Role of ortho in surgery /certified fixed orthodontic courses by Indian dental academy


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Role of ortho in surgery /certified fixed orthodontic courses by Indian dental academy

  2. 2. INTRODUCTION Severe orthodontic problems: - growth modification - camouflage - surgical realignment of jaws or repositioning of dentoalveolar segments
  3. 3. Correction of the malocclusion by tooth movement alone: -Undesirable -Teeth tipped into position of neuromuscular imbalance -Treatment of choice – correction of skeletal jaw dishormony
  4. 4. - Surgery not substitute of orthodontics - Properly coordinated with orthodontics - Dramatic progress in recent years CLOSED CONTAINER - Orthodontics rearranges the content - growth modification and surgery changes the shape
  5. 5. ENVELOPE OF DISCREPENCY -Severity as a indicator for orthognathic surgery -outlines the limit of hard tissue changes towards the ideal occlusion -soft tissue limitations not reflected -amount of changes produced by orthodontics alone -Orthodontic tooth movement + growth modification -Orthodontics + orthognathic surgery
  6. 6. -Not symmetrical with regard to plane of space -retraction / proclination -Extrusion / intrusion UPPER -Growth modification same -Surgery to move lower jaw back has more potential than to advance it LOWER
  7. 7. INDICATIONS Severe class II or class III skeletal discrepancy Deep over bite in non- growing patients Severe anterior open bite Extreme vertical excess or deficiency in maxilla or mandible Severe dentoalveolar problem Skeletal asymmetry
  8. 8. AIMS  Optimal facial esthetics  Optimum dental esthetics  Functional occlusion  Future health of orofacial structures  Rapid treatment  Stable result  Minimum morbidity
  9. 9. PRINCIPLES OF TREATMENT PATIENT MOTIVATION Chief complaint Patient – Parent conference problem list risk- benefit, treatment alternatives patient’s expectations and values Probable outcome
  10. 10. DIAGNOSIS Accurate diagnosis fundamental to treatment planning  clinical examination and evaluation of history  lateral cephalogram and OPG  study models  photographs (extraoral and intraoral)
  11. 11. JOINT PLANNING Orthodontist and oral surgeon Surgical procedure Presurgical orthodontics Extraction Mock model surgery/ prediction Cephalometric prediction tracing Computerized prediction
  12. 12. PRESURGICAL ORTHODONTICS Prepare patient for surgery Treatment objective entirely opposite of conventional orthodontics alone Extraction pattern reverse of orthodontic case PRESURGICAL DECOMPENSATION Teeth inclined to partially offset skeletal discrepencies Nature’s mechanism to compensate Ideal axial inclination
  13. 13. PRESURGICAL OBJECTIVES INTRA ARCH OBJECTIVES  Initial stages – similar objectives Correction of arch length deficiencies Rotation correction Arch alignment  Post surgical interdigitation  Class I canine and molar relationship  Teeth ideal to underlying bases
  14. 14. Malocclusion look worse- underlying skeletal deformity Extractions- spaces closed / segmental surgical closure Tooth size discrepencies-best anterior occlusal interdigitations Interdental enamel reduction Extraction of mandibular incisor Distribution of excess space
  15. 15. ANTEROPOSTERIOR (SAGGITAL) OBJECTIVES Compensation in all three planes Most apparent in saggital Skeletal class II- proclined lower upright upper incisors Skeletal class III- proclined upper upright lower incisors Decompensation- surgery minimum interference from occlusion
  16. 16. Class II case demonstrating incisor positions before (— ) and after (----) dental decompensation. Class III case demonstrating incisor positions before (— ) and after (----) dental decompensation.
  17. 17. REVERSE ORTHODONTICS Class III elastics in Class II- upright lower incisors advance maxillary molars Class II elastics in class III- upright upper incisors advance mandibular molars Anchorage considerations-class II mandibular arch class III maxillary arch
  18. 18. Extraction pattern- class II upper 5’s lower 4’s class III upper 4’s lower 5’s Extractions - to align the teeth to their respective jaws Relapse - dental opposite direction than skeletal chance of maintaining optimal occlusal relation “DECOMPENSATION COMPLIMENTS SURGERY”
  19. 19. A, Class ll case with upper first and lower second premolar extraction requiring maximum anchorage in the maxillary arch using conventional orthodontic techniques to retract the incisors. B,Class II case with upper second and lower first premolar extraction requiring maximum mandibular arch anchorage to retract the proclined incisors prior to orthognathic surgery. A, Class lll case with extraction of upper second and lower first premolars requiring maximum anchorage in the mandibular arch to retract the incisors by conventional orthodontic techniques. B, Class III case with extraction of upper first and lower second premolars requiring maximum anchorage in the maxilla to retract the incisors prior to orthognathic surgery.
  20. 20. TRANSVERSE OBJECTIVES o Skeletal / dental o Study casts articulated to anticipated post surgical relation o Skeletal class II- transverse maxillary deficiency o Skeletal class III- relative transverse maxillary deficiency o Correct buccal segment torque o Isolated maxillary constriction + no maxillary sugery surgically assisted RME o Maxillary constriction +other maxillary problems multiple segment maxillary procedure
  21. 21. A, Clinically normal-appearing transverse relationship in Class II malocclusion. B, Simulated correction of Class II malocclusion to Class I canine relationship exhibiting bilateral palatal crossbite as a result of absolute bilateral transverse maxillary deficiency. A, Clinically exhibited bilateral palatal crossbite in Class III malocclusion. B, Simulated correction of anteroposterior (sagittal) discrepancy, with no palatal crossbite now apparent. This case exemplifies relative bilateral transverse maxillary deficiency
  22. 22. VERTICAL CONSIDERATIONS Open bitesanterior face height to be reduced surgically orthodontic tooth movement prior to surgery minimum post surgical mechanics minimum to moderate curves extractions Continuous arch excessive anterior spacing
  23. 23. Severely accentuated and reverse curve of spee surgical correction segmental arch – segmental surgery Deep bite- short anterior face height leveling of mandibular occlusal plane after surgery maxillary easily prior to surgery vertical elastics occlusion primarily on molars and incisors
  24. 24. A, Class II case leveled presurgically (— ). Surgical changes (----) noted include: A, Closing mandibular rotation; B, increased posterior face height; C, no increase in anterior face height. B, The same Class II case not leveled presurgically (— ). Surgical changes (----) noted include: A, Opening mandibular rotation; B, no increase in posterior face height; C, increased anterior face height
  25. 25. CONSIDERATIONS FOR SEGMENTAL OSTEOTOMY Root divergence at osteotomy site Adequate access- minimize trauma to tooth roots Second order bends to create adequate space Anatomic constrains- unable to position premaxillary segment posteriorly without tipping the segment Leave incisors slightly proclined
  26. 26. APPLIANCE SELECTION Appliance- stabilization of teeth and basal bone Rectangular archwire for strength and stability Variations of edgewise- PEA Begg- edgewise combination Begg- poor control ribbon archwire and special retaining pins Ceramic brackets- fracture during manipulation restricted to maxillary anterior teeth
  27. 27. STABILIZING ARCHWIRES 4 weeks before surgery- passive at the time of splint making 17 x 25 steel in 18 slot 21 x 25 TMA or steel in 22 slot Brackets incorporating hooks Brass lugs soldered to the archwire Ball end hooks soldered, welded or carefully crimped Tight intermaxillary fixation till rigid fixation
  28. 28. 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.
  29. 29. 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
  30. 30. 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.
  31. 31. 6) Plaster knife, Spatula, 15 cm(6 inch) rubber bowl. 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.
  32. 32. 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. 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
  33. 33. Diagnostic pre-orthodontic set-up showing the proposed extractions and tooth movements.
  34. 34.
  35. 35. METHODS OF MODEL SURGERY  Simple method  Anatomically oriented model surgery
  36. 36. Sulcus impressions of the upper and lower arches are obtained.(midline marking can be done before making the impressions) The impressions are cast in stone. Models are trimmed and two duplicate sets prepared. The master set is dated, labeled and preoperative reference study models. stored as 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.
  37. 37. 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 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
  38. 38.  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
  39. 39. • Cuspal interferences can be marked on the cast which can be later ground intra-orally. • Establish a proper over-jet and anterior region. overbite in the • A degree of over-correction may be necessary to compensate for the relapse, especially with mandibular forward movements  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.
  40. 40. ANATOMICALY ORIENTED MODEL SURGERY In complex cases, especially where multiple bimaxillary movements are required, it is essential to use a more refined technique In this technique, in addition to the impressions and sqash bite, a face-bow recording is taken. The working models are anatomically trimmed and articulated on the semi adjustable articulator using the face-bow recording and then the standard squash bite
  41. 41.
  42. 42.
  43. 43. 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. 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
  44. 44.
  45. 45. 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.
  46. 46. Marked models with the recorded distances
  47. 47. 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.
  48. 48. Cuspal reference points are used for transverse changes.
  49. 49. 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 post-operative position
  50. 50. Interrupted line is the proposed osteotomy site
  51. 51. 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
  52. 52. Lower segmental set-down of 3mm is carried out with the forward slide of 5mm to correct the interarch occlusal relationship.
  53. 53. SURGICAL SPLINT  Interocclusal wafer splint  Autopolymerizing acrylic resin  Model surgery  Trimmed on buccal surface- visual verification  Teeth in desired position  Thin- not more than 2mm in thinnest portion  Wire at edges of splint  Holes for fixation
  54. 54.
  55. 55. PATIENT MANAGEMENT AT SURGERY FINAL SURGICAL PLANNING pre- surgical records impressions without stabilizing archwires prediction duplicated in model sugery
  56. 56. POST SURGICAL ORTHODONTICS Removal of splint working archwires Light vertical elastics- to override propioception impulse from teeth undesirable convenience bite- new intercuspation Minor corrections- light round wire 0.016’’ Flexible rectangular archwire in upper 17 x 25 TMA 21 x 25 M- NiTi or braided steel
  57. 57.  Posterior box elastic light elastics full time wear for 4 weeks (including eating) then 4 weeks except for eating followed by night wear for 4 weeks  Triangular, saw tooth ( M,N or W )  Class II or class III elastics  to support surgical correction  Guide jaw function  Settling of occlusion
  58. 58. Triangular vertical elastics Box elastics with a Class III vector
  59. 59.
  60. 60. POST SURGICAL COMLICATIONS ANTERIOR OPEN BITE condylar distraction( sag) (isolated mandibular surgery) difficult-orthodontic compensation reoperation Inadequate posterior impaction(Lefort I) headgear or heavy elastic traction
  61. 61. LATERAL OPEN BITE planned- decreased facial height extrusion of lower buccal segment ASYMMETRY mismatch in dental midline source of problem- submentovertex one of arch shifted laterally or rotated
  62. 62. Asymmetrical headgear Oblique elastics or combination of class II, class III elastics Asymmetric archwires Leaving 1 to 2 mm of space distal to canines Reproximation or interproximal enamel reduction Reoperation
  63. 63. RETENTION No difference Retentive plates-6 months full time wear followed by 6 months wear at night
  64. 64. STABILITY OF RESULTS MORE Maxilla up Mandible forward VERY STABLE Chin, any direction Maxilla forward STABLE PREDICTION STABLE Maxilla, asymmetry Mx up + Mn forward Mx forward + Mn back STABLE(Rigid fix) Mandible, asymmetry Mandible back Maxilla down LESS Maxilla wider PROBLAMATIC
  65. 65. PRINCIPLES INFLUENCING POST SURGICAL STABILITY Relaxed soft tissue / stretched Neuromuscular adaptation Change in orientation of muscle CONCLUSION
  66. 66. THANK YOU