ceph & model Mock surgery /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call

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ceph & model Mock surgery /certified fixed orthodontic courses by Indian dental academy

  1. 1. www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. “Ceph” & Model Mock Surgery For Orthodontic Surgical Planning. www.indiandentalacademy.com Nov 25/11/03
  4. 4. INTRODUCTION: “Ceph” and model mock surgery is done, by using cephalometric tracings and dental casts or by the help computers, to simulate the effects of the orthodontic and surgical treatment. Cephalometric prediction allows two dimensional evaluation of both dental and skeletal movements, whereas cast predictions shows detailed three dimensional dental relationships that indirectly reflect underlying skeletal changes. www.indiandentalacademy.com
  5. 5. Orthognathic surgery Minor procedures Major procedures www.indiandentalacademy.com
  6. 6. Minor procedures Exposure of impacted teeth. Transplantation of teeth. Removal of third molars. These usually does not require “ceph” and model surgery. www.indiandentalacademy.com
  7. 7. Major procedures Mandibular Advancements. Maxillary Superior Repositioning. Combined maxillary and mandibular surgeries. www.indiandentalacademy.com
  8. 8. So, what’s ur opinion? ORTHODONTIST C’MON, LET’S MOCK IT !!!! www.indiandentalacademy.com ORAL SURGEON
  9. 9. There are five general methods of visualizing, planning, and predicting surgical orthodontic outcomes(AJO1997 Dec): 1. Manual acetate tracing "cut and paste" techniques as described by Cohen, McNeill et al., and Henderson. 2. 3. Manipulation of patient photographs to illustrate treatment goals. Computerized diagnostic and planning software that produces a soft tissue profile "line drawing"; as a result of manipulation of digitized structures of lateral cephalometric radiographs. www.indiandentalacademy.com
  10. 10. 4. Computerized diagnostic and planning software that integrates video images with the patient's lateral cephalogram to aid in planning and predicting surgical orthodontic procedures (Videocephalometrics). 5. Three-dimensional computer technology for planning and predicting orthognathic surgery. Moss et al. expanded on the early methods of three-dimensional planning by including laser scanning to model the soft tissue response to hard tissue movements. www.indiandentalacademy.com
  11. 11. Prediction cephalometric tracing: The most important aim of the prediction tracing is to asses the esthetic profile result after the surgery. NOTE: Whatever the prediction method, producing the predicted soft tissue outline is more of an art form than a scientific exercise. www.indiandentalacademy.com
  12. 12. Prediction cephalometric tracing: Computer methods 4 3 1 Tracing overlay method 2 Photographic method Template method www.indiandentalacademy.com
  13. 13. Tracing overlay method  The tracing overlay approach is the simplest way to simulate the effects of the mandibular surgery.  The final prediction tracing is produced without any intermediate tracings.  This method is limited to surgery that does not affect the vertical position of the maxilla(i.e., the mandible does not rotate around the condylar axis.) www.indiandentalacademy.com
  14. 14. Steps in tracing overlay method: Tracing of the structures Original tracing that will not be changed by mandibular surgery www.indiandentalacademy.com
  15. 15. Slide Overlay tracing so that the mandibular teeth can be seen through it in the desired post-surgical position and trace the lower teeth and the jaw. www.indiandentalacademy.com
  16. 16. Measurements are made to find, how far the lower incisor has moved forward by superimposing the overlay back to the cranial base.( lower lip will move forwards by 2/3 rd’s and iswww.indiandentalacademy.com marked. )
  17. 17. Superimpose again on the mandible. Draw the soft tissue chin and the complete the soft tissue profile. www.indiandentalacademy.com
  18. 18. Super impose again on the cranial base and complete the soft tissue profile with the help of table. www.indiandentalacademy.com
  19. 19. Template method  Templates can be used for any type of prediction surgery. Disadvantage: Time consuming. The use of templates for intermediate tracings between the original and the final tracing is mandatory when the maxilla will be repositioned vertically, repositioning of the chin and in cases where major teeth movements has to be carried-out. www.indiandentalacademy.com
  20. 20. Special considerations: 1. Color coding of templates. 2. Use of different colors for the structures to be repositioned. 3. When mandibular template is prepared, the approximate center of the condyle on the original tracing should be marked, and this mark is transferred to the template. The mandibular template can be rotated around this point. www.indiandentalacademy.com
  21. 21. Template method Template for maxillary teeth. www.indiandentalacademy.com
  22. 22. Two mandibular templates are prepared –one without extraction second one with the extraction(crowding resolved.) www.indiandentalacademy.com
  23. 23. Ready templates. www.indiandentalacademy.com
  24. 24. Place the upper anterior template in the desired position approximately 2mm below the www.indiandentalacademy.com
  25. 25. Check for the better fit of the mandibular teeth by placing either of mandibular templates. It is clear that the prominence of the upper anterior teeth will be a function of how much the mandibular incisors are retracted and how far up the maxilla is moved. www.indiandentalacademy.com
  26. 26. Position the upper posterior template. www.indiandentalacademy.com
  27. 27. Complete the prediction tracing on the fresh tracing paper. www.indiandentalacademy.com
  28. 28. Photographic method: Is an attempt to improve communication with patients. This was proposed,as a method of illustrating to the patient, the soft-tissue results of the suggested plan. www.indiandentalacademy.com
  29. 29. METHOD The photographs are physically sectioned;the cut-outs represents the parts that will be moved in the planned osteotomies and are arranged to simulate surgical movements Advantages: It gives the patient better visualization of the profile changes than a acetate tracing does. www.indiandentalacademy.com
  30. 30. www.indiandentalacademy.com
  31. 31. Disadvantages: 1.Does not permit change to soft tissue contours that occurs with treatment. 2.Unavoidable gaps in photo have an unnatural appearance. 3.An experienced clinician with artistic skill are essential with this methodology. www.indiandentalacademy.com
  32. 32. Computer method: The first step in using a computer program for Cephalometric prediction is to enter the digital model of the patients tracing in to computer memory. www.indiandentalacademy.com
  33. 33. www.indiandentalacademy.com
  34. 34. Rocky mountain data systems has developed the the computerized “visual norm” based on the size, age, sex and race. (JCO 1977) Using this data and Brodbents template method, surgical VTO can be constructed. www.indiandentalacademy.com
  35. 35. The final red surgical VTO is prepared showing the skeletal, dental, and soft tissue changes. www.indiandentalacademy.com
  36. 36. Soft tissue changes from the surgical- orthodontic treatment. www.indiandentalacademy.com
  37. 37. Model surgery Model surgery simulates actual surgery, in the dental arch models of the patient. It gives the three dimensional understanding of the post operative relationship of the jaws. www.indiandentalacademy.com
  38. 38. Major aims of the model surgery: 1.To get the definite idea about the extent of bone / arch advancement or reduction required in the surgery. 2.To get a post-operative relationship of the jaws, dentition and occlusion. 3.To decide about the post-surgical orthodontic treatment. 4.As a vehicle for fabrication of splints for stabilization after surgery. www.indiandentalacademy.com
  39. 39. ARMAMENTARIUM: 1) A fret saw and fine blades (size M2) or a 10cm (4 inch) fine fiber or metal cutting disc mounted on a lathe. 2) Hand-piece and motor. 3) A steel fissure bur. 4) A plaster bur or an Ash acrylic cutter pear. 5) Surgical scalpel blades, NO.10 or 20. 6) Plaster knife, Spatula, 15 cm(6 inch) rubber bowl. www.indiandentalacademy.com
  40. 40. 7) Bunsen burner, spirit lamp,or soldering iron. 8) Wax knife and carver. 9) Soft ribbon wax, hard modeling and sticky wax. 10) 15cm (6inch)flexible ruler. 11) Spring dividers(15cm /6 inch) 12) Plane line hinge articulator, and face bow. www.indiandentalacademy.com
  41. 41. Diagnostic set-up A diagnostic set up is employed to be sure that it will be possible to get the teeth to fit together if a given orthodontic treatment plan is employed. www.indiandentalacademy.com
  42. 42. Method: Individually remove the tooth from the dental cast and reset the tooth in soft wax so that their alignment and interdigitation can be observed. www.indiandentalacademy.com
  43. 43. Diagnostic pre-orthodontic set-up showing the www.indiandentalacademy.com proposed extractions and tooth movements.
  44. 44. Paper set- up: Is an alternative method to diagnostic set up, where the occlusograms are digitized which provides the two dimensional representation of the planned post treatment dental arch form and alignment with the help of soft-wares. www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. Methods of model surgery: Simple method. Anatomically oriented model surgery. www.indiandentalacademy.com
  47. 47. Simple method: Simple method is only satisfactory to basic surgical changes. 1. Sulcus impressions of the upper and lower arches are obtained.(midline marking can be done before making the impressions) 2. The impressions are cast in stone. Models are trimmed and two duplicate sets prepared. 3. The master set is dated, labeled and stored as preoperative reference study models. www.indiandentalacademy.com
  48. 48. 4. If movements of the whole arch are anticipated, the upper and lower models are first occluded in the planned postoperative position and carefully marked using a pencil. The amount of movement between the pre-operative and post-operative position is then measured and noted on the models. This may be done with the hand held trimmed study model or,with plaster-less articulator. www.indiandentalacademy.com
  49. 49. The marked models may also be mounted with plaster on a metal hinge articulator in the planned postoperative position. This mounted set of models is also used for designing or making the means of fixation. www.indiandentalacademy.com
  50. 50. 5. If segmental movements are involved, a set of models is sectioned at the osteotomy sites. Care should be taken when sawing not to damage teeth other than those which are going to be extracted at the time of surgery. The sectioned segments are then sited in the desired position and fixed with soft red ribbon wax which will allow the manipulation in to the planned position. www.indiandentalacademy.com
  51. 51.  Cuspal interferences can be marked on the cast which can be later ground intra-orally.  Establish a proper over-jet and overbite in the anterior region.  A degree of over-correction may be necessary to compensate for the relapse, especially with mandibular forward movements. www.indiandentalacademy.com
  52. 52. 6. Once the desired position is achieved the ribbon wax is replaced with hard modelling or sticky wax to secure the mobilized segments in their new place. www.indiandentalacademy.com
  53. 53. Anatomically oriented model surgery. In complex cases, especially where multiple bimaxillary movements are required, it is essential to use a more refined technique such as the following variant of a popular “North American method” www.indiandentalacademy.com
  54. 54. Technique: In this technique, in addition to the impressions and sqash bite, a face-bow recording is taken. 1. The working models are anatomically trimmed and articulated on the semi adjustable articulator using the face-bow recording and then the standard squash bite. www.indiandentalacademy.com
  55. 55. www.indiandentalacademy.com
  56. 56. www.indiandentalacademy.com
  57. 57. 2. Horizontal and vertical reference lines are drawn on the mounting plaster to register the post-operative position of each maxillary and mandibular segments before surgery. Two sets of parallel horizontal lines A/A and B/B are drawn on the upper and lower models. These are easily done by rotating the detached model with the felt pen. www.indiandentalacademy.com
  58. 58. www.indiandentalacademy.com
  59. 59. The B lines should be just clear of the apices of the teeth, and not less than 15mm from the A lines. The actual distance between the A and B lines is then recorded on the plaster. These lines will be used to plan the vertical movements. www.indiandentalacademy.com
  60. 60. 3. Three vertical lines VC, VB, VM are drawn from upper base line (A) to the lower baseline (A) on each buccal segment. These lines pass through the buccal surfaces of the upper cuspid, bicuspid and the distal cusp of the last upper molar tooth., and they are extended to their occluding partners. These will help to indicate the anteroposterior movements achieved by the model surgery. Upper and lower midlines are also drawn. www.indiandentalacademy.com
  61. 61. Marked models with the recorded distances. www.indiandentalacademy.com
  62. 62. 4. The vertical distances from the buccal cusp tips of the three reference teeth to their A base lines are recorded to help calculate any vertical movements. Transverse changes are recorded by the inter-canine and inter-molar distances measured across the palate and recorded by taking reference points on the canine tips and the mesiobuccal cusp of the first molars. www.indiandentalacademy.com
  63. 63. Cuspal reference points are used for transverse changes. www.indiandentalacademy.com
  64. 64. 5. When all the reference lines have been drawn and the measurements completed, the osteotomy lines are drawn between A and B lines to correspond with the bone cuts. The plaster mounting assembly is then sectioned at the osteotomy sites with a saw or large abrasive disc and the whole arch or segments are repositioned in the planned postoperative position. www.indiandentalacademy.com
  65. 65. Interrupted line is the proposed osteotomy site. www.indiandentalacademy.com
  66. 66. 6. After making the horizontal cut, rotate the dental midline on the model to match the facial midline on the mounting plaster. This will rotate the model VB and VM on the deviated side forwards and the contra-lateral side VB and VM lines backwards. Carefully mark their new positions. Additional forward movements are then measured from these new vertical references. www.indiandentalacademy.com
  67. 67. This will be important at the operation, when a significant rotation will increase the actual movement on the deviated side and may eliminate any obvious movement on the contra-lateral side. www.indiandentalacademy.com
  68. 68. Maxilla is reassembled with the wax after the osteotomy cuts. Mandible closes in to the intermediate occusal relationship. Intermediate wafer is made at this stage. www.indiandentalacademy.com
  69. 69. Lower segmental set-down of 3mm is carried out with the forward slide of 5mm to correct the interarch occlusal relationship. www.indiandentalacademy.com
  70. 70. Anterior view: models showing the upper midline split to widen the intercanine width and the lower anterior set-down. www.indiandentalacademy.com
  71. 71. Computer methods Advantages: 1. Software programs often include automatic adjustments in the soft-tissue profile, this can speed up the prediction process and make it more consistent. 2. Having digital model in the computer, it is easy to produce several slightly different cephalometric predictions, so the impact of minor changes can be examined in more detail. 3. Helpful in integrating the information from the dental cast with the cephalometric information. www.indiandentalacademy.com
  72. 72. Disadvantages: 1.Cost of the necessary software and hardware. 2.Limitations of the existing programs. www.indiandentalacademy.com
  73. 73. Recent advances: Over the past few years attempts have been made to image the skull in three dimensions. Computerized tomography(CT) and laser imaging have not only allowed the three dimensional imaging of the skull but also the development of techniques to simulate surgery and predict post-operative facial features before surgery. www.indiandentalacademy.com
  74. 74. Three dimensional image of the skull is produced by octree encoding which means the image is built up from cubes derived from the scan. Once the image is digitized it can be easily manipulated to mock the surgery using the soft-wares. www.indiandentalacademy.com
  75. 75. 3D CT image www.indiandentalacademy.com
  76. 76. Sub apical osteotomy cuts are marked on the screen with the trackerball. www.indiandentalacademy.com
  77. 77. Maxillary set-down 3mm, mandibular upward 5mm www.indiandentalacademy.com
  78. 78. Pre-op (CT) www.indiandentalacademy.com
  79. 79. Post-op (CT, mock) www.indiandentalacademy.com
  80. 80. P r e O p P o s t O p www.indiandentalacademy.com
  81. 81. Post- Op photos and radiographs www.indiandentalacademy.com
  82. 82. VIDEOCEPHALOMETRY. Definition: Video imaging technology is a method in which orthodontist gathers facial frontal,profile,and dental images and modify them to project potential esthetic treatment goals (David .M .Sarver). www.indiandentalacademy.com
  83. 83. ̿ Video cephalometric prediction methodology is virtually identical to the cephalometric tracing method. ̿ Hence the difficulties encountered is similar to the tracing method.(except the improved visualization and recognition of facial profile changes.) www.indiandentalacademy.com
  84. 84. Video cephalometry technique helps in quantifying treatment plans. In other words, co-ordination of calibrated profile images with facial profile images permits precise measurement of bony and dental movements, and through the application of algorithmic prediction ratio’s images are produced that express the expected surgical and/or orthodontic outcome. www.indiandentalacademy.com
  85. 85. Direct Digitization: Indirect www.indiandentalacademy.com
  86. 86. Direct Radiograph is placed on the digitizing tablet, and the anatomy and anatomical landmarks are digitized using a potentiometer such as “electronic pen” or “cross hair cursor” www.indiandentalacademy.com
  87. 87. www.indiandentalacademy.com
  88. 88. Indirect ö A video camera or a scanner captures an image of the cephalometric radiograph. ö Digital radiography can also be used. Captured image can be then displayed on the computer monitor and can be indirectly digitized via mouse or an “onscreen” electronic pen. www.indiandentalacademy.com
  89. 89. Method: Video imaging technique 1.counseling phase 2.treatment planning phase www.indiandentalacademy.com
  90. 90. 1.counseling phase Involves the use of facial or dental image modification without any quantitative aspect to the process. It is simply a graphic way of communicating ,concepts that are difficult to present verbally. www.indiandentalacademy.com
  91. 91. Pre treatment profile modification sessions may be performed with the patient before full records are taken. In the counseling phase profile image is gathered and displayed on the computer screen, & profile changes expected with surgery are illustrated through the use of cut & paste tools www.indiandentalacademy.com
  92. 92. An initial profile image was captured and displayed on computer screen for graphic illustration of the facial changes that should be anticipated with orthodontic decompensation and surgical mandibular advancement. The use of cut & paste art functions in the software programme allows us to copy outlined segments of the image to RAM for short term storage and graphic movement. www.indiandentalacademy.com
  93. 93. The counseling phase is performed without videocephalometric integration,but simulation of the soft tissue reaction to the planned hardtissue movements (orthodontic and orthognathic) can be performed. www.indiandentalacademy.com
  94. 94. procedure First the initial image is captured and displayed on the computer screen with selected ceph analysis overlaid on the profile image. Application of the ceph analysis to the profile demonstrates the dental compensation and mandibular deficiency present in this patient. www.indiandentalacademy.com
  95. 95. Image obtained with video camera , stored & then displayed www.indiandentalacademy.com for digitization and analysis
  96. 96. Simulation of orthodontic decompensation of maxillary incisors through torque and advancement of upper incisors is then performed using the cut and paste function. Profile changes expected with maxillary advancement in preparation for surgery are illustrated by advancing the upper lip on the profile image. www.indiandentalacademy.com
  97. 97. In the computer simulation, a box is placed encompassing the upper lip and copied to RAM.The box is then moved forward by the mouse.The new position reflects soft tissue reaction to decompensation. www.indiandentalacademy.com
  98. 98. www.indiandentalacademy.com
  99. 99. www.indiandentalacademy.com
  100. 100. The next step is to simulate mandibular advancement. A new copy box is placed on the mandible and copied to RAM. This outlined portion is then moved anteriorly to simulate mandibular advancement www.indiandentalacademy.com
  101. 101. Click& drag www.indiandentalacademy.com
  102. 102. The mandible is moved forward ,the amount estimated by the clinician to correct the class II This image simulates orthodontic decompensation and correction of mandibular deficiency & class II malocclusion www.indiandentalacademy.com
  103. 103. www.indiandentalacademy.com
  104. 104. The next logical procedure is advancement genioplasty to improve chin projection.This is simulated by outlining another template on the chin,copying the section of the chin to RAM and then moving the chin anteriorly to an esthetically desired position. www.indiandentalacademy.com
  105. 105. Click & drag Simulation of genioplasty www.indiandentalacademy.com
  106. 106. The final profile created by image modification effectively communicates the anticipated effect of orthodontic decompensation ,surgical mandibular advancement,and advancement genioplasty www.indiandentalacademy.com
  107. 107. Final Profile. www.indiandentalacademy.com
  108. 108. Pre & post counseling photos www.indiandentalacademy.com
  109. 109. In this short preliminary visit the patient has received graphic communication regarding the potential facial changes that will occur during ortho treatment & the anticipated outcome of the proposed treatment plan. After this phase of counseling, patients may then decide whether they value the esthetic changes & are reassured enough by the image modification to pursue more comprehensive treatment planning www.indiandentalacademy.com
  110. 110. 2.treatment planning phase The treatment planning phase of video imaging involves the integration of the facial profile image with the ceph and calibrating it to profile video so as to relate the underlying hard-tissue to overlying soft-tissue. It allows quantification of hard & soft tissue movements and to apply algorithmic response ratios between the two, to project the soft-tissue reaction to hard tissue movement. www.indiandentalacademy.com
  111. 111. In the adult patient the computer projection can be quite accurate.In the adult, major inaccuracy is the actual treatment itself. In the adolescent the unpredictability of the growth dynamics greatly diminishes the predictive value of video cephalometric projection. www.indiandentalacademy.com
  112. 112. procedure The same patient example will be used to explain the treatment planning phase.After the profile image is captured, calibration procedures are performed when the “ceph” is matched to video image. The computer can then perform algorithmic calculations so that the movements on the video screen are translated into real life terms. www.indiandentalacademy.com
  113. 113. A profile treatment planning template is created by integration of the cephalogram, calibrated to the facial profile, and displayed on the computer monitor. Profile projections(hard tissue movement with appropriate soft tissue response)are drawn from the computer data base & applied in algorithmic fashion when the dental or osseous segments are moved. www.indiandentalacademy.com
  114. 114. A profile planning template is created by integration of www.indiandentalacademy.com ceph,calibrated to the facial profile and displayed.
  115. 115. Simulation of orthodontic decompensation is created by up righting and advancing the upper incisor template. The computer not only allows overlay & visualization of the pretreatment tracing & projected dental movement but also measures these anticipated and planned movements, which are reflected in a table on the left, which is shown in the figure. www.indiandentalacademy.com
  116. 116. Anticipated and planned movements, which are reflected in a table www.indiandentalacademy.com
  117. 117. Simulation of orthodontic decompensation is created by up righting and advancing www.indiandentalacademy.comtemplate. the upper incisor
  118. 118. The soft tissue outline of the upper lip is automatically adjusted through the algorithmic response calculations. www.indiandentalacademy.com
  119. 119. The video portion of the software is adjusted to the prediction outline, simulating a soft-tissue response to the incisor movement. www.indiandentalacademy.com
  120. 120. Simulation of mandibular advancement is accomplished by clicking and dragging the mandibular template forward. The quantitation table supplies the amount of advancement required to achieve ideal over jet and over bite. www.indiandentalacademy.com
  121. 121. Simulation of mandibular advancement is accomplished by clicking and dragging www.indiandentalacademy.com the mandibular template forward.
  122. 122. See the soft-tissue response www.indiandentalacademy.com
  123. 123. The profile is judged to be still moderately convex, so an advancement genioplasty is simulated by advancing the template of the chin. The figure illustrates the cephalometric outline prediction of a 4 mm anterior movement of chin. www.indiandentalacademy.com
  124. 124. Advancement genioplasty www.indiandentalacademy.com
  125. 125. This image is auto treated.This movement can be greatly influenced by patient direction and desire because there are few functional demands on this movement www.indiandentalacademy.com
  126. 126. The final prediction image now reflects a treatment plan that has corrected the malocclusion and arrived at an esthetically pleasing profile to both patient and clinician. www.indiandentalacademy.com
  127. 127. Final projected profile outcome with ceph tracing blinked off ceph tracing blinked off www.indiandentalacademy.com
  128. 128. VCD ACTUAL www.indiandentalacademy.com
  129. 129. Key notes in computerized cephalometric prediction: The skeletal and soft tissue response to surgery is different for the type of surgical procedure and osteosynthesis used.(for e.g using of wire osteosynthesis or any other rigid fixation.) www.indiandentalacademy.com
  130. 130. The algorithms in the prediction software should be modifiable by the clinician. The type of fixation and procedure used by the treatment planners and surgeons should be chosen before generating the prediction tracings, so that the odds of the surgical prediction and the actual out come matching closely are maximized. www.indiandentalacademy.com
  131. 131. conclusion A combination of cephalometric prediction and model surgery gives the surgeon a satisfactory idea of the esthetic and occlusal result of the surgery. This also helps the team to decide on the method of combining orthodontics and orthognathic surgery. www.indiandentalacademy.com
  132. 132. Thank You Thank You www.indiandentalacademy.com