Section of Orthodontics

Transcription

1 Section of Orthodontics Akila Aiyar Department of Dentistry, HEALTH Aarhus University - Denmark A A R H U S U N I V E R S I T E T Paolo M. Cattaneo

2 Aarhus Denmark

3

4 Postgraduate program in ORTHODONTICS Head of Section & Course Director: Marie Cornelis Postgraduate residents: 16 Education duration: 3 years full-time Clinical Instructors: 8 (+2) Scientific staff: 5 Facilities: 16 dental chairs (+6 in specialized clinic) CBCT-scanner Digital models & Intra-oral scanner 3D camera 3D Virtual surgery

5 5 days of clinic per week clinical instructors Lene & Morten Susanna & Anne Lill & Tine Marie Vibeke & Bo Thomas & Annelise

6 Research Research Coordinator: Paolo M. Cattaneo Scientific Staff: Marie Cornelis Associate Professor Michel Dalstra Associate Professor Peter Stoustrup Assistant Professor Thomas Klit Pedersen Professor MSO Paolo M. Cattaneo Associate Professor

7 International Short-Term course Course Director: Susanna Botticelli Intensive theoretical and clinical insight in orthodontics Academic-based teaching Targets both dentists and orthodontists Speakers: international speakers & former Aarhus residents 3 months (September to November), 8h/day First part of the program for the postgraduate residents

8 The residents routine at the Orthodontic Section // 8:00-9:00 // Seminar // Every day one of us presents a seminar on a selected topic // 9:00-14:00 // Work in the clinic // Each resident has his/her own chair and starts at least 50 patients // 14:00-16:00 // After clinic // Treatment planning with clinical instructors and research meetings //16:00-? // Work in the office // Research //.

9 Class III malocclusions Patient treated at Aarhus Dental Institute and Aarhus university hospital. Age at start of treatment 18 years. Treatment planning: plaster surgery Supervisor: Annelise Küseler Akila Aiyar ; Aarhus University,Denmark 9

10 Case Summary AGE DENTAL STAGE 18 years and 7 months DS4 M2 DESCRIPTION OF MALOCCLUSION Skeletal open bite, Angle Class I, peg shaped 12 and 22 TREATMENT APPROACH Full fixed appliance, segmented approach, Le fort 1 3 piece and autorotation of mandible, interdisciplinary case TREATMENT STARTED TREATMENT COMPLETED TREATMENT TIME RETENTION PROTOCOL 2 years and 2 months (26 months) Fixed retainers and Essix full time in upper arch

11 Anamnesis CHIEF COMPLAINT GENERAL HEALTH (ALLERGY) RESPIRATORY DISORDER TONSILS/ADENOIDS TRAUMA SYMPTOMS OF TMD PARAFUNCTION EARLIER ORTHODONTIC TX FAMILY S ORTHO HISTORY GROWTH/MATURATION (menarche) ATTITUDE TOWARDS TREATMENT Patient is unhappy with his appearance has difficulty in breathing, mastication and speech.(lisping) Autistic and diagnosed for hay fever. Occasional snoring and mouth breather Nothing to report Nothing reported. No No Was offered OR treatment in community system, a removable plate to correct inverted upper incisor. Both parents have no history of orthodontic treatment. Patient is adult and growth is considered completed Very positive

12 REFERRAL Anamnesis The patient is referred by Aarhus Kommunale tandpleje CHIEF COMPLAINT Patient is unhappy with his appearance has difficulty in breathing, mastication and speech.(lisping) GENERAL HEALTH (ALLERGY) RESPIRATORY DISORDER TONSILS/ADENOIDS TRAUMA SYMPTOMS OF TMD PARAFUNCTION EARLIER ORTHODONTIC TX FAMILY S ORTHO HISTORY GROWTH/MATURATION (menarche) ATTITUDE TOWARDS TREATMENT Autistic and diagnosed for hay fever. Occasional snoring and mouth breather Nothing to report Nothing reported. No No Was offered OR treatment in community system, a removable plate to correct inverted upper incisor. Both parents have no history of orthodontic treatment. Patient is adult and growth is considered completed Very positive

13 Initial photos - extraoral

14 Clinical examination extraoral En Face Face is asymmetric due to an asymmetric mandibular projection. Lower face canting. Eyes are at the same level (bipupilar line is parallel to the floor)(caution picture rotated slightly on z axis) Nose is slightly off to the left and everted Chin is deviated to the right Ramus on the right side seems shorter than the left side (caution picture rotated slightly on z axis) Proportions in the transversal are slightly larger on the right side compared to the left (caution - skew picture) Upper midline to facial midline On

15 Radiographic examination - NEWTOM Minor asymmetry:left gonion is slightly higher positioned than right and left ramus slightly shorter.chin is centered.

16 Clinical examination extraoral Profile Facial profile is slightly convex due to more posterior positioned nasion.(mesocephalic) 39% Lower anterior facial height is increased (LAFH= 61% TAFH) (55% ± 2% Eastman normal value, Mills;1982) 61% 28% 72% Nasolabial angle is increased (132º) (Caucasian norm:114 ± 10, Fitzgerald et al., 1992) Sulcus mento-labialis is shallow(flattened) Chin- and mandibular projection is reduced.

17 Initial photos - intraoral

18 Lingual view Occlusion Lingual view OCCLUSION SAGITTAL ()=from lingual Angle Class I with subdivision Anterior Overjet: 2 mm Molars Right 1/4D (1 N) Left 1/4M (N) Canines - - VERTICAL Anterior Overbite: 5,5 mm Posterior Open bite from 5+ til +5 TRANSVERSAL Anterior Upper midline to facial midline Lower midline to facial midline Posterior Edge to edge at molars On ½mm to right

19 Radiographic examination - Intraoral ROOT LENGTH normal ROOT MORPHOLOGY Roots appear more curved. Distal bending of 21,23

20 Radiographic examination - OPG TEETH PRESENT CARIES - All teeth except third molars BONE LEVEL, APICAL SITES ABNORMALITIES IN BONE CONDYLES Normal bone level, Dense bone islands(enostosis) Right sinus seems to be filled with polyps (retention psuedo cyst) (signs of sinusitis) Condyles appear well defined in this radiographic projection

21 Radiographic examination TMJ Pretreatment R L Condyles seem normal in length and with a normal morphology. Well seated in the fossa on the right side and left side. Both joints have well-defined cortical bone of both condyles and articular fossa.

22 Initial cephalometric analysis Skeletal Class I with Skeletal open bite Decreased sagittal jaw relation with reduced maxillary prognathism. Increased vertical jaw relations due to increased mandibular inclination. Decreased Wits. Akila Aiyar ; Aarhus University,Denmark 22

23 Problem List SUBJECTIVE Patient is unhappy with his appearance feels that his face is asymmetric with open bite and has problem with chewing and breathing. OBJECTIVE Angle Class I, subdivision, Skeletal open bite, peg shaped 12 and 22 APPEARANCE FUNCTION Straight facial profile(slightly convex), Anterior open bite, dark buccal corridors Tongue thrust, oral breathing, lisping ORAL HEALTH - DENTITION Peg shaped 12 and 22 Some rotations and tippings Severe crowding in upper (-8 mm) and lower (-5 mm) arches Increased anterior ratio(86,3%) OCCLUSION Angle class I, subdivision. occlusal plane tilting downwards VOB: -5,5 mm, HOB: - 2 mm OTHER Autistic and Hay fever

24 Treatment options Surgical Advantage Disadvantage Non Surgical Transverse expansion Intrusion of upper and lower molars with miniscrews No need for orthognatic surgery Extractions could ease the closure of open bite(extrusion of anterior teeth) Less risk of morbidity. -Camouflage treatment -Uncertain treatment result -Doubtful if bite can be closed sufficiently as openbite is 5,5mm Surgical: Single procedure LeFort I, 3 piece osteotomy with impaction posteriorly, lowering anteriorly, advancement in total and autorotation of the mandible) Surgical: Double procedure LeFort I, 3 piece osteotomy with impaction posteriorly, lowering anteriorly, advancement in total with BSSO in mandible -Eliminates openbite -Control of upper and lower front inclinations -Optimal aesthetic outcome Eliminates open bite Less movement in one jaw Improves profile and airways Risk of morbidity with surgery Risk of morbidity with surgery and more invasive compared to one jaw surgery

25 Treatment principles TOOTH MOVEMENT Full fixed appliance SURGERY/EXTRACTION FUNCTIONAL ADAPTATION/GROWTH EFFECT PROSTHODONTIC Le Fort I (3-pieces) and auto rotation of mandible - Build up 12 and 22, after treatment evaluate need for implants.

26 Treatment phases PHASE GOALS MECHANICS I Level and align in three segment, prepare for orthognathic surgery. Obtain space between roots 3,2+ and +2,3 Br. 5,4,3,2,1+1,2,3,4,5. Tubes 7+7. Three segments with braided wires. V bends at 3,2+2,3. End in rectangular 0,018 x 0,025 SS wires. Optimize anchorage with TPA. II Levelling of lower arch Work up to 0.019x0.025 SS wires III IV Decrease vertical relation. Obtain consonant smile arch. Surgery: Correct in both vertical, transversal, and sagittal planes of space Arch coordination Post surgical finishing 3-piece maxilla with osteotomies distal of 12, 22. Individual movements for the three segments and further autorotation of the mandible Decrease wire size. Individual bends and leveling of occlusal planes. Intra-maxillary elastics

27 Date: Months in TX: 10

28 Date: Months in TX: 14

29 Surgical plan Date: Months in TX: 15 4 mm 3,5 mm Auto-rotation Before After Le fort 1 with 3 piece between 3,2+2,3 Anterior segment advanced,extruded Posterior segment impacted and expanded Advancement in total. Anterior rotation of mandible

30 Presurgical registrations Date: Months in TX: 15

31 Presurgical registrations Date: Months in TX: 15

32 Date: Months in TX: 17 With surgical wafer( 2 weeks post surgical)

33 Date: Months in TX: 20

34 Date: Months in TX: 25

35 Final photos Date: Months in TX: 28

36 After build ups of 12,22 Date: Months in TX: 27

37 Initial vs. Final: Extraoral

38 Initial vs. Final: Extraoral

39 Initial vs. Final: Intraoral

40 Final radiographic examination Intraoral Before Minor root blunting - mild (grade 0) according to classification (0-4) (Levander and Malmgreen, 1988)

41 Final radiographic examination - OPG Acceptable root parallelism and interradicular spacing. Enostosis still visible and right sinus cleared with few persistent polyps.

42 Skeletal Dentoalvelar Skeletal Dentoalveolar Final radiographic examination Lateral cephalogram A B C M sd A B C M sd OK alv. prognathism Pr-N-Ss Max. incisor to upper lip (vertical) / Mand. incisor to A-Pg UK alv. prognathism CL/ML Nasolabial angle / ,6 --/ Wits appraisal ( / ) / -1/0 1.9/1.8 OK inc. inclination Ils/NL / Lower lip to E-plane / UK inc. inclination Ili/ML Facial contour angle (facial convexity) / / 94 7 G-Sn/Sn-Me (Lower face height) :1 A B C M sd A B C M Sd Sag. jaw relation Ss-N-Pg Max. prognathism S-N-Ss Basis Cranii N-S-Ar / 82 3, ,0 Sag. jaw relation Ss-N-Sm Mand. prognathism S-N-Pg Basis Cranii N-S-Ba , / 131 4,5 OK-zone NL/Ols Max. inclination NSL/NL Beta angle /+ 8 3, ,5 UK-zone Oli/ML Mand. inclination NSL/ML Jaw angle / 33 6, ,0 Vert. jaw relation NL/ML / 25 6 Horizontal Overjet Vertical Overbite 0.2/2.5-6,1/0.9 Sagittal and vertical jaw relations improved. Wits improved. Upper and lower incisor inclinations improved.

43 Before NEWTOM Post treatment Before

44 Treatment evaluation ROOT RESORPTION Minor root bluntings (> 2 mm) are present in the upper front. RETENTION Fixed retainer 43 to 33 and 12 to 22. Removable Essix retainer worn full-time PROGNOSIS ADDITIONAL COMMENTS If the prescribed retention protocol is followed the prognosis is good, but it must be clear for the patient that retention is needed life-long See next slide

45 Additional comments to the treatment Subjective: The patient is satisfied with the treatment outcome - both the functional and the esthetical improvements are appreciated. Objective: The open bite was resolved and thereby improving the function and speech. 12,22 was not affected during surgery, hence good prognosis with prosthetic restorations. The restorations could be better. Inclination of canine on left side could be improved. The patient was diagnosed for autism. It was stated that he has remarkably improved his self esteem. After a month of retention the occlusion seems stable and there is improved settling observed in the both sides.

46 Post treatment models

47 AU Aarhus University Section of Orthodontics AARHUS INTERNATIONAL SHORT-TERM COURSE IN ORTHODONTICS AARHUS UNIVERSITY POSTGRADUATE PROGRAM IN ORTHODONTICS odont.au.dk/postgraduate