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Mulitidisciplinary orthodontic treatment case report

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Case reports of multidisciplinary orthodontic treatment involving orthognathic surgery, prostho, perio, dental implant, TAD (miniscrew)

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Mulitidisciplinary orthodontic treatment case report

  1. 1. Multidisciplinary Orthodontic treatment Case report Dr Sylvain Chamberland D.M.D., Cert. Ortho. M.Sc.
 slideshare.net/sylvainchamberland
  2. 2. ©sylvainchamberland.com •Class III •Mutilated dentition HeAr030909
  3. 3. ©sylvainchamberland.com •Tx Plan?
  4. 4. ©sylvainchamberland.com At baseline •Vector TAS mesio buccal + Palatal of 26 ✦ Intrusion of 26 •Melsen TAD at #36 site ✦ Protraction of 38 HeAr280909
  5. 5. ©sylvainchamberland.com At 21 weeks •Mx: .016 cnt. #26 engaged •Md: .020 x .020 cnt. 
 Passive elastomeric chain 38-TAD HeAr280909 HeAr230210
  6. 6. ©sylvainchamberland.com At 44 weeks •Reassessment of bracket position, arch coordination •Models to assess fitting of the 
 occlusion for the surgery HeAr050810
  7. 7. ©sylvainchamberland.com At 68 weeks •Prior to surgery 
 (planned in April) •Dental arches are coordinated HeAr050810 HeAr170111
  8. 8. ©sylvainchamberland.com •Prior to surgery and bone grafting •#38 protracted + uprighted •Orthodontic decompensation achieved HeAr170111
  9. 9. ©sylvainchamberland.com At 85 weeks •2-3 weeks post-surgery •Autogenous bone graft from right oblique mandibular line to the upper right & left mx edentulous site + resorbable collagen 
 membrane Bio-Guide •Le Fort 1 ✦ Advancement 4 mm ✦ Inferior repositioning 2 mm •Genioplasty: chin to the right 4 mm HeAr160511
  10. 10. ©sylvainchamberland.com •At 111 weeks, Strauman implant ✓ #14: 4,1 X 12 mm bone level ✓ #16: 4,8 X 12 mm bone level ✓ #24: 4,1 X 14 mm bone level ✓ #36: 4,8 X 8 mm tissu level WNI •Debonding Jan 2012 HeAr061211 115 weeks
  11. 11. ©sylvainchamberland.com At 125 weeks •Debonding ✦ Mx removable retainer HeAr061211 115 weeks HeAr210112
  12. 12. ©sylvainchamberland.com •Final restauration in place •Total tx time 128 weeks HeAr120312
  13. 13. ©sylvainchamberland.com •Forward + downward mvt of the maxilla •Posterior rotation of md
  14. 14. ©sylvainchamberland.com Follow up at 2 years post tx HeAr 080514
  15. 15. ©sylvainchamberland.com •Se.Ca
  16. 16. ©sylvainchamberland.com •Class II mutilated dentition •Vertical bite collapse •Impacted 33, 35 SeCa2111-8
  17. 17. ©sylvainchamberland.com •Tx Plan?
  18. 18. ©sylvainchamberland.com •Diagnostic wax set up
  19. 19. ©sylvainchamberland.com •TAD site 46 and 36 •Wire is engage into TAD SeCa020609
  20. 20. ©sylvainchamberland.com At 34 weeks •Mx: .020 xé-25 niti •Md: .016 cnt attached to TADs •17x25 Niti intrusive arch 
 attached to 33, 43, 31-41 SeCa051009
  21. 21. ©sylvainchamberland.com At 116 weeks •Oh! By the way I have to use a CPAP. ✦ Hein! You didn’t tell. •I thought it was not important •Ms: 20x25 SS reverse curve ✦ 19x15 TMA root spring SeCa260411
  22. 22. ©sylvainchamberland.com •Class I relationship is achieved! •Vertical dimension was maintained SeCa140812
  23. 23. ©sylvainchamberland.com •Prior to surgery •Root parallelism is fair •33 & 35 are erupted •#47 is uprighted SeCa1003 SeCa140812 183 weeks
  24. 24. ©sylvainchamberland.com •Le Fort 1 ✦ Mx advancement 10 mm ✦ Bone graft form iliac crest •BSSO ✦ Advancement 12 mm ✦ Advancement of genial process
  25. 25. ©sylvainchamberland.com •Bone graft from iliac crest to increase thickness of the edentulous ridge SeCa141112
  26. 26. ©sylvainchamberland.com
  27. 27. ©sylvainchamberland.com •Brackets are bonded to partial denture SeCa190312
  28. 28. ©sylvainchamberland.com •Strauman implant ✦ #12-22: Bone level 4,1 X 10 mm Zirconium type ✦ #37: 4,8 X 6 mm WNI ✦ #44: 3,3 X 6 mm Zirconium •Implant 44 failed and has been replaced SeCa220513
  29. 29. ©sylvainchamberland.com •Temporary bridge.... SeCa150717
  30. 30. ©sylvainchamberland.com •The patient delayed the restoration 46, 44 •Will likely be done in 2015… SeCa041213
  31. 31. ©sylvainchamberland.com •Ma. He.
  32. 32. ©sylvainchamberland.com •Class II div 2 MaHe220611
  33. 33. ©sylvainchamberland.com •Internal root resorption of #46
  34. 34. ©sylvainchamberland.com •Hopeless #46
  35. 35. ©sylvainchamberland.com At 61 weeks •Removal of RPE •End of Twin Force Bite Corrector •#47 is protracted MaHe031012
  36. 36. ©sylvainchamberland.com At 96 weeks •Class I relationship is achieved MaHe040613
  37. 37. ©sylvainchamberland.com
  38. 38. ©sylvainchamberland.com •Na.Pa.
  39. 39. ©sylvainchamberland.com Class II div 1 NaPa081105
  40. 40. ©sylvainchamberland.com •Short face syndrome •Hypodivergent
  41. 41. ©sylvainchamberland.com Mechanotherapy •Anterior bite plane •Intrusive arch + lingual arch NaPa010206
  42. 42. NP_3 NaPa010206 NaPa140306
  43. 43. ©sylvainchamberland.com •When posturing in class I a posterior open bite is created •This allow clockwise rotation of the distal segment when the BSSO is done •This reduce slightly the advancement of the chin
  44. 44. ©sylvainchamberland.com •Face height increased •Class I relationship is achieved NaPa310507
  45. 45. ©sylvainchamberland.com 2 y Follow up •Incisor display improved •Self esteem improved NaPa030909
  46. 46. ©sylvainchamberland.com •Cl.Pe.
  47. 47. ©sylvainchamberland.com •Class I •Mutilated dentition •Wear sleep apnea device > 2 years ClPe140512
  48. 48. ©sylvainchamberland.com Narval TAP
  49. 49. ©sylvainchamberland.com •Horizontal bone loss in the maxilla •Apical granuloma #42
  50. 50. ©sylvainchamberland.com •Retrognatic maxilla and mandible •Mx incisors retroclination •Md incisors proclination
  51. 51. ©sylvainchamberland.com Tx plan •Apectomy #42 •Perio evaluation and clearance •Alleviate dental compensation •Arch coordination •Orthognatic surgery: maxillo-mandibular advancement
  52. 52. ©sylvainchamberland.com •Lingual button + elastomeric chain to help derotation •Mx + Md: .016 supercable™ ClPe120612
  53. 53. ©sylvainchamberland.com At 15 weeks •Md: 16x22 cnt •Mx: ∆EC. .016 sc™ ClPe240912
  54. 54. ©sylvainchamberland.com At 75 weeks •Mx: EC 14-24. active coil 14-17, 24-27. ✓ ART auxilliary since 6 weeks to be maintained •Md: 21x21x20x58 mm enmasse ret ✓ Cl III elastics ClPe201113
  55. 55. ©sylvainchamberland.com At 100 weeks •Class I relationship… •Mx: space open for implants •Md: space closed ClPe140514
  56. 56. ©sylvainchamberland.com •1/-SN: torque improved 72° to 88° •/1-MP: retroclined 107° to 85° •Occlusal plane improved
  57. 57. ©sylvainchamberland.com •Le Fort 1: 10 mm advancement, 2 mm inferior repositioning at PNS •OSMB: advancement + counterclockwise rotation •Genioplasty: advancement 6 mm
  58. 58. ©sylvainchamberland.com •Iliac bone graft between Mx bone cuts 
 and implant sites. •Note healing of 42 apex •No more snoring, no more apnea ClPe160914
  59. 59. ©sylvainchamberland.com 137 semaines •Dépose des appareils (31 mois) ClPe260115
  60. 60. ©sylvainchamberland.com
  61. 61. ©sylvainchamberland.com •Ke. Bi.-Du.
  62. 62. ©sylvainchamberland.com •Class II div 1 •Missing 17, 26, 35, 45 KeBiDu080609
  63. 63. ©sylvainchamberland.com •Hyperdivergent •Retrognathic mandible •AP chin deficiency + vertical excess •Cant of occlusal plane
  64. 64. ©sylvainchamberland.com •Tx plan ✦ Visual Treatment Objective
 is mandatory
  65. 65. ©sylvainchamberland.com Mechanotherapy •Tx initiated: sept 2012 •Mx: TPA to derotate and upright #26 
 (asymmetric mesial out activation) ✦ 32 weeks of TPA
  66. 66. ©sylvainchamberland.com At 47 weeks •Dental arches are pretty much coordinated •Md space closure to obtain optimal width of a premolar KeBiDu080813
  67. 67. ©sylvainchamberland.com Pearl •Identify the error
  68. 68. ©sylvainchamberland.com •Lip incompetency at repose •Retrognathic mandible •Lower incisors could be more upright but space for implant 35, 45 was needed
  69. 69. ©sylvainchamberland.com 3D Surgical Planning
  70. 70. ©sylvainchamberland.com 3D Surgical Planning
  71. 71. ©sylvainchamberland.com •At 64 weeks: Surgery •Le Fort 1 ✦ Rigid fixation
  72. 72. ©sylvainchamberland.com •BSSO / OSMB •Note good fitting of the occlusion perop
  73. 73. ©sylvainchamberland.com •Genioplasty •Bone graft at edentulous site
  74. 74. ©sylvainchamberland.com At 66 weeks (2 weeks post op) •Change arch wire + ∆ elastics •A good presurgical orthodontic preparation permits a nice post surgical occlusion KeBiDu171213
  75. 75. ©sylvainchamberland.com Tx time: 83 weeks •Class I relationship •Posterior segment to maintain root parallelism
 & avoid extrusion KeBiDu300414
  76. 76. ©sylvainchamberland.com •Conterclockwise rotation of the maxilla and mandible helped to maximize mandibular advancement •But lower incisors proclination reduced md advancement, hence symphysis needed more advancement
  77. 77. ©sylvainchamberland.com
  78. 78. ©sylvainchamberland.com •Restauration implantoportée 36 et 46 •Recommandation d’une greffe gingivale au buccal de 31, 41 KeBiDu181214
  79. 79. ©sylvainchamberland.com •Proéminence radiculaire inférieure peut expliquer le problème mucogingival observé
  80. 80. ©sylvainchamberland.com •Pa.Pl
  81. 81. ©sylvainchamberland.com •Class I, open bite •Severe ALD •Bimaxillary protrusion PaPl150512
  82. 82. ©sylvainchamberland.com •Lip incompetency at repose •Gummy smile at full smile •~Normal incisor showing at repose
  83. 83. ©sylvainchamberland.com Tx plan •Extraction? •Orthognathic surgery? •Or ??
  84. 84. ©sylvainchamberland.com At 13 weeks •Tx initiated Feb.2013. TADs placed 6 weeks later. •TPA .032 x .032 SS + paramedian TADs (Elinks) •Buccal TADs between 15-16, 25-26 (EC) •Buccal TADs between 36-37, 46-47 (lig. tie) PaPl 160513
  85. 85. ©sylvainchamberland.com At 40 weeks •At 25 weeks the TPA was replaced because it impinged into the palate •At 22 weeks: Bonded .032 x .032 SS lingual arch ✦ Posterior inferior teeth are intruded with ∆ EC •At 40 weeks, buccal EC is removed PaPl 211113 .Md:020 x.025 SW .Mx:020 x.025 SW
  86. 86. ©sylvainchamberland.com At 40 weeks •Overbite improved •Still bimax protrusion •Need maximum retraction Initial PaPl 211113
  87. 87. ©sylvainchamberland.com At 48 weeks •Posterior openbite is obtained •Incisors retraction is going on with maximum anchorage •Note the absence of the lingual arch wich which will cause expansion of the molars (adverse side effect) PaPl 160114
  88. 88. ©sylvainchamberland.com At 54 weeks •Tads placed anteriorly to intrude upper incisors •Palatal lingual ligature to maintain intrusion •Lower incisors are still retracting •Mx midline need shifting to the left PaPl 270214
  89. 89. ©sylvainchamberland.com Repose Smile
  90. 90. ©sylvainchamberland.com At 71 weeks •20x25sw U & L •Stop intruding lower teeth •Continue upper intrusion PaPl 230614
  91. 91. ©sylvainchamberland.com At 86 weeks •Removal of the TPA and intrusive links •2 TADs were lost or removed PaPl 091014
  92. 92. ©sylvainchamberland.com
  93. 93. ©sylvainchamberland.com •FMA decrease 4° •/1-MP decrease 10° ✦ /1-APg decreased 3 mm ✦ /1 intrusion 2 mm •Significant upper molar intrusion & upper incisor intrusion
  94. 94. ©sylvainchamberland.com •Significant profile improvement •Competent lip at repose •Improved smile display PaPl 150512 Initial PaPl 091014 Progress
  95. 95. ©sylvainchamberland.com •À 88 semaines
 
 
 
 
 
 •À 93 semaines ✦ Finition PaPl080115 PaPl151214
  96. 96. ©sylvainchamberland.com •Li.Nda.
  97. 97. ©sylvainchamberland.com •Class I, open bite LiNda 040214
  98. 98. ©sylvainchamberland.com •Severe bimaxillary protrusion •Anterior vertical excess •Lip incompetency •Dégagement des dents inférieures lors du sourire
  99. 99. ©sylvainchamberland.com At 13 weeks •Tx initiated February 25 ✦ Mx: 3 segments •At 13 weeks ✦ Mx:Tomas Pin EP 8 mm + .020x.020 cuniti ✦ Md: Tomas Pin EP 6 mm + .020x.020 cuniti LiNda 270514
  100. 100. ©sylvainchamberland.com At 19 weeks •Mx: .020x.020 Cuniti •Md: .020 x .025 SS ✦ Retighten lower right pin LiNda 270514 LiNda080714 Retighten
  101. 101. ©sylvainchamberland.com At 25 weeks •Mx: .021x.021x.020x55 mm + Elinks #4 6-P •Md: .021x.021x.020x58 mm + E #4 ✦ Replaced lower right pin LiNda080714 LiNda190814
  102. 102. ©sylvainchamberland.com At 31 weeks • Mx: ∆ Elinks #4 6-P et E3 palatins • Md: E5 attached to /7s ✦ LR pin loose, lig. tie on both lower pin • Note posterior open bite LiNda190814 LiNda290914
  103. 103. ©sylvainchamberland.com LiNda290914 À 37 semaines • Mx: ∆ Elinks #4 6-P • Md: E5 attached to /7s ✦ resserrer TAD inf droit, E4 TAD-2e PmI • Notez béance postérieure LiNda121114
  104. 104. ©sylvainchamberland.com À 42 semaines • Mx: ∆ Elinks #5 7-P • Md: ∆ E5 to /7s LiNda121114 LiNda171214
  105. 105. ©sylvainchamberland.com •Intrusion postérieure supérieure et inférieure •Autorotation antérieure et supérieure
  106. 106. ©sylvainchamberland.com •Amélioration du profil •Persistence d’une contraction du mentionnier •Léger excès vertical de la symphyse
  107. 107. ©sylvainchamberland.com •Progrès à 42 semaines 
 
 
 
 
 
 •Initial
  108. 108. ©sylvainchamberland.com •On continue la rétraction et l’intrusion •Remarquer les 7s… LaMaNda260115
  109. 109. ©sylvainchamberland.com •Ch.Ol.Ga.
  110. 110. ©sylvainchamberland.com •Classe I •Béance antérieure •DDM inférieure ChOlGa220514
  111. 111. ©sylvainchamberland.com •Hyperdivergence squelettique •Microrami
  112. 112. ©sylvainchamberland.com •Résorption condylienne ou 
 arthrose
  113. 113. ©sylvainchamberland.com ChOlGa030914 Mx: 3 segments .020x.020 cnt. Tomas Pin SD 6 mm, Elinks E3 P-4
 Md: 2 segments .020x.020 cnt. Tomas Pin EP 6 mm, Hamac elastic ChOlGa221014 Mx: 3 segments .020x.025niti. ∆ E3 P-4. Md: ∆ Hamac 7 weeks later
  114. 114. ©sylvainchamberland.com •Vector TAS 6 & 8 mm paramedian (out of stock of Tomas Pin •TPA .032x.032SS. Elinks E6. Md: lingual arch .032x.032TMA ChOlGa030914 ChOlGa221014 •∆ E links E6. ∆ Hamac
  115. 115. ©sylvainchamberland.com À 26 semaines •Fermeture significative de la béance antérieure •Prêt pour exo des 4s ChOlGa060115
  116. 116. ©sylvainchamberland.com •Amélioration du scellement labial •Rotation antihoraire du plan occlusal •Biproalvéolie: Exo des 4s nécessaires
  117. 117. ©sylvainchamberland.com •Amélioration du scellement labial •Rotation antihoraire du plan occlusal •Biproalvéolie: Exo des 4s nécessaires
  118. 118. ©sylvainchamberland.com •Intrusion postérieure supérieure et inférieure •Autorotation antérieure du plan mandibulaire
  119. 119. ©sylvainchamberland.com What does literature say? •Intrusion of the maxillary posterior teeth can give satisfactory correction of moderately severe anterior open bites, with elimination of 5 to 6 mm of open bite, but 0.5 to 1.5 mm of reeruption of these teeth is likely to occur. •Controlling the vertical position of the mandibular molars so that they do not erupt as the maxillary teeth are intruded is important in obtaining a decrease in face height. Scheffler, Nicole R. et al. Outcomes and stability in patients with anterior open bite and long anterior face height treated with temporary anchorage devices and a maxillary intrusion splint, AJODO, Volume 146 , Issue 5 , 594 - 602
  120. 120. ©Dr Sylvain Chamberland •Mx: 60% des patients ont une intrusion de 2 à 4 mm T1-T2
 
 
 •Md: Extrusion occurs during post intrusion of mx teeth. Percent with change in the maxillary first molar distance from the palatal plane. Note that 60% of the patients had the molar intruded 2 to 4 mm during the splint therapy for intrusion (T1-T2), but only 1 patient had greater than 4 mm of intrusion. During the postintrusion orthodontic treatment, only 2 patients (7%) had 2 to 4 mm of reeruption of the maxillary molars; during the first posttreatment year (T3-T4), 3 patients (11%) had 2 to 4 mm of downward movement, most likely caused by continued vertical growth. From the end of treatment to the more than 2-year recall, 4 patients (16%) had 2 to 4 mm of downward movement, which was also largely due to vertical growth. Percent with change in the mandibular first molar distance from the mandibular plane. During splint therapy(T1-T2), 2 patients had greater than 4 mm of eruption of the mandibular first molars (7%), and 1 (3%) had 2 to 4 mm of eruption. During postintrusion orthodontics (T2-T3), 5 (17%) had 2 to 4 mm of eruption. During the first posttreatment year (T3-T4), 5 (19%) had an eruption of 2 to 4 mm, but 1 patient had an eruption of 2 to 4 mm. During the second posttreatment year, 4 (16%) had 2 to 4 mm of eruption, and 1 had 2 to 4 mm of intrusion.
  121. 121. ©sylvainchamberland.com About TADs •I have tried Aarhus system ✦ Sterilisation tray, driver not easy to unlock from the screw. •I have tried Vector TAS ✦ Triangular head is fine. 
 Lack of different component for different mechanics
  122. 122. ©sylvainchamberland.com About TADs •I know use Tomas Pin ✦ Individual dispenser. Head is used for different system
  123. 123. ©sylvainchamberland.com •#47 Molar Uprithing spring •#26 TMA root spring
  124. 124. ©sylvainchamberland.com
  125. 125. ©sylvainchamberland.com •Tomas Pin 6 mm pour renforcer l’ancrage ✦ Elinks attaché sur les potences •Évolution 12 semaines AmCo12-08-14 AmCo29-10-14
  126. 126. ©sylvainchamberland.com •Évolution 18 semaines ✦ Rétraction antérieure maximisée AmCo12-08-14AmCo29-10-14 AmCo10-12-14
  127. 127. ©sylvainchamberland.com •Tomas Pin SD 8 mm CIARLANTINI R., MELSEN B., Miniscrew-Retained Pontics in Growing Patients:A Biological Approach, JCO october 2012
  128. 128. ©sylvainchamberland.com
  129. 129. ©sylvainchamberland.com •Shorter length of 12 could be explain by the long cantilever arm, but i am not sure.
  130. 130. ©sylvainchamberland.com 6 Months Follow up •No inflammation. Esthetic is good despite a too short incisal edge
  131. 131. ©sylvainchamberland.com Cope J., McFadden D.,Temporary replacement of missing maxillary lateral incisors with orthodontic miniscrew implants in growing patients: rationale, clinical technique, and long-term results, Journal of Orthodontics, Vol. 41, 2014, S62–S74
  132. 132. ©sylvainchamberland.com •Kokich was opposed of such approach because he pretend that it would impaired vertical growth of the crest. •Cope et Wilmes ne semblent pas s’en inquiéter. •Melsen a démontré qu’un TAD perpendiculaire maintient le volume BL de la crête •Qui dit vrai? Case 1. A. 14-year-old male patient with missing upper lateral incisors after orthodontic space opening. B. Mini-implants (2mm Å~ 13mm) inserted in lateral incisor spaces. C. Temporary crowns bonded to resin abutments with composite. Mini-Implant-Supported Temporary Pontics, WILMES B,NIENKEMPER M, RENGER S, DRESCHER D,© 2014 JCO, July VOLUME XLVIII NUMBER 7; 422-9
  133. 133. Thanks for your attention

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