Part II-Management of class ii malocclusion with speed appliance part ii

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Clinical case presentation of CL II treatment with SPEED appliance, Forsus, Twin force bite corrector, intrusive arch. Extraction and non extraction approach are explained

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Part II-Management of class ii malocclusion with speed appliance part ii

  1. 1. Management of Class IIMalocclusion with SPEED Appliance Part II slideshare.net/sylvainchamberland www.sylvainchamberland.com
  2. 2. Clinical Case presentation • Class II div 1 and II • Twin Force Bite Corretor • Pendulum appliance and intrusive arch to level the curve of spee • Biomechanical approach for cl II div 2 (mx anterior intrusive arch) • TAD and extraction approach in hyperdivergent cases©Dr Sylvain Chamberland
  3. 3. Stacey (14 y 10 m)
  4. 4. • Class I profile • Retroclined 1/©Dr Sylvain Chamberland
  5. 5. Cl II div 2 St.De 010210, 14y 10 m • Maxillary constriction • Left posterior Xbite • Severe 1 molar mesial rotation st©Dr Sylvain Chamberland
  6. 6. Tx plan • RPE + exo 2 premolars? • RPE, non exo + cl II correctors? • RPE, non exo, molar derotation, mx anterior intrusive arch©Dr Sylvain Chamberland
  7. 7. •At 34 weeks !TFBC are installed Mx:.018 SC™ St.De 100111 Md:.020 x.020 SS Mx:.016 X .016 Sent St.De 140211 Md:.020 x.020 SS •At 52 weeks !TFBC removed !A Hilgers RPE design would have achieved derotation of the 1st molar while an Hyrax had maintained it.©Dr Sylvain Chamberland
  8. 8. At 58 weeks St.De 280311 • Mx molar de-rotation is needed • Class II elastic to wear during night • Coordination of arch form is necessary©Dr Sylvain Chamberland
  9. 9. • Mx molars distalized • /1-MP proclined by 17° • Rotation of occlusal plane noted©Dr Sylvain Chamberland
  10. 10. At 80 weeks St.De 280311 • Finishing bends here and there • Incisal recontouring©Dr Sylvain Chamberland
  11. 11. Roxane (11 y)
  12. 12. Ro.Lé 061009 • Class II div 1 • Constricted maxilla©Dr Sylvain Chamberland
  13. 13. • Skeletal class II • Proclined lower incisors • Lip trapping • Low MPA©Dr Sylvain Chamberland
  14. 14. • Fixed class II correctors (Forsus, Twin force, Herbst, etc) have a tendency to procline the lower incisors • Therefore, maxillary molar distallization was preferred for class II correction in this case©Dr Sylvain Chamberland
  15. 15. At 22 weeks Mx:.018 SC™ • Ro.Lé 060410 Class I molar relationshipx.022 neost + 17x25 niti Md:.016 obtained • Elastomeric chain to distalize the U5S • 17x25 niti intrusive arch attached at the canine to level the lower arch and minimize /1 proclination©Dr Sylvain Chamberland
  16. 16. At 45 weeks Mx:.016 SS, cinch back Ro.Lé 160910 Md:.020 x.025 Niti • Sliding mechanics on a .016 SS, cinch back ! Elastomeric chain attached to U4’s • Class I canine relationship is obtained©Dr Sylvain Chamberland
  17. 17. At 60 weeks Mx:.016 x .016 sent • Bond 7s/ Ro.Lé 281010 ! EC 12 to 22 ! Anteriors will be retracted with .017 x .025 mushroom loop • /7s will be bonded at next RV©Dr Sylvain Chamberland
  18. 18. At 67 weeks Mx:.020 x .025 Nitisw Ro.Lé 170211 Md:.020 x .025 Nitisw • Mx: Elastomeric chain 6 to 6 to maintain space closure • .020 x .025 niti for leveling prior finishing • .020 x .025 SS for finishing " 17 weeks©Dr Sylvain Chamberland
  19. 19. At 97 weeks Ro.Lé 140711©Dr Sylvain Chamberland
  20. 20. 6 weeks into retention Ro.Lé 250811©Dr Sylvain Chamberland
  21. 21. ©Dr Sylvain Chamberland
  22. 22. ©Dr Sylvain Chamberland
  23. 23. Emmanuel (14 y)
  24. 24. Em.Be 250610 • Cl II div 2 • Deep overbite • Mx molar mesially rotated©Dr Sylvain Chamberland
  25. 25. • Dished in profile • Retroclined 1/-SN & /1-MP • Increased 1/1 " 147°©Dr Sylvain Chamberland
  26. 26. Tx objective • Decreased interincisal angle • Procline 1/ and /1 • Obtain class I molar and canine relationship©Dr Sylvain Chamberland
  27. 27. Tx Plan • Forsus? • RPE? • Exo of 2 mx premolars?©Dr Sylvain Chamberland
  28. 28. • TPA .032 SS activated to de-rotate the molars • Molars distalization Em.Be 060710 • Mx 3 segments (016 x 022 niti) for alignment • Overlay 17x25 niti intrusive arch ! Anterior intrusion ! Posterior extrusion ! Tip back at buccal segment©Dr Sylvain Chamberland
  29. 29. Why the intrusive arch is overlayed and not engaged into the brackets of the incisors? • The rectangular wire would create a torquing moment • This would be balanced by anterior extrusion and posterior intrusion • That would substract from the anterior intrusive force and posterior extrusive force • The efficacy of the force sytem would be reduced • Also the intrusive force would be in-line or lingual to the center of resistance of the incisor negating the desired flairing effect©Dr Sylvain Chamberland
  30. 30. Do we need to understand orthodontic mechanics • Yes, because I said so • Yes, because... «...when a case is challenging, orthodontists know what to do.»©Dr Sylvain Chamberland
  31. 31. At 6 weeks Em.Be 190810 Md:.016 SC™ • Anterior mandibular teeth are bonded • Unraveling the lower curve of Spee will assist cl II correction©Dr Sylvain Chamberland
  32. 32. At 13 weeks Mx:.016 SC™ Em.Be 051010 Md:.016 Sent • Mx: 16 SC™ engaging the canines • Derotation of mx molars noted©Dr Sylvain Chamberland
  33. 33. At 20 weeks Mx:.016 Sent Em.Be 221110 Md:.016 x .022 neosent • Md: 016 x 022 neosent • Mx: 016 sent + cl II elastics • Intrusive arch is removed©Dr Sylvain Chamberland
  34. 34. At 27 weeks Mx: 016 x .022 neosent Em.Be 100111 Md:.020 x .020 neosent • Remove the TPA • Continue cl II eastics • Class I relationship is almost achieved©Dr Sylvain Chamberland
  35. 35. At 40 weeks Mx: .020 x .020 neosent Em.Be 120411 Md:.020 x .020 neosent • Reassessment of bk position ! Rebond 12, bond 16, 26, 47 • Continue cl II elastics©Dr Sylvain Chamberland
  36. 36. At 59 weeks Em.Be 220811 Rebonded • Mx: ! elastomeric chain • Md: rebond #47 , #33, .020 x .020 neost©Dr Sylvain Chamberland
  37. 37. • May be some improvement in lip support can be noted • Incisors display is adequate©Dr Sylvain Chamberland
  38. 38. Wi.Ja. 270111 • Is such a treatment approach repeatable? ! Same mechanics: 28 weeks into treatment 3 Segments 16 x16 sent" 16x22 neo"16SC + cl II"16sent + cl II"16x22 neost + cl II Wi.Ja. 260811 2 Segments 16sent"16sent continuous "20 x 20 neost + cl II"20x25 niti + cl II©Dr Sylvain Chamberland
  39. 39. ©Dr Sylvain Chamberland
  40. 40. Eloïse (9 y 7 m)
  41. 41. El.Re 060510 • Cl II div 1 • Mx crowding©Dr Sylvain Chamberland
  42. 42. El.Re 060510, 9 y 7 m • Slight vertical facial asymmetry • Retrognathic mandible • Low FMA, brachycephalic©Dr Sylvain Chamberland
  43. 43. • At 29 weeks Cinch Mx:.020 x .025 sw Cinch El.Re 201210 Md:.020 x .025 sw ! Forsus are engaged ! Md: .020 x .025 SW, loop distal to the canine, cinch back • At 35 weeks El.Re 310111 ! E-links to sliding the canine distally on .020 x .025 SW©Dr Sylvain Chamberland
  44. 44. At 41 weeks • Reassessment of bk position ! Rebond 12, 16, 26, ! Bond 37, 46, rebond 33, 35, 45©Dr Sylvain Chamberland
  45. 45. At 41 weeks Md:.016 x .022 neosent El.Re. 140311 Md:.016 sent • Forsus and Hyrax removed • Canines distalized and a space opened mesially • Side effect: posterior intrusion©Dr Sylvain Chamberland
  46. 46. El.Re 140311 • Molar distallization and intrusion • Increased smile display • /1-PM was maintained at 109°©Dr Sylvain Chamberland
  47. 47. At 64 weeks El.Re. 220811 • Mx & Md: .020 SS SW • Finishing bends, Cl II elastics©Dr Sylvain Chamberland
  48. 48. El.Re. 220811©Dr Sylvain Chamberland
  49. 49. Maude (16 y 7 m)
  50. 50. Ma.Ma 310809, 16y 7 m • Cl II div 2 • Moderate ALD©Dr Sylvain Chamberland
  51. 51. • Straight profile • Lips to E-plane = normal •Tx Plan • Retroclined 1/ #Non extraction? #Extraction? • Proclined /1©Dr Sylvain Chamberland
  52. 52. At 61 weeks • Mx: 21x21x20 x 38 mm, E-links #5 at 17 & 27 Ma.Ma 221110 • Md: 21x21x20 x 38 mm ! To include the canine in the rectangular section ! Upright spring on 1st premolars, E-links #3 ! Cl II elastics 3/6©Dr Sylvain Chamberland
  53. 53. At 74 weeksMa.Ma 240211 • Space closure is effective • Lower curve of Spee remained flat • Continue cl II elastics©Dr Sylvain Chamberland
  54. 54. At 81 weeks • Mx: Continue en masse retraction Ma.Ma 130411 Md:.020 x .025 sw • Md: .020 x .025 SW + EC 6 to 6 ! Continue cl II elastics©Dr Sylvain Chamberland
  55. 55. At 102 weeks Mx:.020 x .025 sw Ma.Ma 080911 Md:.020 x .025 sw • Finishing bend • Enamel recontouring©Dr Sylvain Chamberland
  56. 56. ©Dr Sylvain Chamberland
  57. 57. Marie-Anne (10 y 9 m)
  58. 58. Ma.Co 250809, 10y 9 m • Cl II div 1 • Md deviated to the right • Deep overbite • Mesially rotated 1st molar©Dr Sylvain Chamberland
  59. 59. • Proclined 1/ and /1 (1/-SN = 121°; /1-MP = 104°) • Large overjet, 1/1 = 108° • Deep overbite©Dr Sylvain Chamberland
  60. 60. Tx plan • Any cl II fixed corrector will procline lower incisors • Lower incisor intrusion with a SW will procline /1©Dr Sylvain Chamberland
  61. 61. At 11 weeks Ma.Co 011209 • .032 TMA TPA to derotate U6’s • Md: 3 segments + lingual arch • Intrusive arch 17x25 niti attached at /3’s (distal to C rot) to intrude and retrocline /1©Dr Sylvain Chamberland
  62. 62. At 23 weeks Ma.Co 230210 • Md: 20x20 neost + intrusive arch on /3’s • Mx: 20x25 nitisw (to detorque U1’s) • Cl II elastics • Molars are derotated©Dr Sylvain Chamberland
  63. 63. At 29 weeks Ma.Co 070410 • Mx: 21x21x20 to slide buccal segment distally • TPA removed • Md: 20x25 nitisw, LA + intrusive arch removed • Unilateral FORSUS cl II corrector on the right side is installed©Dr Sylvain Chamberland
  64. 64. • 1/ SN = 102, retracted to normal • /1-MP = 105 maintained • 1/1 = 125 = normal©Dr Sylvain Chamberland
  65. 65. At 53 weeks Ma.Co 200910 • Remove Forsus on the right side • Mx: 17x25 TMA mushroom loop to retract anteriors (note the space mesial to U3’s) • Md: 20x25 nitisw • Class I molar and canine relationship achieved©Dr Sylvain Chamberland
  66. 66. At 59 weeks Ma.Co 011110 • Mx: 20x25nitisw + elastomeric chain • Continue cl II©Dr Sylvain Chamberland
  67. 67. At 78 weeks Ma.Co 210311 • Mx: 20x25 sw + elastomeric chain • Md: 20x25 nitisw • Patient instructed to wear Cl II elastic during nightime©Dr Sylvain Chamberland
  68. 68. At 103 weeks Ma.Co 070911 • Class I molar and canine relationship©Dr Sylvain Chamberland
  69. 69. ©Dr Sylvain Chamberland
  70. 70. ©Dr Sylvain Chamberland
  71. 71. Estelle (28 y 4 m)
  72. 72. Es.Gr 040609 • Class I, congenitally missing #45 • Xbite 22/33©Dr Sylvain Chamberland
  73. 73. • Bimax protrusion • Mx midline to the left • Tx plan ! Exo???©Dr Sylvain Chamberland
  74. 74. Md:.018 SC™ Es.Gr 231109, 20 weeks Md:.016 Sent • Tx initiated with .016 SC™ for 12 weeks, then .018 SC™ for 8 weeks • At 20 weeks: ! Mx: 18 SC; Md: .016 sent • Followed by .016 x .022 neost, .020 x .020 neost, .020 x .025 niti, then .021 x .021 x .020 en masse retraction©Dr Sylvain Chamberland
  75. 75. Es.Gr 071210, 74 weeks #45 was protracted alone before engaging #46 • Sliding #13 on the round section of HDGW • Note the slight curve of Spee in lower arch ! The squared anterior section is limited to lower incisors ! This reduce the stiffness of the anterior segment ! The canine and the 1st premolar have a tendency to tip lingually as the E-links press on the labial surface ! When spaces are closed, it is most often not possible to engage a .020 x .025 SS wire©Dr Sylvain Chamberland
  76. 76. Es.Gr 180111, 80 weeks • Md: .021x.021x.020 x 58 mm ! Extended square anterior section include the 1st premolars ! This increased the wire stiffness in torsion ! Hence it help to maintain a flat curve of Spee ! Once the space are close, a .020 x .025 SS sw can be engage • Mx: #13 distalized into cl I©Dr Sylvain Chamberland
  77. 77. Md: .020 SS Es.Gr 010311, 86 weeks • Mx cl I canine is achieved ! EC 7-6-5-3-o-2 ! 6 weeks later (92w), the EC was changed and an active coil was added Es.Gr 240511, 98 weeks Md: .020 x.025 nitisw • 98 weeks: midline improved ! Sliding mechanics: Light force + round wire©Dr Sylvain Chamberland
  78. 78. At 110 weeks Es.Gr 150811, 110 weeks • Mx: rebond #22 to move the root mesially ! .020 x.025 nitisw + EC • Md: .020 x .025 SSsw + EC©Dr Sylvain Chamberland
  79. 79. A.G.Class II div 1 OB
  80. 80. An.Gr. 160309, 14 y 4 m • Cl II div 1 • Open bite • Moderatle ALD©Dr Sylvain Chamberland
  81. 81. • Hyperdivergent • Bimaxillary protrusion • Lip incompetency©Dr Sylvain Chamberland
  82. 82. Tx plan Tx initiated: July 15-2009 • Extraction? • Surgery? • Non-surgery • TADs©Dr Sylvain Chamberland
  83. 83. At 13 weeks An.Gr. 131009 • Mx: ! TADs 6 x 1,4 mm ! 3 segments .020 x.020 neost + TPA .032 x .032 activated mesial out • Md: .018SC™©Dr Sylvain Chamberland
  84. 84. At 21 weeks An.Gr. 131009 • Mx: Replace TAD distal to 1 m, .016 sent st • Md: TADs 8 x 1,4 mm + .016 sent An.Gr. 071209©Dr Sylvain Chamberland
  85. 85. At 26 weeks An.Gr. 071209 • Mx: .016 x .022 neost, ! EC • Md: .016 x .022 neost, ! EC ! .032 TMA LA An.Gr. 15-01-10©Dr Sylvain Chamberland
  86. 86. At 34 weeks An.Gr. 15-01-10 • Mx: .21 x .021 x .020 x 38 mm -E5 7-3 • Md: .020 x .025 niti Class 1I An.Gr. 08-03-10©Dr Sylvain Chamberland
  87. 87. At 46 weeks An.Gr. 08-03-10 • Mx: .E links: Hook to the TADs • Md: ! E4 • TPA and LA removed Class 1 An.Gr. 07-06-10 Md: .021 x .021 x .020©Dr Sylvain Chamberland
  88. 88. At 59 weeks An.Gr. 15-07-10 Md: .021 x .021 x .020 • Mx: E links: Shep-Hk to the TAD ! EC 11-27 • Md: .020 x .025 niti An.Gr. 02-09-10 Md: .020 x .025 niti + EC©Dr Sylvain Chamberland
  89. 89. At 66 weeks An. Gr. 191010 ! Mx: .021 x .021 x .020. Lig. tie TAD-U3, E links At 75 weeks An. Gr. 231210 Md: .020 x .025 SS ! Mx: EC 6 to 6 ! Md: .020 x .025 SW©Dr Sylvain Chamberland
  90. 90. At 94 weeks Mx: .021 x .021 x .020 SS An. Gr. 020511 Md: .020 x .025 SS • After 2 missed rendez-vous: lost 12 weeks! • Patients involved in a fight!!! ! Luxation of 12, 11, 42, 41, 31 Mx: .016 x .022 neost Md: .06 sent©Dr Sylvain Chamberland
  91. 91. • Significant facial changes • Lip competency improved©Dr Sylvain Chamberland
  92. 92. • Condilar growth • Almost no aveolar growth • Finishing stages to improve root parallelism©Dr Sylvain Chamberland
  93. 93. At 111 weeks An. Gr. 290811 • TAD are removed • Wire cut distal to lower 5’s • Debond in 2 weeks©Dr Sylvain Chamberland
  94. 94. Ma.An.Vo. Bo.
  95. 95. Ma.An.Vo.Bo 260109, 16 y 4 m • Cl II div 1 open bite©Dr Sylvain Chamberland
  96. 96. • Lip incompetency • Bimaxillary protrusion • Vertical maxillary excess (posterior)©Dr Sylvain Chamberland
  97. 97. Tx Plan • Extraction • Would usually involve bimaxillary surgery ! The patient was tx planned for surgery. ! Tx initiated: March 5, 2009©Dr Sylvain Chamberland
  98. 98. 52 weeks into treatment • The patient and his father declined the surgery: No way! • Pull out the TAD box! • TAD: 8 x 1,8 mm Md: .020 x .025 sw Ma.An.Vo.Bo 030310 Md: .021 x .021 x .020 E-4©Dr Sylvain Chamberland
  99. 99. • Mx arch was treated in segments©Dr Sylvain Chamberland
  100. 100. At 67 weeks Ma.An.Vo.Bo 150610 • Upper left TAD is replaced • Lower expansion occurred because of the absence absence of a lingual arch©Dr Sylvain Chamberland
  101. 101. At 110 weeks Ma.An.Vo.Bo 190411 • Upper left TAD failed 3 times • TFBC was used unilaterally on the left from Dec. 2010 to April 2011©Dr Sylvain Chamberland
  102. 102. At 128 weeks Ma.An.Vo.Bo 110811 • A compromised posterior occlusion was accepted • Mandibular asymetry to the left may explain the cl II relationship©Dr Sylvain Chamberland
  103. 103. • Smile display improved • Lip competency improved • Mandibular déviation to the left is noted©Dr Sylvain Chamberland
  104. 104. • Right condyle larger than left condyle©Dr Sylvain Chamberland
  105. 105. • Forward rotation of the mandible ! Intrusion of mx molars ! Intrusion of md molars ! AFH !©Dr Sylvain Chamberland

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