Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical...
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Transcript of Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical...
SARPE (2 stage) vs Le Fort 1 (single stage) Approach to
Complex Maxillary Deformities: A Critical Review and Update
AO North America12th Annual Symposium
Wahsington, DC
1samedi 17 mars 2012
Based on
Short- and Long-Term Stability of SARPE RevisitedAJODO 2011; 138:815-22
2samedi 17 mars 2012
SARPE
Samson Assisted Rapid Palatal Expansion
3samedi 17 mars 2012
Stability of SARPE
• Dental Cast
★ Northway & Meade AO '97
★ Bays and Greco, JOMS '92
★ Stromberg & Holm, JCS '95
★ Antilla et al, EJO '04
★ Pogrel et al, IJAOOS <92
• P-A ceph (+ dental cast)
★ Byloff & Mossaz, EJO '04
★ Berger et al, AJODO '98
★ Koudstaal et al, IJOMS '09
★ Hino et al, JCS '09 (P-A only)
★ Kuo & Will, OMS CNA '90 (P-A only)
Numerous published studies
4samedi 17 mars 2012
©Dr Sylvain Chamberland
Stability of SARPE
Conclusions about stability depend on★What was measured?
★When measurements were made?
Especially whether there were measurements during the sequence as well as before/after?
5samedi 17 mars 2012
©Dr Sylvain Chamberland
Goal of This Presentation
•Present further longitudinal data for short- and long-term stability
•Follow-up previous reports★ (Angke east 2006 Scientific Meeting)
★Closer Look at the Stability of SARPE ✓ JOMS 2008; 66:1895-1900
6samedi 17 mars 2012
©Dr Sylvain Chamberland
Goal of This Presentation
•Larger sample + 2-years stability data
•Data obtained at 6 time points★The only study with PA ceph and models at multiple
time points
7samedi 17 mars 2012
©Dr Sylvain Chamberland
Methods
•Prospective and observational study of SARPE outcomes
•Consecutively treated cases
•Approved by Laval University Ethic Committee
Looking ahead
8samedi 17 mars 2012
©Dr Sylvain Chamberland
Experimental sample
•N = 38★ 19, 19
★ Mean age : 24.9 ± 9,7(range 15,1: 53,7) 0
2
5
7
9
-,17] (17, 20] (20,25] (25,30] (30,35] (35, +
6
5
2
9
7
9
Distribution
# o
f p
atie
nts
Âge
# cas
9samedi 17 mars 2012
©Dr Sylvain Chamberland
Observation Time Point N Mean time (months)
S-D Min. Max.
T1-T2 (Distraction completed) 38 0,68 0,23 0,46 1,81
T2-T3 (Expander retention) 38 5,95 0,68 4,21 7,13
T1-T4 (Start to 2nd surgery) 32 15,27 3,99 9,40 24,28
T2-T5 (End expansion to deband) 37 21,59 5,28 12,88 41,69
T3-T5 (Expander out to deband) 37 15,64 5,09 7,79 35,19
D1-T5 (Total treatment time) 37 23,57 5,27 15,41 43,07
T5-T6 (Post ortho treatment) 23 25,35 4,49 20,96 39,49
Dental cast + PA ceph
10samedi 17 mars 2012
©Dr Sylvain Chamberland
• Of the 38 who completed the distraction phase
• 32 had a 2nd surgical phase planned
• 4 of them did not need it after reassessment
• 1 was over-expanded and needed constriction of the maxilla at the 2nd surgical phase to achieve arch coordination
✦ His data were removed at T5
• 23 patients have returned for records 2-years after the end of orthodontic treatment
11samedi 17 mars 2012
©Dr Sylvain Chamberland
Tooth-borne Expansion Device
•Superscrew™
•Banded; N = 21
•Bonded; N = 17
A
B
12samedi 17 mars 2012
©Dr Sylvain Chamberland
Our SARPE Technique
Zygomatic buttress
Piriform rim
Widening of the osteotomy cut: → lateral rotation hemimaxillae
Piriform rim
Zygomaticomaxillary
Pterygomaxillary junction
Mid-palatal suture
13samedi 17 mars 2012
©Dr Sylvain Chamberland
Separation of thepterygoid junction
Separation with osteotome of the midpalatal suture
Per-op diastema of 1 to 1,5 mm
Our SARPE Technique Piriform rim
Zygomaticomaxillary buttress
Pterygomaxillary junction
Midpalatal suture
14samedi 17 mars 2012
©Dr Sylvain Chamberland
Treatment modality
•Appliance cementation: 1 day to 1 week prior to surgery
•Latency period: 7 days
•Distraction period: 0,25 mm bid
★14 to 21 days; monitored twice a week
•Tx initiated in the mandibular arch 1 week to 2 months before SAPRE
15samedi 17 mars 2012
©Dr Sylvain Chamberland
Treatment modality
•Brackets bonded in maxillary arch 2 months after expansion is stopped
•Expander removal: 6 months after expansion is stopped
•No other retention except the main arch wire
•At debonding: bonded lingual wire 3-3 only, ↑&↓
16samedi 17 mars 2012
©Dr Sylvain Chamberland
• Study cast
• Dental width changes
• Screw width
• Diastema
Outcome Measures
• Standardized PA ceph• DPI set to obtain 1:1
• Screw width in situ vs screw width on the ceph
★ T1: r = 0,99164
★ T2: r = 0,98955
• Nasal cavity width
• Mx width: Jr-Jl
• Screw changes17samedi 17 mars 2012
©Dr Sylvain Chamberland
Statistics
•Paired 2-samples T-tests✓Bonferroni method: α = 0.05/6
•Repeated measures ANOVA
•Unpaired 2 samples T-tests
•Pearson's correlation coefficients
•Shrout and Fleiss's intraclass correlation = 0,99 coefficient of fidelity
Refer to the article for more details about stats
18samedi 17 mars 2012
Results
19samedi 17 mars 2012
©Dr Sylvain Chamberland
Changes in arch dimensions
Maximal expansion T3-T1Relapse T5-T3Net expansion T5-T1Long term relapse T6-T5Net changes T6-T1
• Significant: p < 0.001
★ Expansion T3-T1
★ Relapse T5-T3
★ Net expansion T5-T1
★ 2-years recall T6T1
Canine
1st premolar
2nd premolar
1st molar
2nd molar
1st lower molar, Non exo subgroup
1st lower molar, Exo subgroup
-4 -3 -1 1 2 4 5 7 8
"
Changes (mm)20samedi 17 mars 2012
©Dr Sylvain Chamberland
Changes in skeletal width
• Significant skeletal expansion
★ Mx & Nasal cavity (p < 0.0001)
• Changes T5T3: NS (p=0,1166)
• Skeletal changes = STABLE
0
1,00
2,00
3,00
4,00
5,00
6,00
7,00
8,00
0,68 6,632 15,27 23,57 48,920
11
23
34
46
57
69
80
4146
56
65
80
Changes over time post SARPE
Exp
ansi
on (m
m)
Time point (months)
% S
kele
tal e
xpan
sion
∆ 1st Molar∆ Nasal Cavity∆ Mx% ∆ Mx/∆ M1
21samedi 17 mars 2012
©Dr Sylvain Chamberland
Other outcomes
•Type of expansion device: Bonded vs 2-bands★ Same efficacy for skeletal & dental expansion (No difference: p=0,2727)
★ Same dental relapse (No difference: p=0,5052)
•Effect of phase 2 surgery on transverse relapse at the 1st molar★ No significant effect of any phase 2 surgery (No difference: p=0,6637)
★ Or any combination of phase 2 surgery
22samedi 17 mars 2012
©Dr Sylvain Chamberland
Effect of time on relapse after appliance removal
•Significant relationship between the amount of relapse seen after SARPE and the time the post treatment observation was made
Time point comparisonTime point comparison Relapse (mm) Error T or F value DF P value
T3 vs T4 vs T5 vs T6 T3 vs T4 vs T5 vs T6 T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001
T3 vs T4 (9,5 ± 3,2 m)T3 vs T4 (9,5 ± 3,2 m) -1,05 0,30 3,53 (T) 125 0,0006
T4 vs T5 (5,7 ± 1,5 m)T4 vs T5 (5,7 ± 1,5 m) -0,79 0,30 2,62 (T) 125 0,0098
T3 vs T5 (15,2 ± 5,1 m)T3 vs T5 (15,2 ± 5,1 m) -1,85 0,29 6,43 (T) 125 <.0001
T5 vs T6 (24,7 ± 3,1 m)T5 vs T6 (24,7 ± 3,1 m) -1,09 0,34 3,23 (T) 125 0,0016
23samedi 17 mars 2012
©Dr Sylvain Chamberland
Effect of time on relapse after appliance removal
• 57% of the total relapse occurred during the 1st 9 months after expander removal
• 43% occurred in the following 6 months
•Another 1 mm or so occurred 2 years after debonding
Time point comparisonTime point comparison Relapse (mm) Error T or F value DF P value
T3 vs T4 vs T5 vs T6 T3 vs T4 vs T5 vs T6 T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001
T3 vs T4 (9,5 ± 3,2 m)T3 vs T4 (9,5 ± 3,2 m) -1,05 0,30 3,53 (T) 125 0,0006
T4 vs T5 (5,7 ± 1,5 m)T4 vs T5 (5,7 ± 1,5 m) -0,79 0,30 2,62 (T) 125 0,0098
T3 vs T5 (15,2 ± 5,1 m)T3 vs T5 (15,2 ± 5,1 m) -1,85 0,29 6,43 (T) 125 <.0001
T5 vs T6 (24,7 ± 3,1 m)T5 vs T6 (24,7 ± 3,1 m) -1,09 0,34 3,23 (T) 125 0,0016
24samedi 17 mars 2012
©Dr Sylvain Chamberland
Correlation between variables• 2 variables are significantly correlated with the amount of
expansion of 1st molar at T3
★ Diastema at the end of expansion (r2 = 0,41; p < .0001)
★ Change in length of the screw during expansion (r2 = 0,88; p < .0001)
•Dental changes are not correlated with skeletal changes (r2 = 0,11; p = 0.0381) (supported by Goldenberg et al)
25samedi 17 mars 2012
Discussion
26samedi 17 mars 2012
©Dr Sylvain Chamberland
Short term stability
•Expansion of 1st molar = 7,6 ± 1,57 mm★Similar to other reports measuring to the maximum
expansion point✓ Pogrel et al, Byloff and Mossaz, Koudstaal et al, de Freitas et al
•Significant relapse for all teeth (canine to 2nd molar)
•Mean relapse at 1st molar = 1,83 ± 1,83 mm★24% of the maximum expansion; large std. dev.
27samedi 17 mars 2012
©Dr Sylvain Chamberland
Short term stability
•Post treatment retention is an important factor
•In this study: expansion device maintained 6 months
28samedi 17 mars 2012
©Dr Sylvain Chamberland
Experimentals (n=38; 37;23)
Byloff and Mossaz, (n = 14)
de Freitas et al, 2008 (n = 20)
Koudstaal et al, 2009 (n = 19) T-B
Koudstaal et al, 2009 (n =23) B-B
Berger et al, 1998 (n=28)
Pogrel et al, 1992 (n=12)
-4,00 -3,00 -2,00 -1,00 0 1,00 2,00 3,00 4,00 5,00 6,00 7,00 8,00 9,00
4,57
7,50
5,78
5,20
6,80
8,06
8,70
7,60
6,62
4,77
4,60
6,30
7,12
5,54
5,73
-0,88
-1,01
-0,60
-0,50
-1,48
-3,16
-1,83 -0,99
mm
12 months study period
Comparison to Other Short-Term
Long Term Relapse Short Term Relapse Net expansionMaximum expansion Long term exp
≠Pterygoid + T2 = before Phase2 surgery
≅Exp.
12%
17.5%
24%
18%
11%
11%
36%
29samedi 17 mars 2012
©Dr Sylvain Chamberland
Those 12 months study period
•Concluded that expansion was stable
•But all their patients were still in orthodontic treatment
30samedi 17 mars 2012
©Dr Sylvain Chamberland
Our Study = 49 Months
•Data at T4 were collected 15 months post-SARPE, prior to 2nd surgical phase for those who needed one
•Relapse at T4 = 57% of the relapse we found
•Therefore, any inferences about the stability of SARPE is questionable if arch form coordination or final AP or vertical relationships have not achieved at the time of measurements
31samedi 17 mars 2012
©Dr Sylvain Chamberland
In Our Study
• 42% of the patients have a relapse of 2 mm
• 22 % of a relapse > 3 mm
• This is similar to multisegmented Le Fort 1
0 %
5,0 %
10,0 %
15,0 %
20,0 %
25,0 %
30,0 %
35,0 %
40,0 %
45,0 %
50,0 %
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
SARPE: Post-Tx changes
% o
f pat
ient
s
Relapse (mm)
First MolarFirst Premolar
42%
22%
32samedi 17 mars 2012
©Dr Sylvain Chamberland
Long term stability
Canine
1st premolar
2nd premolar
1st molar
2nd molar
-4 -3 -1 1 2 4 5 7 8
"
Changes (mm)
Maximal expansion T3-T1Long term relapse T6-T5Net changes T6-T1
•Data at T6 = 24,7 ± 3 m
•Relapse NS
•Relapse S : 1st Molar ★= 0,99± 1,1 mm; p= 0.0003
★17% of net expansion at T5 that adds to relapse T5T3
33samedi 17 mars 2012
©Dr Sylvain Chamberland
Long term stability
Canine
1st premolar
2nd premolar
1st molar
2nd molar
-4 -3 -1 1 2 4 5 7 8
"
Changes (mm)
Maximal expansion T3-T1Long term relapse T6-T5Net changes T6-T1
• Cannot be explained by type 1 error (α = 0.05/6)
• Cannot be explained by the effect of a bonded vs banded appliance
• Post treatment arch form adjustment may be the explanation since on the average, lower molar distance was expanded and constricted modestly and a large std dev was noted (-0,18 ± 1,5 mm)
34samedi 17 mars 2012
©Dr Sylvain Chamberland
Experimentals (n=38; 37;23)
Antilla et al, 2004 (n=20; 13)
Stromberg & Holms, 1995 (n=20)
Nortway & Meade, 1997 (n=16)
Bays & Greco, 1992 (n=19)
-2,25 0 2,25 4,50 6,75 9,00
5,9
4,577,60
5,78
5,50
8,30
7,20
5,73-1,83
-0,45
-0,22
-1,20
-1,30
-0,99
mm
Comparison to Other Long-Term Studies
Long Term Relapse Short Term Relapse Net expansionMaximum expansion Long term exp
≅Exp.6%
7%
8.3%
17%
22%
2,4 y
5 y
3,5 y
6 y
2 y
35samedi 17 mars 2012
©Dr Sylvain Chamberland
Skeletal Expansion & Stability
• Immediately after SARPE about half (46%) of the expansion was skeletal
• This is more than Byloff & Mossaz, Berger et al
★ Appliance was removed after 3 months instead of 6 months
• Hino et al (JCS 2008) reported larger skeletal expansion (~ 6,3 to 6,9 mm) but used landmark closer to the teeth
36samedi 17 mars 2012
©Dr Sylvain Chamberland
• Skeletal expansion ranging from 1,3 to 7 mm
✦ Loddi et al, Landes et al, Goldenberg et al, Tausche et al, Zemann et al, Lagravere et al
✦ Koudstaal et al (IJOMS 2009) obtained 3,1 ± 2 mm of expansion at alveolar crest and 2,6 ± 1,8 mm at nasal level
✦ Lagravere et al (AJODO 2010) CBCT study
✓ BAME = 1,3± 1,4 mm vs TAME = 1,83± 1,69 mm at the outer cortex of alveolar bone
• There was no difference between TB and BB appliances (12 month study period)
CBCT study
37samedi 17 mars 2012
©Dr Sylvain Chamberland
•If one look at skeletal changes, it should rank high in the hierarchy
•But if one looks at dental changes★64% of the patients have > 2 mm change
★22% have > 3 mm changes
Stability?0 %
10,0 %
20,0 %
30,0 %
40,0 %
50,0 %
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
SARPE: Post-Tx changes
% o
f pat
ient
s
Relapse (mm)
First MolarFirst Premolar
38samedi 17 mars 2012
©Dr Sylvain Chamberland
•This could be attributed to★The device itself
★The surgical technique
★The timing of observation
Stability?
39samedi 17 mars 2012
©Dr Sylvain Chamberland
•For all other surgery★Presurgical orthodontic preparation is done
★Few if any dental movements need to be accomplish after surgery
•This is not the case for SARPE★Many dental movement are done after expander
removal including correction of overexpansion
Stability?
40samedi 17 mars 2012
©Dr Sylvain Chamberland
SARPE and other surgical procedure
• It is appropriate to focus on skeletal, not dental stability— which has not been clearly reported previously because appropriate P-A ceph were not available at multiple time point
41samedi 17 mars 2012
©Dr Sylvain Chamberland
Related variables
•Correlation between the width of the diastema at the end of distraction (T2) and the amount of 1st molar expansion at T3 indicates that the adequate molar expansion is occurring
• If no diastema appears ➙ no separation of the hemimaxillae and tipping of buccal segment is occurring
42samedi 17 mars 2012
©Dr Sylvain Chamberland
Related variabless
•Dental changes are not correlated with skeletal changes (r2 = 0,11; p = 0.0381) (supported by Goldenberg et al)
• In frontal view, rotation of the hemimaxillae occurs
★Teeth expands more widely than the bone
★Palatal depth decrease
•No significant relationship between the amount of expansion and the amount of relapse (r2 = 0,07; p = 0.1186)
43samedi 17 mars 2012
©Dr Sylvain Chamberland
Before Expansion
After ExpansionA
B
CC
44samedi 17 mars 2012
©Dr Sylvain Chamberland
lAs the appliance is activated,note that the hemimaxilla move inwardrelatively to the upper part
lThis may explain why CBCT study may find less skeletal expansion than PA ceph because of the precision of the landmarks
45samedi 17 mars 2012
©Dr Sylvain Chamberland
Phase 2 surgery
• A classic study of the stability of transverse expansion obtained with segmented Le Fort 1 reported that patients who had concurrent mandibular surgery had significantly greater relapse at the 1st and 2nd molar
• Our data show no significant effect of any phase 2 surgery on dental relapse
• This might be an important decision factor if large transverse changes are necessary along with vertical and AP changes
46samedi 17 mars 2012
©Dr Sylvain Chamberland
Conclusion
•Skeletal change were modest (3-4 mm) but stable
•Relapse in dental expansion was almost totally attributed to lingual movement of posterior teeth
47samedi 17 mars 2012
©Dr Sylvain Chamberland
Conclusion
•Phase 2 surgery did not affect dental relapse
•Diastema at the end of distraction is a predictor that adequate molar expansion is occurring
•Bonded expanders show the same efficacy as banded expanders.
48samedi 17 mars 2012
©Dr Sylvain Chamberland
Conclusion
•Doing 2 phase surgery (SARPE + Bimax surgery) thinking that the transverse changes will be more stable than Le Fort 1 changes is not warranted
•When maxilla need to be repositioned AP or vertically in a 2nd phase ★Decision should be based on the risk, morbidity & cost of 2
surgery versus risk, morbidity & cost of 1 stage segmental Le Fort 1 for large expansion along with vertical and AP changes
49samedi 17 mars 2012
©Dr Sylvain Chamberland
Conclusion
•Most of the transverse change of 5-6 mm the maxilla can be corrected by a segmented Le Fort 1
•Expansion greater than 6-7 mm is an indication for SARPE
50samedi 17 mars 2012
©Dr Sylvain Chamberland
Le Fort 1 Morbidity
•Pulpal necrosis
•Periodontal defectsB
A
51samedi 17 mars 2012
©Dr Sylvain Chamberland
• Aseptic necrosis
★ Most likely to occur with Le Fort 1 osteotomies done in multiple segments in conjonction with superior repositioning and transverse expansion
Le Fort 1 Morbidity
Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990
Courtesy of Dr Brian Alpert
52samedi 17 mars 2012
©Dr Sylvain Chamberland
• Nasopalatal cyst
• Fibrous healing
SARPE MorbidityA B
A B
53samedi 17 mars 2012
©Dr Sylvain Chamberland
• Asymmetric fracture of interdental septum + gingival defect
• Non-separation of the pterygoid junction or attempting too much expansion (3mm) intraoperatively may lead to aberrant fracture that can run to the base of the skull, orbit and pterygopalatine fossa
Lanigan DT, Mintz SM, J Oral Maxillofac Surg 60: 104-110, 2002
Cureton SL, Cuenin M, AJODO, 1999
SARPE Morbidity
54samedi 17 mars 2012
©Dr Sylvain Chamberland
Clinical Implications
• If only transverse changes are needed★ SARPE = Choice # 1
MC; tx:18m Ka.Ri. Tx: 103w
55samedi 17 mars 2012
©Dr Sylvain Chamberland
SARPE may be indicated
• For very large transverse (>6 mm), AP and vertical changes or periodontally compromised patients
(Personal opinion)
56samedi 17 mars 2012
©Dr Sylvain Chamberland
Retrospective look
• This case would have had an excellent outcome with exo of 5's/5's and 1 phase surgery that would include segmented Le Fort 1 & BSSO
• Nevertheless, a non extraction 2 phase surgery was done
Ka.Tr.271107
Ka.Tr.210909
57samedi 17 mars 2012
©Dr Sylvain Chamberland
Retrospective look
• 2 years post treatment
✦ Some bite opening occured
✓ As the transverse relapse, Mx incisors may procline to accomodate
• Therefore, we can not conclude that 2 phase surgery was any better than 1 phase surgery for this particular case
Ka.Tr.120911
58samedi 17 mars 2012
©Dr Sylvain Chamberland
Case 1
• Class I ( cl III tendency)
• Mx constriction
• Moderate to severe crowding
• Heavily restored teeth
Ka.La.270510
59samedi 17 mars 2012
©Dr Sylvain Chamberland
• Moderate apnea, severe snoring
• Orthodontic Tx plan: exo 5's/5's
• Surgical Tx plan = Mx & Md advancement
60samedi 17 mars 2012
©Dr Sylvain Chamberland
Progess reports
• Reassessment of bracket position
• Mx: 3 segments
• Md: finishing space closure
• Surgery in May
Ka.La.120312
61samedi 17 mars 2012
©Dr Sylvain Chamberland
• Decompensation of the dentition is done
• Surgical tx plan will focus on skeletal changes
62samedi 17 mars 2012
©Dr Sylvain Chamberland
Case 2
• Class III
• Severe Mx constriction Ω
• Could this case be treated in 1 phase surgery?
✦ YES. (exo 15, 24 / non ex)
St.Gi.191009
37,12
33,52
63samedi 17 mars 2012
©Dr Sylvain Chamberland
• Retrusive maxilla
• Retroclined /1
• Md laterodeviation to the left
64samedi 17 mars 2012
©Dr Sylvain Chamberland
• Pre-surgical
✦ Segmented Le Fort 1: to constrict!
✦ Md set back and laterodeviation
✦ Surgery tomorrow...
St.Gi.221111
43,85
41,26
65samedi 17 mars 2012
©Dr Sylvain Chamberland
• /1: proclined by 12°
• 1/: retroclined by 10°
St.Gi.221111
66samedi 17 mars 2012
©Dr Sylvain Chamberland
St.Gi.211211;
29 days post surgery
St.Gi.061211;
14 days post surgery
67samedi 17 mars 2012
©Dr Sylvain Chamberland
• Finishing stages
• Tooth mass discrepancy may help to explain the cl II canine relationship
• Significant arch width improvement
43,85
St.Gi.221111
33,52
St.Gi.191009 St.Gi.130212
40,07
St.Gi.130212
St.Gi.120312
68samedi 17 mars 2012
©Dr Sylvain Chamberland
Case 3
• Class III
• Mutilated dentition
• Moderate Mx constriction
• Overerupted UL6
Hé.Ar.030909
69samedi 17 mars 2012
©Dr Sylvain Chamberland
• Retrusive maxilla
• Proclined 1/
• Retroclined /1
70samedi 17 mars 2012
©Dr Sylvain Chamberland
• TADs
✦ Mx: to intrude UL6
✦ Md: to get some protraction of LL8
71samedi 17 mars 2012
©Dr Sylvain Chamberland
Pre-Surgical
• Edentulous space prepared
• Surg. Plan:
✦ Mx: Le Fort 1 advancement
✦ Bone graft at implant site
Hé.Ar.171111
72samedi 17 mars 2012
©Dr Sylvain Chamberland
• Mx: Le Fort 1 to advance
• Md: Genioplasty to correct the chin déviation
73samedi 17 mars 2012
©Dr Sylvain Chamberland
• 17 days post surgery
Hé.Ar.160511
74samedi 17 mars 2012
©Dr Sylvain Chamberland
At 121 weeks
• Crowns are scheduled next month
• Operative dentistry will follow
Hé.Ar.250112
75samedi 17 mars 2012
©Dr Sylvain Chamberland
• Bridge and crown placed today
• Total Tx time 128 weeks
Hé.Ar.120312
76samedi 17 mars 2012
©Dr Sylvain Chamberland
Class 4
• Anterior open bite
• Moderate crowding
Ma-Je.Be210808
77samedi 17 mars 2012
©Dr Sylvain Chamberland
• Slight vertical maxillary excess
• Bimaxillary protrusion
• Lip incompetency
Ma-Je.Be210808
78samedi 17 mars 2012
©Dr Sylvain Chamberland
Tx Plan
• Would you do SARPE?
• Would you plan a non extraction approach?
• Would you extract?
• Would you plan a segmented Le Fort 1?
• Would you plan a 1 piece Le Fort 1?
• My plan:
✦ Exo of 5's
✦ Bimaxillary surgery
79samedi 17 mars 2012
©Dr Sylvain Chamberland
At 85 weeks
• Normal OJ & OB
• Class I molar and canine relationship
• Midline coincident
Ma-Je.Be300410
80samedi 17 mars 2012
©Dr Sylvain Chamberland
• Retracting and uprighting the incisors helped to close the bite
• Slight maxillary excess
81samedi 17 mars 2012
©Dr Sylvain Chamberland
At 109 weeks20 weeks post surgery
• Class I occlusion is achieved
Ma-Je.Be210808
Ma-Je.Be131010
82samedi 17 mars 2012
©Dr Sylvain Chamberland
• Mx: Le Fort 1: superior repositionning & advancement
• Md: BSSO & genio
83samedi 17 mars 2012
©Dr Sylvain Chamberland
84samedi 17 mars 2012
©Dr Sylvain Chamberland
Case 5
• Narrow maxillary arch
• Cl II div 1, open bite
• Avulsion 22, fractured 11, 21
• Exfoliation 74, missing 35
Lu.Mo.030708
85samedi 17 mars 2012
©Dr Sylvain Chamberland
• Retrognathic mandible
• Bimaxillary protrusion
• Lip incompetency
86samedi 17 mars 2012
©Dr Sylvain Chamberland
Tx Plan
• Would you do SARPE?
• Would you plan a non extraction approach?
• Would you extract?
• Would you plan a segmented Le Fort 1?
• Would you plan a 1 piece Le Fort 1?
87samedi 17 mars 2012
©Dr Sylvain Chamberland
Tx Plan
• Exo of 5's & E
• Mx Le Fort 1
✦ Impaction, advancement, expansion
• Md: BSSO
• Genio advancement
88samedi 17 mars 2012
©Dr Sylvain Chamberland
Lu.Mo.200409
At 36 weeksMx: Step distal to the canine. Prothetic tooth bonded to a bracketMd: En masse retraction
At 85 weeksMx: 3 segmentsMd: Spaces closed•Surgery in June
Lu.Mo.010410
89samedi 17 mars 2012
©Dr Sylvain Chamberland
• Incisors were retracted, no extrusion
90samedi 17 mars 2012
©Dr Sylvain Chamberland
Presurgical models
• Selective grinding to maximize toot contact
• Left posterior Xbite noted
✦ Expansion needed
91samedi 17 mars 2012
©Dr Sylvain Chamberland
• Surgery at 96 weeks
✦ Le Fort 1: advancement 3,5 mm, impaction 3,5 mm, expansion 1,6 mm
✦ BSSO: advancement 8 mm; genio: advancement 6 mm, vertical reduction 2,5 mm
• At the removal of the surgical splint
✦ Note lack of posterior occlusal contact
Lu.Mo.010710
92samedi 17 mars 2012
©Dr Sylvain Chamberland
Osteotomy half way between apices of the teeth and infraorbital nerve
Rigid fixation to the piriform rim & zygomatic buttress buttress
Courtesy Dr Carl Bouchard
Osteotomy sites filled with bone from the slice removed at the symphysis
DL 130312
93samedi 17 mars 2012
©Dr Sylvain Chamberland
BSSOBicortical screw
Courtesy Dr Carl Bouchard
GenioplastyPre-bended 6 mm monocortical plate
94samedi 17 mars 2012
©Dr Sylvain Chamberland
• Tx time = 123 weeks
• Implant #22 was placed
Lu.Mo.201210
95samedi 17 mars 2012
©Dr Sylvain Chamberland
• Nice profile
• Lips are competent
96samedi 17 mars 2012
©Dr Sylvain Chamberland
• At 28 weeks into retention
✦ Crown is placed on #22
• At 60 weeks into retention
✦ Note some midline deviation to the right and slight cl II
Lu.Mo.070711
Lu.Mo.130112
97samedi 17 mars 2012
©Dr Sylvain Chamberland
• Recall at 60 weeks
98samedi 17 mars 2012
©Dr Sylvain Chamberland
Why I don't like rigid fixation for a genioplasty
Poor contact between distal & proximal segment
Screw EmbedLu.Mo.010710 Lu.Mo.130212
Note bone formation over superior portion of fixation device and resorption in area of inferior
portion of fixation device
Screw in the resorptive zone
Apposition zone
Screw prominent
99samedi 17 mars 2012
©Dr Sylvain Chamberland
Courtesy Dr Dany Morais
Why do I prefer osteosynthesis?
Resorptive zone
R: RemodelingA: Apposition
De.Le060608 De.Le130410
Resorptive zone
Apposition zone
Improved contact between proximal and distal segment
Precious D., Armstrong J., Morais D., Anatomic placement of fixation device in genioplasty, OOO 1992,; 73-2-8
Note complete coverage of fixation wires by bone and smooth labial
cortical bone of anterior manbible
100samedi 17 mars 2012
©Dr Sylvain Chamberland
Why I don't like posterior openbite after orthognathic
surgery?
• Lack of posterior occlusion may increase pressure at the condyle and cause non-physiologic remodeling or condylar resorption
Jam-packedScrewed Setting occlusion
Pressure
The bite openSlight progressive
retrusion
Condyle resorb
101samedi 17 mars 2012
Distinguished AttendeesThank you
www.slideshare.net/sylvainchamberlandwww.sylvainchamberland.com
102samedi 17 mars 2012
©Dr Sylvain Chamberland
• Mx: segmented Le Fort 1
✦ Advancement
✦ Anterior elongation
✦ Expansion
• Md: BSSO + genio
115samedi 17 mars 2012