presurgical orthodontic prepatation for optimal outcome aao ......presurgical orthodontic...

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


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


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


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


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



• 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



• Proclination of Md Incisors-Cl II

✦ Affect the aesthetic outcome

AuSan initial AuSan préop

AuSan final ©sylvainchamberland.com


• Too much retraction of 1/

• Decrease the amplitude Md advancement

• Increase chin advancement to compensate

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Beginner’s error


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


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


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


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


Open Bite + Bimax Protrusion

•Extraction of all 2nd Pm

•Mx: Space closed on segmented arch

✦ Self leveling of Mx Curve of Spee

Initial Presurgical


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


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


Skeletal Etiology of OpenBite

Distance apex-hard palateOcclusal plane Short ramus

Gui-Dev Ma26-05-14Ra-Ch-An14-09-17

VME No VME


Skeletal Etiology of OpenBite

Distance apex-hard palateOcclusal plane

Ra-Ch-An14-09-17Blo Ja 28-11-18 Mel Moris 25-10-17


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


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


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


Change of Occlusal Plane

Counterclockwise rotation

LachSab


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°


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



• 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



• 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


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


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


What is the Advantage of Presurgical Flat Curve of Spee

• Permits optimal occlusal outcome per-op


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


What Can be Done After Surgery?• Root parallelism

• Finishing and detailing posterior occlusion

• Minor transverse problems

• Closing residual space if any


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


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


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?


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.


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


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


• 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


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 ?


Visual Surgical Treatment ObjectivesVTO

• Dental objectives

• Surgical objectives


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


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


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

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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


End of distraction

• Note the position of the screw in line with 1st molars


Pre Phase 2 Surgery• Arch coordination

• Midline coincident

LiDu17102012


Dental Arch Symmetry


• Upright lower incisors, /1-PM = 84°

✦ Permit max md advancement

• Too upright upper incisors

✦ But Mx advancement is planned


• Class I occlusion achieved

• Coordinated arch form

LiDu06052013


• 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


• Counterclockwise rotation of occlusal plane +

• Full dimensional 21x25 finishing wire

✦Help to improve 1/-SN from 79° to 87°


• At 61, she feel younger and healthier than in her mid 50s

LiDu08092015

Follow up 2 years


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


• Hyperdivergent, FMA = 41°

• Vertical excess: maxilla and lower facial 3rd

• Laterodeviation to the right

• Bimax dentoalveolar protrusion


• Left condylar hyperplasia (or right condylar hypoplasia)

• Impacted 3rd molars


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


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


3D Planning


3D Planning


3D Planning

• Counterclockwise rotation of occlusal plane 2°


3 weeks post op•Arch change

•Finishing elastics

LaVi 17-05-2017


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


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


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


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


Class II div 2• Moderate ALD

DaMo18012011


• FMA = 23°

• /1-PM = 98°

• 1/-SN = 100°


Tx Plan• Exo 15, 25, 35, 45

• Assess 1/ & /1

✦ /1:retract 1 mm; /1: retract 3 mm

• BSSO advancement ~ 4,7 mm


Prior to Surgery

• Full dimensional archwire

DaMo 22052013©sylvainchamberland.com

• 1/-SN = 104°

• /1-PM = 95°

DaMo 22052013 119 w


Post Surgery Orthodontics• Cl II elastics

• Finishing bend

DaMo 02072013 ©sylvainchamberland.com

Tx time 138 weeks• Class I occlusion

DaMo 02102013


• Ideal 1/ & /1 angulation

✦ /1-MP = 92°; 1/-SN = 105°; 1/1 = 129°



Class III• Excess of space

• Retroclines /1; proclined 1/

Br-Ca Ste 13-04-2016 16y 9m


• FMA = 26°

• /1-PM = 76°; 1/-SN = 116°

• Witts (ABOP) = -15 mm

• Cant of occlusal plane

Br-Ca Ste 13-04-2016 16y 9m


Visual Treatment Objective

Br-Ca Ste 13-04-2016 16y 9m

Dental objective


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


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


•1/-SN = 106°

• /1-MP = 82°

•OJ = -14 mm; witts = -18 mm

•Md growth did occur

Br-Ca Ste 08-08-2017 18y 1m


3D Surgical Planning ProPLan CMF


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


Final

• Tx time: 92 weeks

Br-Ca Ste 05-08-2018 18y 10m

Witts = -6 mm


Improuved Self-Esteem


Follow up at 11 Months


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


• Hypodivergent, FMA = 16°

• Proclined: 1/-SN = 121°, /1-MP = 103°

• Vertical insufficiency of lower facial height


Class II div 1• Deep overbite impinging palate

• Mx spacing

• Light Md crowding

KaVe05052012


Tx goal

• Increase vertical dimension

• Place 1/-SN = 103° (upright incisors)

• Maintain (not procline) /1-PM


Tx Plan• Le Fort 1:

✦ Advancement 4,6 mm

✦ Downward at ANS

✦ Upward at PNS

• BSSO

✦ Advancement 6 mm

✦ Clockwise rotation of distal segment


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


At 36 weeks • Presurgical reassessment

• 20x25SS U & L

KaVe05022013


•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°



At 50 weeks

• Post Surgical Orthodontics


65 weeks

• Class I occlusion

©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


Tx Plan

• Place 1/-SN = ~100°

• Level curve of Spee by posterior extrusion

• Maintain /1-MP

• BSSO advancement ~5 mm

• Génio: Elongation 2 mm (?)


Mechanotherapy• Mx anterior bite plan

• Align and level

GeRo21062010


• 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


• Mx: Anterior root torque auxiliary for 6 weeks

✦20x25 SS U & L.

• Preop at 65 weeks

GeRo01112010

GeRo08082011


• At 65 weeks

• 1/ to SN improved from 72° to 100°

• /1-MP proclined 99° to 107°


At 74 weeks• Post surgical orthodontics

• Class II elastics

GeRo08102011


Complication


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


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



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


Surgical Treatment Planning

•Exo 5s/4s

•BSSO: advancement ~6 mm

•Génio: advancement ~ 7 mm + vertical reduction ~ 1,5 mm


Presurgery

•Tips: note .016 niti root spring

✦Elastomeric chain to correct rotation of 4s & 6s

•Exo 15, 25, 44, missing 36


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


Surgical Treatment Planning

• Exo 5s

• BSSO: Advancement 5 mm

• Genio: Advancement 3 mm to obtain normal /1-APg & lip comptency


Presurgey

• Normodivergent

• 1/-SN = 100°

• /1-PM = 93°


Outcome

• Nice occlusal outcome

• Patient would have benefited from advancement genioplasty as it was planned


• 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


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