Fixed applicance management of class II correction

Fixed Appliance Management of Class II

MalocclusionSUS2 Corrector

Dr Sylvain Chamberlandsylvainchamberland.com

http://sylvainchamberland.com

Literature review

sylvainchamberland.com

Xbow applianceSample of 69 consecutive cl II patients compared to

30 historical cl II controls. Retrospective study.

Xbow 4,5 months; T2 ceph : 6,5 months post Xbow removal Therefore, T2 measurement include relapse of most side effect Skeletal change:

Diminution of Mx protrusion, without md advancement

Increase vertical dimension compare to untreated controlFlores-Mir C, Barnett G, Higgins DW, Heo G, and Major PW. Short-term skeletal and dental effects of the Xbow appliance as measured on lateral cephalograms. AJODO; 2009;136(6):822-832.

Flores-Mir, AJODO 2009



Xbow applianceDental change

Overjet

Correction by increase incisor proclination (IMPA 4,7 4,1)

No mx incisor movement

Molar relationship

U6 distalize 0,9 1,2 mm

L6 mesialize 1,1 1,3 mmFlores-Mir C, Barnett G, Higgins DW, Heo G, and Major PW. Short-term skeletal and dental effects of the Xbow appliance as measured on lateral cephalograms. AJODO; 2009;136(6):822-832.

Flores-Mir, AJODO 2009



Xbow vs ForsusSample of 38 consecutive xbow appliance tx compared to

36 Forsus appliance tx. Retrospective study.

T1 ceph at baseline. T2 ceph at the end of tx Both appliance generate the same amount of incisors inclination The older the patient, the more OJ and upper incisors inclination remain The longer the tx time, the more the lower incisors procline Total tx time for both appliance is about the same

Flores-Mir et al AO 2013

Miller, Robert A, Long Tieu, and Carlos Flores-Mir. "Incisor Inclination Changes Produced by Two Compliance-free Class II Correction Protocols for the Treatment of Mild to Moderate Class II Malocclusions." Angle orthodontist 83, no. 3 (2013): doi:10.2319/062712-528.1.



Xbow appliance

Sample of 25 consecutive cl II patients. Mean age 11,1 1,1 y. Prospective study CBCT at T0 and after debonding Xbow (T1). Tx time 6,0 m (5,0-8,0) Skeletal effect Mild SNA decrease (0,67 1,35)

Erbas, Banu, and Ilken Kocadereli. "Upper Airway Changes After Xbow Appliance Therapy Evaluated with Cone Beam Computed Tomography." Angle Orthod 2014; 84, no. 4: doi:10.2319/072213-533.1

Erbas, A0 2014



Xbow appliance

Dental effect U1: Palatal tipping (-3,58 3,56)+ extrusion (1,72 1,87 mm)

U6: No significant distal tipping or intrusion. Mesial mvt inhibited

L1: Labial tipping (10,87 4,91)

L6: Mesial mvt (2,07 1,24 mm) + extrusion (1,52 1,08 mm)

Erbas, Banu, and Ilken Kocadereli. "Upper Airway Changes After Xbow Appliance Therapy Evaluated with Cone Beam Computed Tomography." Angle Orthod 2014; 84, no. 4:: doi:10.2319/072213-533.1

p< .001

p< .001

p< .001

Erbas, A0 2014



, 12 a. 5 m. End of Xbow Lower incisor proclination is

obvious (+21)

La.Sha 0807

La.Sha 0308



Xbow undesirable side effect relapsed

Incisor proclination return to normal

Sometimes, we pray for relapse

La.Sha 0308. 5 month of Xbow



Tx time 23 months Outcome 82 weeks into retention

La.Sha 22-03-11



Forsus vs Cl II elasticSample of 30 consecutive patients, 23 treated with Forsus (13,4 y), 7 with cl II

elastics (14,3 y). Prospective.

Ceph T0 after alignment, ceph T1 at removal of Forsus. Tx time 6 m. No difference in skeletal effect Mx or Md Dental effect Forsus:

1/FH retroclined. /1-MP proclined

Significant increase of occlusal plane to FHDubois A, Rompr P, Rodrigue C, Remise C, Comparaison des effets sur la croissance des maxillaires de lutilisation du Forsus versus celle des lastiques de classe II, Thse de matrise

Dubois, Master thesis U. MTL.



Forsus effectivenessRetrospective study, 32 consecutive patients (12,7 1,2 y) matched to 27 historical

untreated controls (12,8 1,3 y)

Ceph T0 prior tx and Ceph T1 at completion of ortho therapy. Tx time 2,4 0,4 y Mean duration of FRD active phase: 5,2 1,3 m

Successful cl II correction in 87,5% of the patients

Greater skeletal effect on maxillary structures by restraining sagittal advancement of the mx (SNA 1,6 1,4)

Effect on the mandible is mainly dentoalveolar: large amount of mesial mvt of L1 (6,1 6,3) and L6 (2,4 1,6 mm), extrusion of L6 (3,6 1,5 mm)

Franchi L, Lisa Alvetro, Veronica Giuntini, Caterina Masucci, Efisio Defraia, and Tiziano Baccetti. "Effectiveness of Comprehensive Fixed Appliance Treatment Used with the Forsus Fatigue Resistant Device in Class II Patients." Angle orthodontist 2011; 81, no. 4: doi:10.2319/102710-629.1

Franchi, A0 2011



Forsus effectivenessFollow-up at 2,3 1,1 y post comprehensive tx. 36 consecutive patients/

20 historical untreated controls. Retrospective study.

Mean FRD duration 4,8 2,4 m

Outcome (retrospective study)

T1-T2: Baseline to end of ortho

T2-T3: End of ortho to end of retention

T1-T3: Baseline to end of retentionCacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist (2014):doi:10.2319/112613-867.1

Cacciatore, A0 2014



Forsus effectivenessFollow-up T1-T2 FRD vs untreated controls

Significant skeletal effect on Mx (SNA 1,7 )

No significant effect on Md

Significant improve of dental relationship

OJ -5,1mm; OB -3,1 mm; molar relationship +3,5 mm

U1 retruded 1,6 mm, L1 proclined 5,6/ 1,5 mm. L6 extruded 1.3 mm. U6: no vertical change

Cacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist 2014 doi:10.2319/112613-867.1

Cacciatore, A0 2014




Significant greater increase in sagittal position of Mx (SNA 1,4)

Significantly increase of both OJ (1,3 mm) and OB (1,5 mm)

Significant intrusion of U1 (-1,2 mm)

Cacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist 2014 doi:10.2319/112613-867.1

Cacciatore, A0 2014




No significant sagittal or vertical skeletal change

Significant reduction of OJ (-3,8 mm), OB (-1,5 mm)

Significant improvement of molar relationship (+ 3,7 mm)

Significant retrusion of U1 (-1,1 mm)

Significant intrusion of L1 (-1,2 mm)

Success rate of overall correction: 83,3%Cacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist 2014 doi:10.2319/112613-867.1

Cacciatore, A0 2014



Fatigue Resistant Device29 subjects, prospective study, 15 prior growth peak; 14 post growth peak. Tx time 9 months. Ceph + MRI study Palatal tipping + extrusion of mx incisors

Protrusion + intrusion + labial tipping (5,5 - 6) of md incisors

Distal tipping of Mx molars

Mesial movement + mesial tipping of Md molars

No change in disk positionAras, Ada, Saracoglu, Gezer, and Aras. "Comparison of Treatments with the Forsus Fatigue Resistant Device in Relation to skeletal maturity: A cephalometric and magnetic resonance imaging study. AJODO 2011; 140: 616-25: doi:10.1016/j.ajodo.2010.12.018.

Aras, AJODO 2011



Class II div 1 Constricted maxilla Tx time: 99 weeks

Gu.Ma. 0707

Gu.Ma. 0708

Gu.Ma.250811; 2 years out of ortho



Side effects relapsed



Twin Force Bite CorrectorSample of 23 patients before Pubertal Growth Spurt compared to 18

patients post PGS. Retrospective study.

Skeletal change Mx restriction SNA 1,22

Dental change IMPA increased 4,4 to 5,5

Chhibber, Aditya, Madhur Upadhyay, Flavio Uribe, and Ravindra Nanda. "Mechanism of Class II Correction in Prepubertal and Postpubertal Patients with Twin Force Bite Corrector." Angle Orthod. 2013; 83, n718-727: doi:10.2319/090412-709.1

Chhibber, A0 2013



Twin Force Bite Corrector

At end of ortho No difference between skeletal and dental parameters of both

groups

Significant longer tx time for the youngest group (3,67 y vs 2,75 y)

Tx efficiency is greater for the post pubertal group

Chhibber, Aditya, Madhur Upadhyay, Flavio Uribe, and Ravindra Nanda. "Mechanism of Class II Correction in Prepubertal and Postpubertal Patients with Twin Force Bite Corrector." Angle Orthod. 2013; 83, n718-727: doi:10.2319/090412-709.1

Chhibber, A0 2013



SaAl180111

SaAl271009. male; 13y 10 m

SaAl151112, 16y 11 m



Tx plan: exo 4s/5s Cl II correction device helped to maintain

anchorage while retracting U1 and protracting L6



SUS2 vs Forsus FRDSample: 20 SUS2, 20 Forsus, 19 controls. All post pubertal (~15 y1 y) Both appliances. Tx time 5 m 1 m. Prospective study. Dentoalveolar effect

1/: retrusion + extrusion

/1: protrusion + intrusion

No significant skeletal effect on Mx and Md. No vertical change

Soft tissue profile improvement is limitedOztoprak MO, Nalbantgil D, Uyanlar A, and Arun T. A cephalometric comparative study of class II correction with Sabbagh Universal Spring. European journal of dentistry. 2012 Turkey;6(3):302-10

Oztoprak, Eur. J. Dent. 2012



SUS2 vs Forsus FRDHowever: Lower incisors proclination more prominent with Forsus FRD

SUS2 : IMPA= 5,78 3,91

Forsus: IMPA = 10,8 3,07

N-A-Pg: better reduction in facial convexity with SUS2

SUS2 : -2,13 2,85

Forsus: + 0,65 3.04

p < .001

p < .05

Oztoprak MO, Nalbantgil D, Uyanlar A, and Arun T. A cephalometric comparative study of class II correction with Sabbagh Universal Spring. European journal of dentistry. 2012 Turkey;6(3):302-10

Oztoprak, Eur. J. Dent. 2012



Study DesignExperimental groups Observation Time Point

Sample size (>25) Untreated Controls T0 Baseline T1 Prior Cl II device T2 Post Cl II device T3 End of Ortho T4 Follow-up

Flores-Mir AJODO 2009 R 69 30

6 m. post Xbow

Miller AO 2013 R 38/36

Erbas AO 2014 P 25

Dubois et al P 23 / 7

Franchi AO 2011 R 32 27

Cacciatore AO In press R 36 20

Aras AJODO 2011 P 15 / 14

Chhibber AO 2013 R 23 / 18

Oztoprak EJD 2012 R 20 / 20 19



Poor Study Design

Study about Cl II correction device are not at the level of RCT. Evidences are below that level of confidence Even meta-analysis should be interprete with caution

Giuseppe Perinetti, Jasmina Primoi, Giovanna Furlani, Lorenzo Franchi, and Luca Contardo (2014) Treatment effects of fixed functional appliances alone or in combination with multibracket appliances: A systematic review and meta-analysis. The Angle Orthodontist In-Press.


SUS2 Corrector


SUS2 Telescope Element

Telescope rod with ring

Position for turbo spring or spacer

Arch adaptor

Fixing screw

Middle telescope tube

Inner spring 2,4 N

Guide Tube

Hexagon socket screw

Eye



Inner SpringAt maximum activation Spring path of 6 mm

2,4 N at full compression

Deactivation with hexagon screw Spring path 2,1 mm

1,0 N at full compression

Spring span

Front stop

Back stop

Spring span



Turbo Spring

Place on the telescope element Force of 3,0 N

Spacer of 1 or 2 mm If required for reactivation,

although seldom necessary



SPEED Convertible Tube

For class II correction devices!Repeatably convertible Facilitate insertion and removal

of cinched back SS wire



SPEED Convertible Tube

Tips for bonding Adapt meshpad on the model

Microetch enamel

Use light bond adhesive or 2 paste system

Extra care should be taken to ensure sufficient curing time



Tips for bondingEtch enamel 15s Wash, rince & dry Apply Assure sealant on the tooth & light cure Apply Assure sealant on the bracket base & light cure Wipe the bracket base into Assure paste Place on the tooth & light cure



Large mesh pad needs slight adjustment to obtain best fit on the buccal surface

Good adaptation of the mesh pad is warrant of good bond strength Left side is not as nicely bonded than the right side



SPEEDConvertible Tube

Cinching a 20 x 25 SS wire in the gum and without debonding the tube is challenging

Convertible tube permits easy cinching outside the mouth

Insertion and removal of the SS wire takes seconds and done without fear of debonding



Buccal offset of the L pin at 3-4 mm distal to the tube Longer extension may impinge over the bracket of the 7s

The L ball-pin is bent gingivally or occlusally at the mesial

After some trial and errors, I prefer occlusal bend of the L pin



L PinInserted distally on the eye of the telescope Inserted distally into the head gear tube Buccal offset 3-4 mm long The pin is bent gingivally or occlusally at the mesial of the tube With bonded convertible head gear tube, I prefer to bend occlusally

Distal buccal offset and mesial occlusal bend are at 90 each other



SUS2 telescope is used without the outer turbo spring for the first 6 weeks

AlLa110814



SUS2 telescope is used without the outer turbo spring for the first 6 weeks

Turbo spring is added to maintain forward activation

AlLa110814

LaShMa080813

This is not the same case as above



L pin bent occlusally SPEED convertible tube on lower molars for easier insertion



Arch adaptor tightly screwed onto the arch wire distal to the offset Buccal offset of the archwire distal to the lower canines


Case Presentation


Class II div 1 Deep overbite

LaShMa160712



Class II skeletal relationship ANB 7, ABOP = 4 mm

Bimax protrusion

12y 0m



Tx plan

Comprehensive tx + SUS2 cl II corrector device Alternative tx plan Comprehensive + Extractions 4s/5s



At 44 weeksSUS2 corrector engaged in june 2013 at 36 weeks .020 X .025 SS wire U & L

Turbo spring added in august at 44 weeks

LaShMa080813



At 52 weeksE links from the molars to the canines

LaShMa021013



At 62 weeksSUS2 for 26 weeks

LaShMa121213



Tx time = 105 weeks Class I relationship achieved White spot lesion: !!! poor oral hygiene despite several warning

MaLaSh270814



14y



/1 AP relationship nicely controlled

/1 intrusion obtained /6 eruption occurred



Class II div 1 Deep curve of Spee. deep overbite

EmEho121212



Severe class II skeletal relationship ANB 6,4; ABOP = 7.5 mm

Hypodivergent

13y 6m



Tx plan

Comprenhensive tx, RPE + Fixed cl II correctors Increase vertical dimension

Alternate tx plan Comprehensive tx+ Orthognathic surgery (BSSO)



At 32 weeksSUS2 were engaged at 26 weeks 32 weeks E links 6-3 to distallize the canines

EmEho190913



At 43 weeksSUS2 removal (breakage occurred) 17 weeks of SUS2 cl II correctors 17x25 TMA mushroom loop

EmEho021213



!

At 71 weeks Rebond 16, 26. Mx: 20x20 niti. Cl II elastic nightime

At 81 weeks Mx: 21x25TMA, CE

EmEho180614

EmEho170714 EmEho260814



Vertical dimension improved /1 proclined 19 Not only because of SUS2 but also to arch leveling

1/ retroclined 11

15y 1mANB = 5,6 ABOP = 4,3 mm



Some condylar growth and molar eruption + mesialisation helped to achieve cl II correction



Improved facial profile13y 6m 15y 1m



Class II div 1 Severe ALD, impacted 37 Heavily restored 16, 46 Md dental asymmetry

KiLe250311



Hyperdivergent Convexe profile Mild skeletal cl II (ANB = 6; ABOP = 4 mm)

11y 8m



Tx plan

Extraction of 16, 24, 46, 38 SUS2 corrector Alternate tx plan Likely 14, 24, 35, 44



SUS2 engaged at 30 weeks (march 2012) E links to distalize the canines + protract 47

KiLe040612 43 w

KiLe230412 37 w



20 weeks of SUS2 corrector #47 protracted Arch symmetry achieved

KiLe160712 50 w

KiLe160712 50 w Bond #37



Dentoalveolar protrusion Lower lip procumbency Unpleasant smile

12y 10m



Class I canine relationship achieved

KiLe160913 110 w



post SUS20712

Lip incompetency Strain of the mentalis muscle

14y 0m



End of Ortho

KiLe091213 122W



Functional genioplasty to Obtain lip competency

Improve profile + smile display

14y 2m



11y 8m 12y 10m 14y 2m

Initial Post SUS2 Pre genio Final14y 0m

Chamberland S, Proffit WR, Chamberland P-E, Genioplasty in growing patients, Angle Orthod, in press



Cl II div 1 Accentuated curve of Spee Mx + Md

ElLa210812



14y

Vertical maxillary excess Gummy smile Lip incompetency at repose

14y 5 m



Mini screwMx: Palatal side (one on the left failed)

Replace by one paramedian

Md: Buccal The one on the left is too low and became

submerged

ElLa221112



Intrusion of mx posterior teeth help achieve some cl II correction Posterior open bite Deep overbite

ElLa070313



Posterior intrusion helped to improved AP relationship

14y 11 m



Md forward rotation Upper molar intrusion Limited eruption of lower

molars



SUS2 corrector E links were maintained for a few weeks

ElLa100613



Classe I relationship achieved

ElLa190814



Facial profile improve Lip strain persist A functional genioplasty is indicated

16y 5 m



Limited mx dentoalvolar growth

Favourable md growth L6 extrusion L1 proclination +

intrusion



Lip competency Smile display

16y 5 m14y 5 m



Anchorage for molar protraction Congenitally missing 35, 45

BiAu 190814

BiAu060513



Molar protraction + Cl II correction device

Classe II div 2 Internal root resorption of #46 Tx plan RPE, Cl II correction device. Exo 46. Protraction 47.

MaHe220611



Molar protraction + Cl II correction device

Class I relationship + molar protraction achieved in 96 weeksMaHe220611 MaHe031012

MaHe040613



Class II div 2, deep overbite Hopeless 14, 36, 46 Impacted 13

FrRo211111 16 y 2 m



Tx plan Would usually not need extraction in the md arch

How about exo 4s/6s + SUS2



SUS2 were engaged ~ 1 years after tx was initiated because the above mentioned reasons

SUS2 was used 36 weeks

FrRo041113

FrRo270114

The patient delayed extraction of U4 some 3 months and L6 some 9 months



Reassessment of bracket position Lower 7s protracted (3 mm to go for 47)

FrRo260814

Patient didnt show for 4 months (april to august)



/1- maintained AP 1/ torque improved Lip support maintained



L7s protracted /1s maintained AP


Discussion - Conclusion


Does the approach really matter?Most studies showed Some restriction of Mx forward growth

No significant increase of Md growth

Significant dentoalveolar change at end of ortho

Class II correction is maintained at 2 y follow-up (83%)

No significant skeletal change at 2 y follow up.



Side effect Incisor proclination occurred in spite of arch wire cinchback and -6 torque

embed in the brackets (19x25 into .22 slot)

Wire-slot interplay should be reduce 20x25 or 21x25 SS wire + cinchback

TADs + Cl II correction device reduce lower incisors proclination /1 change 3,61 5,07 vs 9,29 3,81

Extraction + cl II correction device: good marriage when space is necessary along cl II correction

Cacciatore G, et al AO in press

Aslan B, et al AO 2014;84;76-87



CostSUS2 : 135$ buy 3 get 1 (101$). One size fits all Forsus: 260$, need large inventory for all different sizes. Must buy > 15000$ annually to get 50% discount

TFBC: 239$ buy 4 get 1 (210$) ( 2 lenght sizes + double lock or anchor wire)

XBow: 220$ + 260$ =480$ Esprit corrector : ~ 169$

101/260 = 39%



Cost

If most appliances do about the same Why should we pay >twice (257%) the price to get a Cl II corrector

device?



Key pointsSUS2 Easy to install and remove.

Less expensive.

Minimal breakage if any

U6 SPEED convertible tubes headgear tube L6 & L7 SPEED convertible tube Repeatably convertible Much easier to cinchback


Thank you

Fixed applicance management of class II correction

Healthcare

Transcript of Fixed applicance management of class II correction