treatment planning of surgical orthodontic cases dgkfo

Treatment Planning of Surgical Orthodontic Cases

Kieferorthopädie auf den Punkt gebracht11. - 14. Oktober 2017

World Conference Center Bonn

Consensus Sequence: Pre- and Post-Surgical Orthodontics

©sylvainchamberland.com

Orthodontic plan Preliminary surgical plan (STO ou VTO)

Presurgical Orthodontics

Final surgery plan

Orthognathic surgery

Minimal postsurgical orthodontics

Courtesy of Dr Bill Proffit

http://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



Problems Created by Inadequately Decompensated Incisors

• Inadequate incisor positioning

✦ Can compromise buccal interdigitation

✦ Can substantially affect the aesthetic outcome

• Adequate preoperative decompensation

✦ Mandatory for ideal outcomes

• Normalizing incisor inclination only by surgical movement without appropriate preoperative decompensation can increase the surgical morbidity and compromise the facial esthetics 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



Retroclination of Mx Incisors-Cl II•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, Sem.Ortho 1999;5: 257-274



Proclination of Md Incisors

• Decrease the amount of md advancement

• Increase the chin advancement to compensate for the lack of Md advancement



Self-criticism

• Patient had SARPE + + bimax surgery, non exo

• We can ask if extraction of 2nd Pm to obtain better pre-surgical incisor position and 1 bimax surgical phase would have provide a better profile outcome

AuSan initial AuSan préop AuSan final AuSan follow up 2 ans



Self-criticism

•Too much retraction of 1/

•Decrease the amplitude Md advancement

• Increase chin advancement to compensate pour compenser

11/11/66 11/11/9024yr 0mo femaleinitial

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11/11/66 11/12/9226yr 1mo femalefinal

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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



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



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



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 remodeling

Initial Presurgical

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 should be made to extrude anterior teeth

✦ Leveling will be made surgicallyViLa 29-11-2015 ViLa 24-01-2017



Skeletal Etiology of OpenBite

Distance apex-hard palateOcclusal plane

Short ramus



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

✦ Coïncident with the arch form



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



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 postsurgery

• Leveling the curve of Spee?

✦ On this point, Dr Profit and I have a different opinion

✓ On the other hand, when it says "level / depress lower 2nd molars", it is like leveling the curve of Spee



• "In patients who will have surgery, often it is advantageous to use the surgery rather than just tooth movement to make vertical changes. If so, the orthodontist should not, indeed must not, automatically level the arches during the presurgical treatment. A better result may be achieved by completing the leveling postsurgically.”

• My opinion:

✦ Yes maybe, but the better I can level preop, the less I will have to do postop.

✦ 1 or 2 more months in preop preparation is not wasted timeProffit WR., White RP. Sarver DM.,Contemporary treatment of dentofacial deformity Mosby 2003, p 254



Dr Proffit’s Reply• I guess the point on which we disagree is that leveling first and

managing it to minimize intrusion and labial tipping increases total treatment time because there’s no occlusal resistance to postsurgical leveling and it happens more quickly. But you’re right, there might be a small increase in postsurgical time. I would put it that a considerable increase in presurgical time might produce a slightly shorter postsurg time.

Prof

Personal communication, January 10, 2016



What Can be Done After Surgery?•Root parallelism

• Finishing and detailing posterior occlusion

•Minor transverse problems

•Closing residual space if any



Pre-Surgical Preparation•Courbe de Spee = 0

• Leveled marginal ridges

•Extraction site closed

•Alignement of the cusp MD



Per op

•Favour maximum interdigitation

•Do not leave posterior openbite

✦ To close an anterior openbite


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 position

Courtesy 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?



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



Orthosurgical Tx vs Surgery 1st

•We are in the era of fast food and there is a clientele for fast food

✦ A Big Mac, it is eaten fast, but it take times to digest…

✦ A good meal take more time

•An orthosurgery tx requires surgical decompensation certainly, but the post surgery finish 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




Syurgery 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).




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

✓ Stability

Hernandez-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



Surgery 1st

•What about the risk of necrosis of certain segments?Hernandez-Alfaro F et al, Surgery first in orthodontics: what have we learned? J Oral Maxillofac Surg 72:376-390, 2014 (February).

FIGURE 2. In cases in which the maxilla is not segmented, 4 transmucosal 2.0-mm miniscrews are placed.

FIGURE 3. Bimaxillary surgery with maxillary segmentation A, before and B, after the execution of buccal interdental corticotomies with a piezoelectric device to accelerate postoperative orthodontic movement. In addition to the longitudinal cortical cuts, selective cortical drilling was performed to further promote the regional acceleratory phenomenon.

FIGURE 3. B, Cortical bone from the maxillary osteotomy was used to graft the right gap of the frontal maxillary segment.



FIGURE 4 (cont’d). D, Final occlusion with end splint. Eight transmucosal 2.0-mm miniscrews were used to stabilize the occlusion. These were placed between the canines and the first premolars and between the second premolars and the first molars. The front segment of the segmented maxilla was not fixated with osteosynthesis material to allow for precise vertical control of the postoperative overbite.

FIGURE 4. Bimaxillary surgery with maxillary segmentation and mandibular front-block osteotomy. A, Preoperative occlusion

FIGURE 4B. Virtual planning of mandibular segmental osteotomy 4C. Intraoperative view of mandibular segmental osteotomy. The regional acceleratory phenomenon was enhanced with the execution of buccal corticotomies.

Hernandez-Alfaro F et al, Surgery first in orthodontics: what have we learned? J Oral Maxillofac Surg 72:376-390, 2014 (February).



• 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?



Timing of Surgery in the Sequence of Treatment

•Ray White’s thought:

✦ “With good data for the consensus sequence outcomes and no data to support surgery first, why would you do that?”




Surgery 1st

•For me, it’s like a return of 40 years back

• This reminds me of the case of a dental assistant who worked for me in 1986 ...



●Retention

Historic: My first case!

●Presurgical orthodontic preparation

●Finition

~1986


Merci de votre attentionAvez-vous des questions ?

©sylvainchamberland.com Wolford LM, Chemello PD, AJODO 1994;106:304-16

Change of Occlusal Plane ●Clockwise rotation decrease incisor ∠ ° + chin projection ●Counterclockwise rotation increase incisor ∠ ° + chin projection ●The same apply to /1-MP



Lesson from the past

•What is the classic orthodontic preparation for an open bite?

✦ Do not extrude 1/?

✦ Maintain 2 mx occlusal plane?

DaPe230597



Problems• Presurgical orthodontics

✦ Bimax protrusion was not addressed

✓ Proclined upper incisors

✓ Prominent lower lip & /1

‣ Imply more genio advancement

DaPe03089



• A decent occlusion is achieved, but chin is still deficient AP

✦ A 2nd genio was performed 1 month post debonding

• Moreover…



•Pulpal necrosis #24

•Relapse Cl II & Xbite on the right side

•Chin is still deficient AP despite a 2nd genio

DaPe03-06-2003 follow up 5 years



•Relapse can be explained by condylar resorption

DaPe23-05-97

DaPe 03-06-03



May I say

•Such preparation was doomed to fail.


Hyperdivergent Cases

Pont de l’Île d’Orléans


Hyperdivergent Case•Assessment of /1-MP

•Assessment of 1/-SN

• Flat curve of Spee prior to surgery

•Superior repositioning of the maxilla

✦ Clockwise or counterclockwise rotation

✓ Effect on 1/, /1, chin projection



Class II div 1•Constricted Mx

•Missing 46

•Md dental asymmetry

• Lower midline deviation to the right

LiDu19012011 56a



• 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 34

•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

Dr. Sylvain Chamberland

Quick Ceph® Studio

Name: Line DubéBirth: 16/12/1954 Status: Tx chir bimaxGender: Féminin Record: 19/01/2011

Case: 5800:2011-004 Age: 56Année 1mo

Disclaimer: This presentation is a SIMULATION ONLY and is not intended to be a guarantee of the actual orthodontic or surgical results.

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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


Quick Ceph® Studio

Name: Line DubéBirth: 16/12/1954 Status: Tx chir bimaxGender: Féminin Record: 19/01/2011

Case: 5800:2011-004 Age: 56Année 1mo




End of distraction

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



Pre Phase 2 Surgery•Arch coordination

•Midline coincident

LiDu17102012



•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 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



Class I Open Bite•Girl, 16 y

•Moderate crowding

Be.M-J 21-08-08, tx initiated 08-09-2008



•Lip Incompetency

•Bimaxillary protrusion

•Hyperdivergent, FMA = 31°



• Impacted 3rd molars



Tx Plan

•Goals

✦ Reduce dentoalveolar protrusion

✦ Maintain class I dental relationship

✦ Obtain lip competency

✦ Obtain normal vertical proportion



Tx Plan•Specific treatment objectives



Prior to surgery•At 85.6 weeks

✦ Class I relationship is maintain

✦ Normal OJ and OB is obtained

✦ Mx space closed segmentally

✓ Autolevelling of Mx C. of Spee

Be.M-J 30-04-10, at 85.6 weeks



• Impacted molars were removed > 6 months prior to surgery



Prior to surgery

•Lip incompetency persist

•Patient was asked if she still want surgery

•Note uprighted /1-PM = 87°



15 days post surgery

•Change surgical archwire

•Vertical elastics



•Tx time = 109 weeksBe.M-J 13-10-10, at 109 weeks



•Upright lower incisors permits nice AP relationship and facial profile



She’s Happy!

Be.M-J 13-10-10



Class II div 1•Severe ALD

•Deep OB impinging palate

•Prominent Mx incisors

SeMa280308



•Hyperdivergent, FMA 31°

•Procline 1/ = 112°

•Retrocline /1 = 80°



Tx Plan

•Exo 4s/4s

✦ Retrospectively, I would likely extract 5s/5s

•BSSO

•Presurgical leveling



• Md: Intrusive arch attached to /3s and /1-1

• After 7 months of leveling

SeMa171208

SeMa100609



At 25 months•Arch leveling is achieved

SeMa05082010



• /1-PM = 84° (improved)

• 1/-SN = 96° (slightly too upright)



•Nice occlusion

✦ But we may argue that more proclined 1/ could have helped achieve better cl I relationship

SeMa25042011



•Bimax surgery

✦ Mx+ Md advancement


©sylvainchamberland.com Apple orchard, île d’Orleans



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

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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


Quick Ceph® Studio

Name: Virginie LaquerreBirth: 08/05/1986 Status: Traitement1Gender: Féminin Record: 20/10/2015Case: 2015-069 Age: 29Année 5mo




At 30 weeks•Mx: 16X22 SS

•Md: 21x21x20 SS en masse retraction

• 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



•Loss of 1/ torque

• /1 retracted 5,4 mm

LaVi24-01-2017



3D Planning



3D Planning: Maxillary Movement

•C3-piece maxilla, midline 1mm left, cant corrected, 6mm anterior impaction, 5mm posterior impaction, 2mm advancement, 1.5º CCW yaw rotation

•CR at central incisor



3D Planning: Mandible Movement•Mandible moved into

occlusion with planned maxilla

✓ Advance 1 mm on the right

✓ Set back 3 mm on the left

✓ Midline 2,3 mm to left

•Genio

✦ 5mm advancement,

✦ 5mm impaction

✦ right edge brought down



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

LaVi 21-09-2017



• Improved profile

• Lip competency

•Normal LAFH



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


●Cl II subdivision right

●Upper midline deviated to the left

●Deep curve of Spee

●Moderate ALD

StRo10-10-2001



●Retrognathic mandible

●Proclined lower incisors

●TMJ: normal

●Impacted 3rd molars

★To be removed 1 y prior to surgery

SR 3

StRo10-10-2001



Tx Objective•Tx Objective

✦ Maintain 1/ NA ~ 16° (minimal retraction)

✦ Obtain /1- MP ~ 90° (maximal retraction)

✦Coordinate upper dental midline to columella

•Tx Plan

✦Exo 14, 25, 34, 44

✦Md advancement BSSO

•Alternate tx plan

✦Non surgical?? exo 14, 25, 35, 45?



●After a visit to her dentist for annual dental exam and cleaning

●Limited mouth opening, pain into or near the left joint

●Deflection to the left on opening

●Disc displacement without reduction left TMJ

At 10 months



• 10 months into tx

✦ Mx: 16x22 cnt, rebond #26 / 21x25 SS ret en masse

• 15 months into Tx

✦ Mx & Md: 21x25 SS



At 18 months•1 day prior to surgery

✦ Surgical post

✦ Full dimensional archwire for 3 months



•Upper midline coïncident

• 1/ SN ~ 96° (maintained, but retracted 3mm)

•/1- MP ~ 91° (retracted 4 mm)



TMJ

•Appears normal



Presurgical models

●If models fits in class I relationship, teeth will fit



•Occlusal adjustments done on models are repeated into the mouth

•New models for the surgeon are made

•Note the arch symmetry



20 days post surgery•Class I occlusion

•Maximum intercuspation

•No intermediary splint



•Tx time: 23 months

•Coordinated arch form

•Class I occlusion



Follow up 13 years•Came back because of left TMJ clicking and

pain

•Deviation to the left on opening

•Had a car accident in late 2002

•Had a DDWR may 2002

StRo16-06-2016



At Debond

•TMJ appears normal



At Follow up

•Right condylar resorption

•Osteophyte on left condyle

•Referred to Oral Surgeon



Class II div 2•Moderate ALD

DaMo18012011



•FMA = 23°

• /1-PM = 98°

• 1/-SN = 100°



Tx Plan

•Exo 15, 25, 35, 45

•BSSO advancement ~ 4,7 mm



Prior to Surgery

•Full dimensional archwire

DaMo 22052013



•1/-SN = 104°

• /1-PM = 95°

DaMo 22052013 119 w



•Post surgery orthodontics

•Cl II elastics

• Finishing bend

DaMo 02072013



Tx time 138 weeks•Class I occlusion

DaMo 02102013



• Ideal 1/ & /1 angulation

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



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


•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 II div 2•Cl II subdivision right

•Deep overbite

•Md midline deviated to the right

GeRo12042010



•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



•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


GeRo23-05-2012



• 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



Benefits from Genioplasty

• Bone apposition at the labial surface of the chin extending above B point

• Therefore, a sliding genioplasty (advancement and vertical reduction) would likely improve the periodontium of 31-41

Chamberland et al, Genioplasty in growing patient, AO may 2015



Complication

•Tooth #48 was extracted at the surgery

2 weeks post surgeryStDu 17022015 StDu17032015

7,6 weeks post surgery



Complication

•Indicators of chronic inflammation (bleeding on probing) exist in periodontal pockets (≥ 4 mm) in and around asymptomatic third molars and should be recognized as possible predictors of future progression of periodontitis..

• Pathogenic bacteria (red and orange complexes) in clinically significant numbers exist in and around asymptomatic third molars

White paper on third molars, AAOMS, 2007 Garaas et al, Prevalence of Third Molars With Caries Experience or Periodontal Pathology in Young Adults, JOMS 2012 White RP, Proffit WR. "Evaluation and Management of Asymptomatic Third Molars: Lack of Symptoms Does Not Equate to Lack of Pathology. AJODO 2011

He had the classic opening down the exposed side of the crown, and it looks to me as if he had a possible lesion in the bone adjacent to the root at the time of the extraction. The partially exposed third molars are the dangerous ones. Prof (Jan 23, 2016)




•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




•Exo 5s/4s

•BSSO + Genio



Presurgery

• 1/-SN = 83°: torque loss while retracting (patient went Afganhistan tour. I had to catch up tx time, too heavy force while closing space)

✦ That will reduce md advancement and increase the need for genio advancement

• Hypermobile lip shows gummy smile, but normal incisor showing at repose



Outcome

•An impaction too far…

OUCH!



• Maxilla is embedded

• Moreover, clockwise rotation of the occlusal plane change /1-PM

✦ Chin had to be advance to compensate for posterior rotation of the md distal segment

• No incisor showing at repose



Outcome

•Extrusive mechanics was used to promote incisor eruption

• Too upright 1/ impaired canine relationship




•Normal Incisor showing

•Exo 5s/5s

•BSSO + Genio



Presurgery

•Normal smile display

•Md advancement + genio (advancement & vertical reduction) is all she need



Outcome

•I called the surgeon 2 days prior to surgery to tell him that she did not need mx impaction because her 6 mm incisor showing is normal at her age

•He did not listen…

•Moreover, mx midline is 2 mm to the left

Ouch!



Outcome

•???

• Incisor showing at repose ~ 0 mm

•Loss of vermillion

•Smile display ???



Epilogue•Underwent a 2nd orthognathic surgery

• Le Fort 1

✦ Inferior repositioning of the Mx

✦ 2 mm to the right for Mx midline

•OSMB

•Genioplasty: vertical reduction



•Thanks for your attention

•Merci de votre attention

Church Ste-Famille Îles d’Orléans


treatment planning of surgical orthodontic cases dgkfo

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