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SARPE (2 stage) vs Le Fort 1                        (single stage) Approach to                      Complex Maxillary Defo...
Based on                      Short- and Long-Term Stability of SARPE Revisited                                     AJODO ...
SARPE                      Samson Assisted Rapid Palatal Expansionsamedi 17 mars 2012                                     ...
Stability of SARPE                                         Numerous published studies        • Dental Cast                ...
Stability of SARPE                               Conclusions about stability depend on                               ★ Wha...
Goal of This Presentation                               •   Present further longitudinal data for short-                  ...
Goal of This Presentation                               •Larger sample + 2-years stability data                           ...
Methods                               •   Prospective and observational                                   study of SARPE o...
Experimental sample                                                                                                     Di...
Observation Time Point       N Mean time S-D     Min.   Max.                                                     (months) ...
•    Of the 38 who completed the distraction phase                                 •    32 had a   2nd   surgical phase pl...
Tooth-borne Expansion Device                               •Superscrew™                               • Banded; N = 21    ...
Our SARPE Technique                                                                                             Mid-palata...
Our SARPE Technique                                                                                              Midpalata...
Treatment modality                               • Appliance cementation: 1 day to 1 week prior to                        ...
Treatment modality                               •   Brackets bonded in maxillary arch 2 months                           ...
Outcome Measures                               • Standardized PA ceph                               • Study cast          ...
Statistics   Refer to the                                                                        article for more         ...
Resultssamedi 17 mars 2012             19
"Changes in                                        Caninearchdimensions                                  1st premolar   • ...
∆ 1st Molar                ∆ Nasal Cavity                ∆ Mx                % ∆ Mx/∆ M1      Changes in skeletal width   ...
Other outcomes                               •   Type of expansion device: Bonded vs 2-bands                              ...
Effect of time on relapse after appliance removal                                           Time point comparison Relapse ...
Effect of time on relapse after appliance removal                                            Time point comparison Relapse...
Correlation between variables                               • 2 variables are significantly correlated with the amount of  ...
Discussionsamedi 17 mars 2012                26
Short term stability                               •   Expansion of               1st   molar = 7,6 ± 1,57 mm             ...
Short term stability                               •   Post treatment retention is an important                           ...
Comparison to Other Short-Term                                                                         -0,99          Expe...
Those 12 months study period                               •Concluded that expansion was stable                           ...
Our Study = 49 Months                               •   Data at T4 were collected 15 months post-                         ...
In Our Study                                                                              SARPE: Post-Tx changes          ...
Maximal expansion T3-T1              Long term relapse T6-T5              Net changes T6-T1                               ...
Maximal expansion T3-T1              Long term relapse T6-T5              Net changes T6-T1                               ...
Comparison to Other Long-Term                                   Studies                17%             -0,99              ...
Skeletal Expansion & Stability                               • Immediately after SARPE about half (46%) of the expansion w...
CBCT study                               •       Skeletal expansion ranging from 1,3 to 7 mm                              ...
SARPE: Post-Tx changes                                                                                    50,0 %          ...
Stability?                               •   This could be attributed to                               ★ The device itself...
Stability?                               •   For all other surgery                               ★ Presurgical orthodontic...
SARPE and other surgical                                             procedure                               •   It is app...
Related variables                               •   Correlation between the width of the diastema                         ...
Related variabless                               • Dental changes are not correlated with skeletal                        ...
Before Expansion                                   After Expansion                               A                        ...
lAs       the appliance is activated,                               note that the hemimaxilla move inward                ...
Phase 2 surgery                               • A classic study of the stability of transverse expansion                  ...
Conclusion                               •   Skeletal change were modest (3-4 mm) but                                   st...
Conclusion                               •   Phase 2 surgery did not affect dental relapse                               •...
Conclusion                          •    Doing 2 phase surgery (SARPE + Bimax surgery)                               think...
Conclusion                          •    Most of the transverse change of 5-6 mm the                               maxilla...
Le Fort 1 Morbidity                                                         A                               •   Pulpal nec...
Le Fort 1 Morbidity                       • Aseptic necrosis                          ★ Most likely to occur with Le Fort ...
SARPE Morbidity         •                                          A     B                      Nasopalatal cyst         •...
SARPE Morbidity         •            Asymmetric fracture of interdental septum + gingival defect                          ...
Clinical Implications                          •     If only transverse changes are needed                               ★...
SARPE may be indicated                  • For very large transverse (>6 mm), AP and vertical                        change...
Retrospective look                                 Ka.Tr.271107                                  • This case would have ha...
Retrospective look                                 •     2 years post treatment                                     ✦ Some...
Case 1                          •    Class I ( cl III tendency)                          •    Mx constriction             ...
•    Moderate apnea, severe snoring                          •    Orthodontic Tx plan: exo 5s/5s                          ...
Progess reports                          •       Reassessment of bracket position                          •       Mx: 3 s...
•   Decompensation of the dentition is done                               •   Surgical tx plan will focus on skeletal chan...
Case 2                          •     Class III                          •     Severe Mx constriction Ω                   ...
•   Retrusive maxilla                               •   Retroclined /1                               •   Md laterodeviatio...
•     Pre-surgical                               ✦ Segmented Le Fort 1: to constrict!                               ✦ Md s...
St.Gi.221111                               •   /1: proclined by 12°                               •   1/: retroclined by 1...
29 days post surgery                               St.Gi.211211;           St.Gi.061211;                                  ...
St.Gi.130212                               St.Gi.120312                          •     Finishing stages                   ...
Case 3                          •    Class III                          •    Mutilated dentition                          ...
•    Retrusive maxilla                          •    Proclined 1/                          •    Retroclined /1     ©Dr Syl...
•     TADs                               ✦ Mx: to intrude UL6                               ✦ Md: to get some protraction ...
Pre-Surgical                          •     Edentulous space prepared                          •     Surg. Plan:          ...
•   Mx: Le Fort 1 to advance                               •   Md: Genioplasty to correct the chin                        ...
•   17 days post surgery Hé.Ar.160511     ©Dr Sylvain Chamberlandsamedi 17 mars 2012                                      ...
At 121 weeks                          •    Crowns are scheduled next month                          •    Operative dentist...
•    Bridge and crown placed today                          •    Total Tx time 128 weeks                                  ...
Class 4                          •    Anterior open bite                          •    Moderate crowding                  ...
Ma-Je.Be210808                               •   Slight vertical maxillary excess                               •   Bimaxi...
Tx Plan                          •     Would you do SARPE?                          •     Would you plan a non extraction ...
At 85 weeks                          •    Normal OJ & OB                          •    Class I molar and canine relationsh...
•   Retracting and uprighting the incisors helped to                                   close the bite                     ...
Ma-Je.Be210808                                                               At 109 weeks                                 ...
•   Mx: Le Fort 1: superior                                   repositionning &                                   advanceme...
©Dr Sylvain Chamberlandsamedi 17 mars 2012            84
Case 5                          •    Narrow maxillary arch                          •    Cl II div 1, open bite           ...
•   Retrognathic mandible                               •   Bimaxillary protrusion                               •   Lip i...
Tx Plan                          •    Would you do SARPE?                          •    Would you plan a non extraction ap...
Tx Plan                          •     Exo of 5s & E                          •     Mx Le Fort 1                          ...
Lu.Mo.200409                         At 36 weeks                         Mx: Step distal to the canine. Prothetic tooth bo...
•   Incisors were retracted, no extrusion     ©Dr Sylvain Chamberlandsamedi 17 mars 2012                                  ...
Presurgical models                          •     Selective grinding to maximize toot contact                          •  ...
•     Surgery at 96 weeks                        Lu.Mo.010710                               ✦ Le Fort 1: advancement 3,5 m...
Osteotomy half way between                                           apices of the teeth and                              ...
BSSO                                            Bicortical screw                                   Genioplasty            ...
•    Tx time = 123 weeks                          •    Implant #22 was placed                                   Lu.Mo.2012...
•   Nice profile                               •   Lips are competent     ©Dr Sylvain Chamberlandsamedi 17 mars 2012       ...
Lu.Mo.070711                          •     At 28 weeks into retention                               ✦ Crown is placed on ...
•   Recall at 60 weeks     ©Dr Sylvain Chamberlandsamedi 17 mars 2012                                     98
Why I dont like rigid fixation                                    for a genioplasty            Lu.Mo.010710                ...
Why do I prefer                                                       osteosynthesis?                                     ...
Why I dont like posterior                               openbite after orthognathic                                       ...
Distinguished Attendees                             Thank you                         www.slideshare.net/sylvainchamberlan...
•     Mx: segmented Le Fort 1                               ✦ Advancement                               ✦ Anterior elongat...
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Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical review and update

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Orthognathic surgery seeks to correct maxillofacial deformities often associated with significant functional impairment. Procedures to alter the relationship of the jaws and teeth include osteotomies of the maxilla, mandible and chin. An understanding of the evolution of the principles and practices, combined with knowledge of recent advances in surgical technique and technology, helps the clinician effectively treat challenging problems. Interdisciplinary treatment planning, backed by strategies to manage complications, are necessary components of effective Orthognathic surgery.

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Transcript of "Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical review and update"

  1. 1. SARPE (2 stage) vs Le Fort 1 (single stage) Approach to Complex Maxillary Deformities: A Critical Review and Update AO North America 12 th Annual Symposium Wahsington, DCsamedi 17 mars 2012 1
  2. 2. Based on Short- and Long-Term Stability of SARPE Revisited AJODO 2011; 138:815-22samedi 17 mars 2012 2
  3. 3. SARPE Samson Assisted Rapid Palatal Expansionsamedi 17 mars 2012 3
  4. 4. Stability of SARPE Numerous published studies • Dental Cast • P-A ceph (+ dental cast) ★ Northway & Meade AO 97 ★ Byloff & Mossaz, EJO 04 ★ Bays and Greco, JOMS 92 ★ Berger et al, AJODO 98 ★ Stromberg & Holm, JCS 95 ★ Koudstaal et al, IJOMS 09 ★ Antilla et al, EJO 04 ★ Hino et al, JCS 09 (P-A only) ★ Pogrel et al, IJAOOS <92 ★ Kuo & Will, OMS CNA 90 (P-A only)samedi 17 mars 2012 4
  5. 5. Stability of SARPE Conclusions about stability depend on ★ What was measured? ★ When measurements were made? Especially whether there were measurements during the sequence as well as before/after? ©Dr Sylvain Chamberlandsamedi 17 mars 2012 5
  6. 6. Goal of This Presentation • Present further longitudinal data for short- and long-term stability • Follow-up previous reports ★ (Angke east 2006 Scientific Meeting) ★Closer Look at the Stability of SARPE ✓ JOMS 2008; 66:1895-1900 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 6
  7. 7. Goal of This Presentation •Larger sample + 2-years stability data • Data obtained at 6 time points ★ The only study with PA ceph and models at multiple time points ©Dr Sylvain Chamberlandsamedi 17 mars 2012 7
  8. 8. Methods • Prospective and observational study of SARPE outcomes • Consecutively treated cases Looking ahead • Approved by Laval University Ethic Committee ©Dr Sylvain Chamberlandsamedi 17 mars 2012 8
  9. 9. Experimental sample Distribution 9 9 9 # cas 7 • 7 # of patients N = 38 5 5 6 ★ 19, 19 2 ★ Mean age : 24.9 ± 9,7 2 (range 15,1: 53,7) 0 -,17] (17, 20] (20,25] (25,30] (30,35] (35, + Âge ©Dr Sylvain Chamberlandsamedi 17 mars 2012 9
  10. 10. Observation Time Point N Mean time S-D Min. Max. (months) Dental cast + PA ceph T1-T2 (Distraction completed) 38 0,68 0,23 0,46 1,81 T2-T3 (Expander retention) 38 5,95 0,68 4,21 7,13 T1-T4 (Start to 2nd surgery) 32 15,27 3,99 9,40 24,28 T2-T5 (End expansion to 37 21,59 5,28 12,88 41,69 deband) T3-T5 (Expander out to 37 15,64 5,09 7,79 35,19 deband) D1-T5 (Total treatment time) 37 23,57 5,27 15,41 43,07 T5-T6 (Post ortho treatment) ©Dr Sylvain Chamberland 23 25,35 4,49 20,96 39,49samedi 17 mars 2012 10
  11. 11. • Of the 38 who completed the distraction phase • 32 had a 2nd surgical phase planned • 4 of them did not need it after reassessment • 1 was over-expanded and needed constriction of the maxilla at the 2 nd surgical phase to achieve arch coordination ✦ His data were removed at T5 • 23 patients have returned for records 2-years after the end of orthodontic treatment ©Dr Sylvain Chamberlandsamedi 17 mars 2012 11
  12. 12. Tooth-borne Expansion Device •Superscrew™ • Banded; N = 21 A • Bonded; N = 17 B ©Dr Sylvain Chamberlandsamedi 17 mars 2012 12
  13. 13. Our SARPE Technique Mid-palatal suture Zygomaticomaxillary Piriform rim Pterygomaxillary junction Zygomatic buttress Piriform rim Widening of the osteotomy cut: ©Dr Sylvain Chamberland → lateral rotation hemimaxillaesamedi 17 mars 2012 13
  14. 14. Our SARPE Technique Midpalatal suture Zygomaticomaxillary buttress Piriform rim Pterygomaxillary junction Separation of the pterygoid junction Separation with osteotome of the midpalatal suture ©Dr Sylvain Chamberland Per-op diastema of 1 to 1,5 mmsamedi 17 mars 2012 14
  15. 15. Treatment modality • Appliance cementation: 1 day to 1 week prior to surgery • Latency period: 7 days • Distraction period: 0,25 mm bid ★ 14 to 21 days; monitored twice a week • Tx initiated in the mandibular arch 1 week to 2 months before SAPRE ©Dr Sylvain Chamberlandsamedi 17 mars 2012 15
  16. 16. Treatment modality • Brackets bonded in maxillary arch 2 months after expansion is stopped • Expander removal: 6 months after expansion is stopped • No other retention except the main arch wire • At debonding: bonded lingual wire 3-3 only, ↑&↓ ©Dr Sylvain Chamberlandsamedi 17 mars 2012 16
  17. 17. Outcome Measures • Standardized PA ceph • Study cast • DPI set to obtain 1:1 • Screw width in situ vs screw width on the ceph ★ T1: r = 0,99164 ★ T2: r = 0,98955 • Nasal cavity width • Dental width changes • Mx width: Jr-Jl • Screw width ©Dr Sylvain Chamberland • Screw changes • Diastemasamedi 17 mars 2012 17
  18. 18. Statistics Refer to the article for more • Paired 2-samples T-tests details about stats ✓ Bonferroni method: α = 0.05/6 • Repeated measures ANOVA • Unpaired 2 samples T-tests • Pearsons correlation coefficients ©Dr Sylvain Chamberland • Shrout and Fleisss intraclass correlation coefficient of fidelity = 0,99samedi 17 mars 2012 18
  19. 19. Resultssamedi 17 mars 2012 19
  20. 20. "Changes in Caninearchdimensions 1st premolar • Significant: p < 0.001 2nd premolar ★ Expansion T3-T1 1st molar ★ Relapse T5-T3 ★ Net expansion T5-T1 2nd molar ★ 2-years recall T6T1 1st lower molar, Non exo subgroup 1st lower molar, Exo subgroup Maximal expansion T3-T1 Relapse T5-T3 Net expansion T5-T1 -4 -3 -1 1 2 4 5 7 8 Long term relapse T6-T5 ©Dr Sylvain Chamberland Net changes T6-T1 Changes (mm)samedi 17 mars 2012 20
  21. 21. ∆ 1st Molar ∆ Nasal Cavity ∆ Mx % ∆ Mx/∆ M1 Changes in skeletal width Changes over time post SARPE 8,00 80 80 • Significant skeletal expansion 7,00 65 69 6,00 ★ Mx & Nasal cavity (p < 0.0001) 56 57 % Skeletal expansion Expansion (mm) 5,00 • Changes T5T3: NS (p=0,1166) 41 4,00 46 46 • Skeletal changes = STABLE 34 3,00 23 2,00 1,00 11 0 0 0,68 6,632 15,27 23,57 48,92 Time point (months) ©Dr Sylvain Chamberlandsamedi 17 mars 2012 21
  22. 22. Other outcomes • Type of expansion device: Bonded vs 2-bands ★ Same efficacy for skeletal & dental expansion (No difference: p=0,2727) ★ Same dental relapse (No difference: p=0,5052) • Effect of phase 2 surgery on transverse relapse at the 1st molar ★ No significant effect of any phase 2 surgery (No difference: p=0,6637) ★ Or any combination of phase 2 surgery ©Dr Sylvain Chamberlandsamedi 17 mars 2012 22
  23. 23. Effect of time on relapse after appliance removal Time point comparison Relapse (mm) Error T or F value DF P value T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001 T3 vs T4 (9,5 ± 3,2 m) -1,05 0,30 3,53 (T) 125 0,0006 T4 vs T5 (5,7 ± 1,5 m) -0,79 0,30 2,62 (T) 125 0,0098 T3 vs T5 (15,2 ± 5,1 m) -1,85 0,29 6,43 (T) 125 <.0001 T5 vs T6 (24,7 ± 3,1 m) -1,09 0,34 3,23 (T) 125 0,0016 • Significant relationship between the amount of relapse seen after SARPE and the time the post treatment observation was made ©Dr Sylvain Chamberlandsamedi 17 mars 2012 23
  24. 24. Effect of time on relapse after appliance removal Time point comparison Relapse (mm) Error T or F value DF P value T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001 T3 vs T4 (9,5 ± 3,2 m) -1,05 0,30 3,53 (T) 125 0,0006 T4 vs T5 (5,7 ± 1,5 m) -0,79 0,30 2,62 (T) 125 0,0098 T3 vs T5 (15,2 ± 5,1 m) -1,85 0,29 6,43 (T) 125 <.0001 T5 vs T6 (24,7 ± 3,1 m) -1,09 0,34 3,23 (T) 125 0,0016 • 57% of the total relapse occurred during the 1st 9 months after expander removal • 43% occurred in the following 6 months ©Dr Sylvain Chamberland • Another 1 mm or so occurred 2 years after debondingsamedi 17 mars 2012 24
  25. 25. Correlation between variables • 2 variables are significantly correlated with the amount of expansion of 1st molar at T3 ★ Diastema at the end of expansion (r2 = 0,41; p < .0001) ★ Change in length of the screw during expansion (r2 = 0,88; p < .0001) • Dental changes are not correlated with skeletal changes (r 2 = 0,11; p = 0.0381) (supported by Goldenberg et al) ©Dr Sylvain Chamberlandsamedi 17 mars 2012 25
  26. 26. Discussionsamedi 17 mars 2012 26
  27. 27. Short term stability • Expansion of 1st molar = 7,6 ± 1,57 mm ★ Similar to other reports measuring to the maximum expansion point ✓ Pogrel et al, Byloff and Mossaz, Koudstaal et al, de Freitas et al • Significant relapse for all teeth (canine to 2nd molar) • Mean relapse at 1st molar = 1,83 ± 1,83 mm ©Dr Sylvain Chamberland ★ 24% of the maximum expansion; large std. dev.samedi 17 mars 2012 27
  28. 28. Short term stability • Post treatment retention is an important factor • In this study: expansion device maintained 6 months ©Dr Sylvain Chamberlandsamedi 17 mars 2012 28
  29. 29. Comparison to Other Short-Term -0,99 Experimentals (n=38; 37;23) 24% -1,83 5,73 7,60 4,57 -3,16 Byloff and Mossaz, (n = 14) 36% 5,54 8,70 18% -1,48 de Freitas et al, 2008 (n = 20) 7,12 8,06 ≠Pterygoid + T2 = before Phase2 surgery -0,50Koudstaal et al, 2009 (n = 19) T-B 11% 6,30 12 months study 6,80 period 4,60 ≅Exp.Koudstaal et al, 2009 (n =23) B-B 11% -0,60 5,20 17.5% -1,01 Berger et al, 1998 (n=28) 4,77 5,78 Pogrel et al, 1992 (n=12) 12% -0,88 6,62 7,50 -4,00 -3,00 -2,00 -1,00 0 1,00 2,00 3,00 4,00 5,00 6,00 7,00 8,00 9,00 mm Long Term Relapse Short Term Relapse Net expansion ©Dr Sylvain Chamberland Maximum expansion Long term expsamedi 17 mars 2012 29
  30. 30. Those 12 months study period •Concluded that expansion was stable • But all their patients were still in orthodontic treatment ©Dr Sylvain Chamberlandsamedi 17 mars 2012 30
  31. 31. Our Study = 49 Months • Data at T4 were collected 15 months post- SARPE, prior to 2nd surgical phase for those who needed one • Relapse at T4 = 57% of the relapse we found • Therefore, any inferences about the stability of SARPE is questionable if arch form coordination or final AP or vertical relationships have not achieved at the time of measurements ©Dr Sylvain Chamberlandsamedi 17 mars 2012 31
  32. 32. In Our Study SARPE: Post-Tx changes 50,0 % First Molar 45,0 % First Premolar 42% 40,0 % • 42% of the patients have a 35,0 % relapse of 2 mm % of patients 30,0 % 25,0 % • 22 % of a relapse > 3 mm 20,0 % 22% • This is similar to 15,0 % multisegmented Le Fort 1 10,0 % 5,0 % 0% -,-3] (-3 to -1] (-1 to 1] (1 to 3] ©Dr Sylvain Chamberland Relapse (mm)samedi 17 mars 2012 32
  33. 33. Maximal expansion T3-T1 Long term relapse T6-T5 Net changes T6-T1 Long term stability " • Canine Data at T6 = 24,7 ± 3 m • 1st premolar Relapse NS • 2nd premolar Relapse S : 1 st Molar 1st molar ★ = 0,99± 1,1 mm; p= 0.0003 ★ 17% of net expansion at T5 that 2nd molar adds to relapse T5T3 -4 -3 -1 1 2 4 5 7 8 Changes (mm) ©Dr Sylvain Chamberlandsamedi 17 mars 2012 33
  34. 34. Maximal expansion T3-T1 Long term relapse T6-T5 Net changes T6-T1 Long term stability " • Cannot be explained by type 1 Canine error (α = 0.05/6) • Cannot be explained by the effect 1st premolar of a bonded vs banded appliance 2nd premolar • Post treatment arch form 1st molar adjustment may be the explanation since on the average, lower molar 2nd molar distance was expanded and constricted modestly and a large -4 -3 -1 1 2 4 5 7 8 std dev was noted (-0,18 ± 1,5 mm) ©Dr Sylvain Chamberland Changes (mm)samedi 17 mars 2012 34
  35. 35. Comparison to Other Long-Term Studies 17% -0,99 -1,83 Experimentals (n=38; 37;23) 5,73 7,60 2y 4,57 -1,30 22% Antilla et al, 2004 (n=20; 13) 7,20 6y 5,9 8.3%-1,20 Stromberg & Holms, 1995 (n=20) 8,30 3,5 y -0,22 ≅Exp. 6% Nortway & Meade, 1997 (n=16) 5,50 5y -0,45 7% Bays & Greco, 1992 (n=19) 5,78 2,4 y -2,25 0 2,25 4,50 6,75 9,00 mm Long Term Relapse Short Term Relapse Net expansion ©Dr Sylvain Chamberland Maximum expansion Long term expsamedi 17 mars 2012 35
  36. 36. Skeletal Expansion & Stability • Immediately after SARPE about half (46%) of the expansion was skeletal • This is more than Byloff & Mossaz, Berger et al ★ Appliance was removed after 3 months instead of 6 months • Hino et al (JCS 2008) reported larger skeletal expansion (~ 6,3 to 6,9 mm) but used landmark closer to the teeth ©Dr Sylvain Chamberlandsamedi 17 mars 2012 36
  37. 37. CBCT study • Skeletal expansion ranging from 1,3 to 7 mm ✦ Loddi et al, Landes et al, Goldenberg et al, Tausche et al, Zemann et al, Lagravere et al ✦ Koudstaal et al (IJOMS 2009) obtained 3,1 ± 2 mm of expansion at alveolar crest and 2,6 ± 1,8 mm at nasal level ✦ Lagravere et al (AJODO 2010) CBCT study ✓ BAME = 1,3± 1,4 mm vs TAME = 1,83± 1,69 mm at the outer cortex of alveolar bone • There was no difference between TB and BB appliances (12 month study ©Dr Sylvain Chamberland period)samedi 17 mars 2012 37
  38. 38. SARPE: Post-Tx changes 50,0 % First Molar First Premolar 40,0 % Stability? % of patients 30,0 % 20,0 % 10,0 % 0% • -,-3] (-3 to -1] (-1 to 1] (1 to 3] If one look at skeletal changes, it should Relapse (mm) rank high in the hierarchy • But if one looks at dental changes ★ 64% of the patients have > 2 mm change ★ 22% have > 3 mm changes ©Dr Sylvain Chamberlandsamedi 17 mars 2012 38
  39. 39. Stability? • This could be attributed to ★ The device itself ★ The surgical technique ★ The timing of observation ©Dr Sylvain Chamberlandsamedi 17 mars 2012 39
  40. 40. Stability? • For all other surgery ★ Presurgical orthodontic preparation is done ★ Few if any dental movements need to be accomplish after surgery • This is not the case for SARPE ★ Many dental movement are done after expander removal including correction of overexpansion ©Dr Sylvain Chamberlandsamedi 17 mars 2012 40
  41. 41. SARPE and other surgical procedure • It is appropriate to focus on skeletal, not dental stability— which has not been clearly reported previously because appropriate P-A ceph were not available at multiple time point ©Dr Sylvain Chamberlandsamedi 17 mars 2012 41
  42. 42. Related variables • Correlation between the width of the diastema at the end of distraction (T2) and the amount of 1 st molar expansion at T3 indicates that the adequate molar expansion is occurring • If no diastema appears ➙ no separation of the hemimaxillae and tipping of buccal segment is occurring ©Dr Sylvain Chamberlandsamedi 17 mars 2012 42
  43. 43. Related variabless • Dental changes are not correlated with skeletal changes (r2 = 0,11; p = 0.0381) (supported by Goldenberg et al) • In frontal view, rotation of the hemimaxillae occurs ★ Teeth expands more widely than the bone ★ Palatal depth decrease • No significant relationship between the amount of expansion and the amount of relapse (r2 = 0,07; p = 0.1186) ©Dr Sylvain Chamberlandsamedi 17 mars 2012 43
  44. 44. Before Expansion After Expansion A B C C ©Dr Sylvain Chamberlandsamedi 17 mars 2012 44
  45. 45. lAs the appliance is activated, note that the hemimaxilla move inward relatively to the upper part lThis may explain why CBCT study may find less skeletal expansion than PA ceph because of the precision of the landmarks ©Dr Sylvain Chamberlandsamedi 17 mars 2012 45
  46. 46. Phase 2 surgery • A classic study of the stability of transverse expansion obtained with segmented Le Fort 1 reported that patients who had concurrent mandibular surgery had significantly greater relapse at the 1st and 2nd molar • Our data show no significant effect of any phase 2 surgery on dental relapse • This might be an important decision factor if large transverse changes are necessary along with vertical and AP changes ©Dr Sylvain Chamberlandsamedi 17 mars 2012 46
  47. 47. Conclusion • Skeletal change were modest (3-4 mm) but stable • Relapse in dental expansion was almost totally attributed to lingual movement of posterior teeth ©Dr Sylvain Chamberlandsamedi 17 mars 2012 47
  48. 48. Conclusion • Phase 2 surgery did not affect dental relapse • Diastema at the end of distraction is a predictor that adequate molar expansion is occurring • Bonded expanders show the same efficacy as banded expanders. ©Dr Sylvain Chamberlandsamedi 17 mars 2012 48
  49. 49. Conclusion • Doing 2 phase surgery (SARPE + Bimax surgery) thinking that the transverse changes will be more stable than Le Fort 1 changes is not warranted • When maxilla need to be repositioned AP or vertically in a 2 nd phase ★ Decision should be based on the risk, morbidity & cost of 2 surgery versus risk, morbidity & cost of 1 stage segmental Le Fort 1 for large expansion along with vertical and AP changes ©Dr Sylvain Chamberlandsamedi 17 mars 2012 49
  50. 50. Conclusion • Most of the transverse change of 5-6 mm the maxilla can be corrected by a segmented Le Fort 1 • Expansion greater than 6-7 mm is an indication for SARPE ©Dr Sylvain Chamberlandsamedi 17 mars 2012 50
  51. 51. Le Fort 1 Morbidity A • Pulpal necrosis B • Periodontal defects ©Dr Sylvain Chamberlandsamedi 17 mars 2012 51
  52. 52. Le Fort 1 Morbidity • Aseptic necrosis ★ Most likely to occur with Le Fort 1 osteotomies done in multiple segments in conjonction with superior repositioning and transverse expansion Courtesy of Dr Brian Alpert Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 52
  53. 53. SARPE Morbidity • A B Nasopalatal cyst • A B Fibrous healing ©Dr Sylvain Chamberlandsamedi 17 mars 2012 53
  54. 54. SARPE Morbidity • Asymmetric fracture of interdental septum + gingival defect Cureton SL, Cuenin M, AJODO, 1999 • Non-separation of the pterygoid junction or attempting too much expansion (3mm) intraoperatively may lead to aberrant fracture that can run to the base of the skull, orbit and pterygopalatine fossa Lanigan DT, Mintz SM, J Oral Maxillofac Surg 60: 104-110, 2002 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 54
  55. 55. Clinical Implications • If only transverse changes are needed ★ SARPE = Choice # 1 MC; tx:18m Ka.Ri. Tx: 103w ©Dr Sylvain Chamberlandsamedi 17 mars 2012 55
  56. 56. SARPE may be indicated • For very large transverse (>6 mm), AP and vertical changes or periodontally compromised patients ©Dr Sylvain Chamberland (Personal opinion)samedi 17 mars 2012 56
  57. 57. Retrospective look Ka.Tr.271107 • This case would have had an excellent outcome with exo of 5s/5s and 1 phase surgery that would include segmented Le Fort 1 & BSSO • Nevertheless, a non extraction 2 phase surgery was done ©Dr Sylvain Chamberland Ka.Tr.210909samedi 17 mars 2012 57
  58. 58. Retrospective look • 2 years post treatment ✦ Some bite opening occured ✓ As the transverse relapse, Mx incisors may procline to accomodate • Therefore, we can not conclude that 2 phase surgery was any better than 1 phase surgery for this particular case Ka.Tr.120911 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 58
  59. 59. Case 1 • Class I ( cl III tendency) • Mx constriction • Moderate to severe crowding • Heavily restored teeth ©Dr Sylvain Chamberland Ka.La.270510samedi 17 mars 2012 59
  60. 60. • Moderate apnea, severe snoring • Orthodontic Tx plan: exo 5s/5s • Surgical Tx plan = Mx & Md advancement ©Dr Sylvain Chamberlandsamedi 17 mars 2012 60
  61. 61. Progess reports • Reassessment of bracket position • Mx: 3 segments • Md: finishing space closure • Surgery in May Ka.La.120312 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 61
  62. 62. • Decompensation of the dentition is done • Surgical tx plan will focus on skeletal changes ©Dr Sylvain Chamberlandsamedi 17 mars 2012 62
  63. 63. Case 2 • Class III • Severe Mx constriction Ω • Could this case be treated 37,12 in 1 phase surgery? ✦ YES. (exo 15, 24 / non ex) 33,52 St.Gi.191009 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 63
  64. 64. • Retrusive maxilla • Retroclined /1 • Md laterodeviation to the left ©Dr Sylvain Chamberlandsamedi 17 mars 2012 64
  65. 65. • Pre-surgical ✦ Segmented Le Fort 1: to constrict! ✦ Md set back and laterodeviation 41,26 ✦ Surgery tomorrow... 43,85 St.Gi.221111 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 65
  66. 66. St.Gi.221111 • /1: proclined by 12° • 1/: retroclined by 10° ©Dr Sylvain Chamberlandsamedi 17 mars 2012 66
  67. 67. 29 days post surgery St.Gi.211211; St.Gi.061211; 14 days post surgery ©Dr Sylvain Chamberlandsamedi 17 mars 2012 67
  68. 68. St.Gi.130212 St.Gi.120312 • Finishing stages • Tooth mass discrepancy may help to explain the cl II canine relationship • Significant arch width improvement St.Gi.191009 St.Gi.221111 St.Gi.130212 43,85 40,07 33,52 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 68
  69. 69. Case 3 • Class III • Mutilated dentition • Moderate Mx constriction • Overerupted UL6 Hé.Ar.030909 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 69
  70. 70. • Retrusive maxilla • Proclined 1/ • Retroclined /1 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 70
  71. 71. • TADs ✦ Mx: to intrude UL6 ✦ Md: to get some protraction of LL8 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 71
  72. 72. Pre-Surgical • Edentulous space prepared • Surg. Plan: ✦ Mx: Le Fort 1 advancement ✦ Bone graft at implant site Hé.Ar.171111 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 72
  73. 73. • Mx: Le Fort 1 to advance • Md: Genioplasty to correct the chin déviation ©Dr Sylvain Chamberlandsamedi 17 mars 2012 73
  74. 74. • 17 days post surgery Hé.Ar.160511 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 74
  75. 75. At 121 weeks • Crowns are scheduled next month • Operative dentistry will follow Hé.Ar.250112 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 75
  76. 76. • Bridge and crown placed today • Total Tx time 128 weeks Hé.Ar.120312 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 76
  77. 77. Class 4 • Anterior open bite • Moderate crowding Ma-Je.Be210808 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 77
  78. 78. Ma-Je.Be210808 • Slight vertical maxillary excess • Bimaxillary protrusion • Lip incompetency ©Dr Sylvain Chamberlandsamedi 17 mars 2012 78
  79. 79. Tx Plan • Would you do SARPE? • Would you plan a non extraction approach? • Would you extract? • Would you plan a segmented Le Fort 1? • Would you plan a 1 piece Le Fort 1? • My plan: ✦ Exo of 5s ✦ Bimaxillary surgery ©Dr Sylvain Chamberlandsamedi 17 mars 2012 79
  80. 80. At 85 weeks • Normal OJ & OB • Class I molar and canine relationship • Midline coincident Ma-Je.Be300410 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 80
  81. 81. • Retracting and uprighting the incisors helped to close the bite • Slight maxillary excess ©Dr Sylvain Chamberlandsamedi 17 mars 2012 81
  82. 82. Ma-Je.Be210808 At 109 weeks 20 weeks post surgery • Class I occlusion is achieved Ma-Je.Be131010 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 82
  83. 83. • Mx: Le Fort 1: superior repositionning & advancement • Md: BSSO & genio ©Dr Sylvain Chamberlandsamedi 17 mars 2012 83
  84. 84. ©Dr Sylvain Chamberlandsamedi 17 mars 2012 84
  85. 85. Case 5 • Narrow maxillary arch • Cl II div 1, open bite • Avulsion 22, fractured 11, 21 • Exfoliation 74, missing 35 Lu.Mo.030708 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 85
  86. 86. • Retrognathic mandible • Bimaxillary protrusion • Lip incompetency ©Dr Sylvain Chamberlandsamedi 17 mars 2012 86
  87. 87. Tx Plan • Would you do SARPE? • Would you plan a non extraction approach? • Would you extract? • Would you plan a segmented Le Fort 1? • Would you plan a 1 piece Le Fort 1? ©Dr Sylvain Chamberlandsamedi 17 mars 2012 87
  88. 88. Tx Plan • Exo of 5s & E • Mx Le Fort 1 ✦ Impaction, advancement, expansion • Md: BSSO • Genio advancement ©Dr Sylvain Chamberlandsamedi 17 mars 2012 88
  89. 89. Lu.Mo.200409 At 36 weeks Mx: Step distal to the canine. Prothetic tooth bonded to a bracket Md: En masse retraction Lu.Mo.010410 At 85 weeks Mx: 3 segments Md: Spaces closed •Surgery in June ©Dr Sylvain Chamberlandsamedi 17 mars 2012 89
  90. 90. • Incisors were retracted, no extrusion ©Dr Sylvain Chamberlandsamedi 17 mars 2012 90
  91. 91. Presurgical models • Selective grinding to maximize toot contact • Left posterior Xbite noted ✦ Expansion needed ©Dr Sylvain Chamberlandsamedi 17 mars 2012 91
  92. 92. • Surgery at 96 weeks Lu.Mo.010710 ✦ Le Fort 1: advancement 3,5 mm, impaction 3,5 mm, expansion 1,6 mm ✦ BSSO: advancement 8 mm; genio: advancement 6 mm, vertical reduction 2,5 mm • At the removal of the surgical splint ✦ Note lack of posterior occlusal contact ©Dr Sylvain Chamberlandsamedi 17 mars 2012 92
  93. 93. Osteotomy half way between apices of the teeth and infraorbital nerve Osteotomy sites filled with bone from the slice removed at the symphysis Rigid fixation to the piriform rim & zygomatic buttress buttress DL 130312 ©Dr Sylvain Chamberland Courtesy Dr Carl Bouchardsamedi 17 mars 2012 93
  94. 94. BSSO Bicortical screw Genioplasty Pre-bended 6 mm monocortical plate ©Dr Sylvain Chamberland Courtesy Dr Carl Bouchardsamedi 17 mars 2012 94
  95. 95. • Tx time = 123 weeks • Implant #22 was placed Lu.Mo.201210 ©Dr Sylvain Chamberlandsamedi 17 mars 2012 95
  96. 96. • Nice profile • Lips are competent ©Dr Sylvain Chamberlandsamedi 17 mars 2012 96
  97. 97. Lu.Mo.070711 • At 28 weeks into retention ✦ Crown is placed on #22 Lu.Mo.130112 • At 60 weeks into retention ✦ Note some midline deviation to the right and slight cl II ©Dr Sylvain Chamberlandsamedi 17 mars 2012 97
  98. 98. • Recall at 60 weeks ©Dr Sylvain Chamberlandsamedi 17 mars 2012 98
  99. 99. Why I dont like rigid fixation for a genioplasty Lu.Mo.010710 Lu.Mo.130212 Apposition zone Screw Embed Screw in the resorptive zone Screw Poor contact between distal prominent Note bone formation over superior & proximal segment portion of fixation device and resorption in area of inferior portion of fixation device ©Dr Sylvain Chamberlandsamedi 17 mars 2012 99
  100. 100. Why do I prefer osteosynthesis? Apposition zone R: Remodeling A: Apposition Courtesy Dr Dany Morais Resorptive Note complete coverage of fixation zone wires by bone and smooth labial Resorptive zone Improved contact between proximal and cortical bone of anterior manbible distal segment De.Le060608 De.Le130410 ©Dr Sylvain Chamberland Precious D., Armstrong J., Morais D., Anatomic placement of fixation device in genioplasty, OOO 1992,; 73-2-8samedi 17 mars 2012 100
  101. 101. Why I dont like posterior openbite after orthognathic surgery? Pressure Condyle resorb • Lack of posterior occlusion may increase pressure at the condyle and cause non-physiologic remodeling or condylar resorption Screwed Setting Jam-packed Slight progressive occlusion retrusion The bite open ©Dr Sylvain Chamberlandsamedi 17 mars 2012 101
  102. 102. Distinguished Attendees Thank you www.slideshare.net/sylvainchamberland www.sylvainchamberland.comsamedi 17 mars 2012 102
  103. 103. • Mx: segmented Le Fort 1 ✦ Advancement ✦ Anterior elongation ✦ Expansion • Md: BSSO + genio ©Dr Sylvain Chamberlandsamedi 17 mars 2012 115
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