I relationship is achieved

MaHe040613



•Na.Pa.



Class II div 1

NaPa081105



•Short face syndrome

•Hypodivergent



Mechanotherapy•Anterior bite plane

• Intrusive arch + lingual arch

NaPa010206


NP_3

NaPa010206

NaPa140306


•When posturing in class I a posterior open bite is created

• This allow clockwise rotation of the distal segment when the BSSO is done

• This reduce slightly the advancement of the chin



•Face height increased

•Class I relationship is achieved

NaPa310507



2 y Follow up

•Incisor display improved

•Self esteem improved

NaPa030909



•Cl.Pe.



•Class I

•Mutilated dentition

•Wear sleep apnea device > 2 years

ClPe140512



Narval

TAP



•Horizontal bone loss in the maxilla

•Apical granuloma #42



•Retrognatic maxilla and mandible

•Mx incisors retroclination

•Md incisors proclination



Tx plan

•Apectomy #42

•Perio evaluation and clearance

•Alleviate dental compensation

•Arch coordination

•Orthognatic surgery: maxillo-mandibular advancement



•Lingual button + elastomeric chain to help derotation

•Mx + Md: .016 supercable™

ClPe120612



At 15 weeks•Md: 16x22 cnt

•Mx: ∆EC. .016 sc™

ClPe240912



At 75 weeks•Mx: EC 14-24. active coil 14-17, 24-27.

✓ ART auxilliary since 6 weeks to be maintained

•Md: 21x21x20x58 mm enmasse ret

✓ Cl III elastics

ClPe201113



At 100 weeks•Class I relationship…

•Mx: space open for implants

•Md: space closed

ClPe140514



•1/-SN: torque improved 72° to 88°

• /1-MP: retroclined 107° to 85°

•Occlusal plane improved



•Le Fort 1: 10 mm advancement, 2 mm inferior repositioning at PNS

•OSMB: advancement + counterclockwise rotation

•Genioplasty: advancement 6 mm



• Iliac bone graft between Mx bone cuts and implant sites.

•Note healing of 42 apex

•No more snoring, no more apnea

ClPe160914



137 semaines

•Dépose des appareils (31 mois)

ClPe260115



•Ke. Bi.-Du.



•Class II div 1

•Missing 17, 26, 35, 45

KeBiDu080609



•Hyperdivergent

•Retrognathic mandible

•AP chin deficiency + vertical excess

•Cant of occlusal plane



•Tx plan

✦ Visual Treatment Objectiveis mandatory



Mechanotherapy

•Tx initiated: sept 2012

•Mx: TPA to derotate and upright #26 (asymmetric mesial out activation)

✦ 32 weeks of TPA



At 47 weeks•Dental arches are pretty much

coordinated

•Md space closure to obtain optimal width of a premolar

KeBiDu080813



Pearl

• Identify the error



•Lip incompetency at repose

•Retrognathic mandible

• Lower incisors could be more upright but space for implant 35, 45 was needed



3D Surgical Planning



•At 64 weeks: Surgery

• Le Fort 1

✦ Rigid fixation



•BSSO / OSMB

•Note good fitting of the occlusion perop



•Genioplasty

•Bone graft at edentulous site



At 66 weeks (2 weeks post op)•Change arch wire + ∆ elastics

•A good presurgical orthodontic preparation permits a nice post surgical occlusion

KeBiDu171213



Tx time: 83 weeks

•Class I relationship

•Posterior segment to maintain root parallelism& avoid extrusion

KeBiDu300414



•Conterclockwise rotation of the maxilla and mandible helped to maximize mandibular advancement

•But lower incisors proclination reduced md advancement, hence symphysis needed more advancement



•Restauration implantoportée 36 et 46

•Recommandation d’une greffe gingivale au buccal de 31, 41

KeBiDu181214



•Proéminence radiculaire inférieure peut expliquer le problème mucogingival observé



•Pa.Pl



•Class I, open bite

•Severe ALD

•Bimaxillary protrusion

PaPl150512



•Lip incompetency at repose

•Gummy smile at full smile

•~Normal incisor showing at repose



Tx plan

•Extraction?

•Orthognathic surgery?

•Or ??



At 13 weeks•Tx initiated Feb.2013. TADs placed 6 weeks later.

• TPA .032 x .032 SS + paramedian TADs (Elinks)

•Buccal TADs between 15-16, 25-26 (EC)

•Buccal TADs between 36-37, 46-47 (lig. tie)

PaPl 160513



At 40 weeks•At 25 weeks the TPA was replaced because it impinged into

the palate

•At 22 weeks: Bonded .032 x .032 SS lingual arch

✦ Posterior inferior teeth are intruded with ∆ EC

•At 40 weeks, buccal EC is removed

PaPl 211113 .Md:020 x.025 SW

.Mx:020 x.025 SW



At 40 weeks•Overbite improved

•Still bimax protrusion

•Need maximum retraction

Initial

PaPl 211113



At 48 weeks•Posterior openbite is obtained

• Incisors retraction is going on with maximum anchorage

•Note the absence of the lingual arch wich which will cause expansion of the molars (adverse side effect)

PaPl 160114



At 54 weeks•Tads placed anteriorly to intrude upper incisors

•Palatal lingual ligature to maintain intrusion

• Lower incisors are still retracting

•Mx midline need shifting to the left

PaPl 270214



Repose Smile



At 71 weeks•20x25sw U & L

•Stop intruding lower teeth

•Continue upper intrusion

PaPl 230614



At 86 weeks•Removal of the TPA and intrusive links

• 2 TADs were lost or removed

PaPl 091014



•FMA decrease 4°

• /1-MP decrease 10°

✦ /1-APg decreased 3 mm

✦ /1 intrusion 2 mm

•Significant upper molar intrusion & upper incisor intrusion



•Significant profile improvement

•Competent lip at repose

• Improved smile display

PaPl 150512

Initial

PaPl 091014

Progress



•À 88 semaines

•À 93 semaines

✦ Finition

PaPl080115

PaPl151214



•Li.Nda.



•Class I, open bite

LiNda 040214



•Severe bimaxillary protrusion

•Anterior vertical excess

• Lip incompetency

•Dégagement des dents inférieures lors du sourire



At 13 weeks•Tx initiated February 25

✦ Mx: 3 segments

•At 13 weeks

✦ Mx:Tomas Pin EP 8 mm + .020x.020 cuniti

✦ Md: Tomas Pin EP 6 mm + .020x.020 cuniti

LiNda 270514



At 19 weeks

•Mx: .020x.020 Cuniti

•Md: .020 x .025 SS

✦ Retighten lower right pin

LiNda 270514

LiNda080714

Retighten



At 25 weeks

•Mx: .021x.021x.020x55 mm + Elinks #4 6-P

•Md: .021x.021x.020x58 mm + E #4

✦ Replaced lower right pin

LiNda080714

LiNda190814



At 31 weeks

• Mx: ∆ Elinks #4 6-P et E3 palatins

• Md: E5 attached to /7s

✦ LR pin loose, lig. tie on both lower pin

• Note posterior open bite

LiNda190814

LiNda290914



LiNda290914

À 37 semaines

• Mx: ∆ Elinks #4 6-P

• Md: E5 attached to /7s

✦ resserrer TAD inf droit, E4 TAD-2ePmI

• Notez béance postérieure

LiNda121114



À 42 semaines

• Mx: ∆ Elinks #5 7-P

• Md: ∆ E5 to /7s

LiNda121114

LiNda171214



• Intrusion postérieure supérieure et inférieure

•Autorotation antérieure et supérieure



•Amélioration du profil

• Persistence d’une contraction du mentionnier

• Léger excès vertical de la symphyse



•Progrès à 42 semaines

• Initial



•On continue la rétraction et l’intrusion

•Remarquer les 7s…

LaMaNda260115



•Ch.Ol.Ga.



•Classe I

•Béance antérieure

•DDM inférieure

ChOlGa220514



•Hyperdivergence squelettique

•Microrami



•Résorption condylienne ou arthrose



ChOlGa030914

Mx: 3 segments .020x.020 cnt. Tomas Pin SD 6 mm, Elinks E3 P-4Md: 2 segments .020x.020 cnt. Tomas Pin EP 6 mm, Hamac elastic

ChOlGa221014

Mx: 3 segments .020x.025niti. ∆ E3 P-4.Md: ∆ Hamac

7 weeks later



•Vector TAS 6 & 8 mm paramedian (out of stock of Tomas Pin

• TPA .032x.032SS. Elinks E6. Md: lingual arch .032x.032TMA

ChOlGa030914

ChOlGa221014

•∆ E links E6. ∆ Hamac



À 26 semaines•Fermeture significative de la béance antérieure

•Prêt pour exo des 4s

ChOlGa060115



•Amélioration du scellement labial

•Rotation antihoraire du plan occlusal

•Biproalvéolie: Exo des 4s nécessaires



• Intrusion postérieure supérieure et inférieure

•Autorotation antérieure du plan mandibulaire



What does literature say?•Intrusion of the maxillary posterior teeth can give satisfactory

correction of moderately severe anterior open bites, with elimination of 5 to 6 mm of open bite, but 0.5 to 1.5 mm of reeruption of these teeth is likely to occur.

•Controlling the vertical position of the mandibular molars so that they do not erupt as the maxillary teeth are intruded is important in obtaining a decrease in face height.

Scheffler, Nicole R. et al. Outcomes and stability in patients with anterior open bite and long anterior face height treated with temporary anchorage devices and a maxillary intrusion splint, AJODO, Volume 146 , Issue 5 , 594 - 602


©Dr Sylvain Chamberland

•Mx: 60% des patients ont une intrusion de 2 à 4 mm T1-T2

•Md: Extrusion occurs during post intrusion of mx teeth.

Percent with change in the maxillary first molar distance from the palatal plane. Note that 60% of the patients had the molar intruded 2 to 4 mm during the splint therapy for intrusion (T1-T2), but only 1 patient had greater than 4 mm of intrusion. During the postintrusion orthodontic treatment, only 2 patients (7%) had 2 to 4 mm of reeruption of the maxillary molars; during the first posttreatment year (T3-T4), 3 patients (11%) had 2 to 4 mm of downward movement, most likely caused by continued vertical growth. From the end of treatment to the more than 2-year recall, 4 patients (16%) had 2 to 4 mm of downward movement, which was also largely due to vertical growth.

Percent with change in the mandibular first molar distance from the mandibular plane. During splint therapy(T1-T2), 2 patients had greater than 4 mm of eruption of the mandibular first molars (7%), and 1 (3%) had 2 to 4 mm of eruption. During postintrusion orthodontics (T2-T3), 5 (17%) had 2 to 4 mm of eruption. During the first posttreatment year (T3-T4), 5 (19%) had an eruption of 2 to 4 mm, but 1 patient had an eruption of 2 to 4 mm. During the second posttreatment year, 4 (16%) had 2 to 4 mm of eruption, and 1 had 2 to 4 mm of intrusion.


About TADs

•I have tried Aarhus system

✦ Sterilisation tray, driver not easy to unlock from the screw.

• I have tried Vector TAS

✦ Triangular head is fine. Lack of different component for different mechanics



About TADs•I know use Tomas Pin

✦ Individual dispenser. Head is used for different system



•#47 Molar Uprithing spring

• #26 TMA root spring



•Tomas Pin 6 mm pour renforcer l’ancrage

✦ Elinks attaché sur les potences

•Évolution 12 semaines

AmCo12-08-14

AmCo29-10-14



•Évolution 18 semaines

✦ Rétraction antérieure maximisée

AmCo12-08-14AmCo29-10-14

AmCo10-12-14



•Tomas Pin SD 8 mm

CIARLANTINI R., MELSEN B., Miniscrew-Retained Ponticsin Growing Patients:A Biological Approach, JCO october 2012



•Shorter length of 12 could be explain by the long cantilever arm, but i am not sure.



6 Months Follow up

•No inflammation. Esthetic is good despite a too short incisal edge



Cope J., McFadden D.,Temporary replacement of missing maxillary lateral incisors with orthodontic miniscrew implants in growing patients: rationale, clinical technique, and long-term results, Journal of Orthodontics, Vol. 41, 2014, S62–S74



•Kokich was opposed of such approach because he pretend that it would impaired vertical growth of the crest.

•Cope et Wilmes ne semblent pas s’en inquiéter.

•Melsen a démontré qu’un TAD perpendiculaire maintient le volume BL de la crête

•Qui dit vrai?

Case 1. A. 14-year-old male patient with missing upper lateral incisors after orthodontic spaceopening. B. Mini-implants (2mm Å~ 13mm) inserted in lateral incisor spaces. C. Temporary crowns bondedto resin abutments with composite.

Mini-Implant-Supported Temporary Pontics, WILMES B,NIENKEMPER M, RENGER S, DRESCHER D,© 2014 JCO, July VOLUME XLVIII NUMBER 7; 422-9


Thanks for your attention

mulitidisciplinary orthodontic treatment case report

Health & Medicine

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