Weitere ähnliche Inhalte Mehr von Dr Sylvain Chamberland (20) Kürzlich hochgeladen (20) Sarpe (2 stages) vs le fort 1 (single stage) approach to complex maxillary deformities a critical review and update1. SARPE (2 stage) vs Le Fort 1
(single stage) Approach to
Complex Maxillary Deformities:
A Critical Review and Update
AO North America
12 th Annual Symposium
Wahsington, DC
samedi 17 mars 2012 1
2. Based on
Short- and Long-Term Stability of SARPE Revisited
AJODO 2011; 138:815-22
samedi 17 mars 2012 2
3. SARPE
Samson Assisted Rapid Palatal Expansion
samedi 17 mars 2012 3
4. Stability of SARPE
Numerous published studies
• Dental Cast • P-A ceph (+ dental cast)
★ Northway & Meade AO '97 ★ Byloff & Mossaz, EJO '04
★ Bays and Greco, JOMS '92 ★ Berger et al, AJODO '98
★ Stromberg & Holm, JCS '95 ★ Koudstaal et al, IJOMS '09
★ Antilla et al, EJO '04 ★ Hino et al, JCS '09 (P-A only)
★ Pogrel et al, IJAOOS <92 ★ Kuo & Will, OMS CNA '90 (P-A only)
samedi 17 mars 2012 4
5. 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?
©Dr Sylvain Chamberland
samedi 17 mars 2012 5
6. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 6
7. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 7
8. Methods
• Prospective and observational
study of SARPE outcomes
• Consecutively treated cases
Looking ahead
• Approved by Laval University
Ethic Committee
©Dr Sylvain Chamberland
samedi 17 mars 2012 8
9. Experimental sample
Distribution
9
9 9 # cas
7
•
7
# of patients
N = 38 5 5
6
★ 19, 19
2
★ Mean age : 24.9 ± 9,7 2
(range 15,1: 53,7) 0
-,17] (17, 20] (20,25] (25,30] (30,35] (35, +
Âge
©Dr Sylvain Chamberland
samedi 17 mars 2012 9
10. Observation Time Point N Mean time S-D Min. Max.
(months)
Dental cast + PA ceph
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
37 21,59 5,28 12,88 41,69
deband)
T3-T5 (Expander out to
37 15,64 5,09 7,79 35,19
deband)
D1-T5 (Total treatment time) 37 23,57 5,27 15,41 43,07
T5-T6 (Post ortho treatment)
©Dr Sylvain Chamberland 23 25,35 4,49 20,96 39,49
samedi 17 mars 2012 10
11. • 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 2 nd 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 11
13. Our SARPE Technique
Mid-palatal suture
Zygomaticomaxillary
Piriform rim
Pterygomaxillary junction
Zygomatic buttress
Piriform rim
Widening of the osteotomy cut:
©Dr Sylvain Chamberland
→ lateral rotation hemimaxillae
samedi 17 mars 2012 13
14. Our SARPE Technique
Midpalatal suture
Zygomaticomaxillary buttress
Piriform rim
Pterygomaxillary junction
Separation of the
pterygoid junction
Separation with osteotome
of the midpalatal suture
©Dr Sylvain Chamberland
Per-op diastema of 1 to 1,5 mm
samedi 17 mars 2012 14
15. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 15
16. 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, ↑&↓
©Dr Sylvain Chamberland
samedi 17 mars 2012 16
17. Outcome Measures
• Standardized PA ceph • Study cast
• 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 • Dental width changes
• Mx width: Jr-Jl • Screw width
©Dr Sylvain Chamberland • Screw changes • Diastema
samedi 17 mars 2012 17
18. Statistics Refer to the
article for more
• Paired 2-samples T-tests details about stats
✓ Bonferroni method: α = 0.05/6
• Repeated measures ANOVA
• Unpaired 2 samples T-tests
• Pearson's correlation coefficients
©Dr Sylvain Chamberland
• Shrout and Fleiss's intraclass correlation
coefficient of fidelity
= 0,99
samedi 17 mars 2012 18
20. "
Changes in Canine
arch
dimensions 1st premolar
• Significant: p < 0.001 2nd premolar
★ Expansion T3-T1
1st molar
★ Relapse T5-T3
★ Net expansion T5-T1
2nd molar
★ 2-years recall T6T1
1st lower molar, Non exo subgroup
1st lower molar, Exo subgroup
Maximal expansion T3-T1
Relapse T5-T3
Net expansion T5-T1 -4 -3 -1 1 2 4 5 7 8
Long term relapse T6-T5
©Dr Sylvain Chamberland
Net changes T6-T1 Changes (mm)
samedi 17 mars 2012 20
21. ∆ 1st Molar
∆ Nasal Cavity
∆ Mx
% ∆ Mx/∆ M1 Changes in skeletal width Changes over time post SARPE
8,00 80 80
• Significant skeletal expansion 7,00
65
69
6,00
★ Mx & Nasal cavity (p < 0.0001) 56 57
% Skeletal expansion
Expansion (mm)
5,00
• Changes T5T3: NS (p=0,1166) 41
4,00
46 46
• Skeletal changes = STABLE
34
3,00
23
2,00
1,00 11
0 0
0,68 6,632 15,27 23,57 48,92
Time point (months)
©Dr Sylvain Chamberland
samedi 17 mars 2012 21
22. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 22
23. Effect of time on relapse after appliance removal
Time point comparison Relapse (mm) Error T or F value DF P value
T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001
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) -0,79 0,30 2,62 (T) 125 0,0098
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) -1,09 0,34 3,23 (T) 125 0,0016
• Significant relationship between the amount of
relapse seen after SARPE and the time the post
treatment observation was made
©Dr Sylvain Chamberland
samedi 17 mars 2012 23
24. Effect of time on relapse after appliance removal
Time point comparison Relapse (mm) Error T or F value DF P value
T3 vs T4 vs T5 vs T6 28.98 (F) 3, 125 <0.0001
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) -0,79 0,30 2,62 (T) 125 0,0098
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) -1,09 0,34 3,23 (T) 125 0,0016
• 57% of the total relapse occurred during the 1st 9 months
after expander removal
• 43% occurred in the following 6 months
©Dr Sylvain Chamberland
• Another 1 mm or so occurred 2 years after debonding
samedi 17 mars 2012 24
25. 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 (r 2 = 0,11; p = 0.0381) (supported by Goldenberg et al)
©Dr Sylvain Chamberland
samedi 17 mars 2012 25
27. 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
©Dr Sylvain Chamberland
★ 24% of the maximum expansion; large std. dev.
samedi 17 mars 2012 27
28. Short term stability
• Post treatment retention is an important
factor
• In this study: expansion device maintained 6
months
©Dr Sylvain Chamberland
samedi 17 mars 2012 28
29. Comparison to Other Short-Term
-0,99
Experimentals (n=38; 37;23) 24% -1,83
5,73
7,60
4,57
-3,16
Byloff and Mossaz, (n = 14) 36%
5,54
8,70
18% -1,48
de Freitas et al, 2008 (n = 20) 7,12
8,06
≠Pterygoid + T2 = before Phase2 surgery
-0,50
Koudstaal et al, 2009 (n = 19) T-B 11% 6,30
12 months study 6,80
period 4,60 ≅Exp.
Koudstaal et al, 2009 (n =23) B-B 11% -0,60
5,20
17.5% -1,01
Berger et al, 1998 (n=28) 4,77
5,78
Pogrel et al, 1992 (n=12) 12% -0,88
6,62
7,50
-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
mm
Long Term Relapse Short Term Relapse Net expansion
©Dr Sylvain Chamberland Maximum expansion Long term exp
samedi 17 mars 2012 29
30. Those 12 months study period
•Concluded that expansion was stable
• But all their patients were still in
orthodontic treatment
©Dr Sylvain Chamberland
samedi 17 mars 2012 30
31. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 31
32. In Our Study
SARPE: Post-Tx changes
50,0 %
First Molar
45,0 % First Premolar
42%
40,0 %
• 42% of the patients have a 35,0 %
relapse of 2 mm
% of patients
30,0 %
25,0 %
• 22 % of a relapse > 3 mm 20,0 %
22%
• This is similar to 15,0 %
multisegmented Le Fort 1 10,0 %
5,0 %
0%
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
©Dr Sylvain Chamberland
Relapse (mm)
samedi 17 mars 2012 32
33. Maximal expansion T3-T1
Long term relapse T6-T5
Net changes T6-T1
Long term stability
"
•
Canine
Data at T6 = 24,7 ± 3 m
•
1st premolar
Relapse NS
•
2nd premolar
Relapse S : 1 st Molar
1st molar
★ = 0,99± 1,1 mm; p= 0.0003
★ 17% of net expansion at T5 that 2nd molar
adds to relapse T5T3 -4 -3 -1 1 2 4 5 7 8
Changes (mm)
©Dr Sylvain Chamberland
samedi 17 mars 2012 33
34. Maximal expansion T3-T1
Long term relapse T6-T5
Net changes T6-T1
Long term stability
"
• Cannot be explained by type 1 Canine
error (α = 0.05/6)
• Cannot be explained by the effect
1st premolar
of a bonded vs banded appliance 2nd premolar
• Post treatment arch form 1st molar
adjustment may be the explanation
since on the average, lower molar
2nd molar
distance was expanded and
constricted modestly and a large -4 -3 -1 1 2 4 5 7 8
std dev was noted (-0,18 ± 1,5 mm)
©Dr Sylvain Chamberland
Changes (mm)
samedi 17 mars 2012 34
35. Comparison to Other Long-Term
Studies 17% -0,99
-1,83
Experimentals (n=38; 37;23) 5,73
7,60
2y 4,57
-1,30
22%
Antilla et al, 2004 (n=20; 13) 7,20
6y 5,9
8.3%-1,20
Stromberg & Holms, 1995 (n=20) 8,30
3,5 y
-0,22
≅Exp.
6%
Nortway & Meade, 1997 (n=16) 5,50
5y
-0,45
7%
Bays & Greco, 1992 (n=19) 5,78
2,4 y
-2,25 0 2,25 4,50 6,75 9,00
mm
Long Term Relapse Short Term Relapse Net expansion
©Dr Sylvain Chamberland Maximum expansion Long term exp
samedi 17 mars 2012 35
36. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 36
37. CBCT study
• 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
©Dr Sylvain Chamberland period)
samedi 17 mars 2012 37
38. SARPE: Post-Tx changes
50,0 % First Molar
First Premolar
40,0 %
Stability?
% of patients
30,0 %
20,0 %
10,0 %
0%
•
'-,-3] (-3 to -1] (-1 to 1] (1 to 3]
If one look at skeletal changes, it should Relapse (mm)
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
©Dr Sylvain Chamberland
samedi 17 mars 2012 38
39. Stability?
• This could be attributed to
★ The device itself
★ The surgical technique
★ The timing of observation
©Dr Sylvain Chamberland
samedi 17 mars 2012 39
40. Stability?
• 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 40
41. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 41
42. Related variables
• Correlation between the width of the diastema
at the end of distraction (T2) and the amount of
1 st 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 42
43. 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)
©Dr Sylvain Chamberland
samedi 17 mars 2012 43
44. Before Expansion
After Expansion
A
B
C
C
©Dr Sylvain Chamberland
samedi 17 mars 2012 44
45. lAs the appliance is activated,
note that the hemimaxilla move inward
relatively 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 45
46. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 46
47. Conclusion
• Skeletal change were modest (3-4 mm) but
stable
• Relapse in dental expansion was almost
totally attributed to lingual movement of
posterior teeth
©Dr Sylvain Chamberland
samedi 17 mars 2012 47
48. 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.
©Dr Sylvain Chamberland
samedi 17 mars 2012 48
49. 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 2 nd 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 49
50. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 50
51. Le Fort 1 Morbidity
A
• Pulpal necrosis
B
• Periodontal defects
©Dr Sylvain Chamberland
samedi 17 mars 2012 51
52. Le Fort 1 Morbidity
• Aseptic necrosis
★ Most likely to occur with Le Fort 1
osteotomies done in multiple
segments in conjonction with
superior repositioning and
transverse expansion Courtesy of Dr Brian Alpert
Lanigan et al, J Oral Maxillofac Surg 48: 142-156, 1990
©Dr Sylvain Chamberland
samedi 17 mars 2012 52
53. SARPE Morbidity
•
A B
Nasopalatal cyst
•
A B
Fibrous healing
©Dr Sylvain Chamberland
samedi 17 mars 2012 53
54. SARPE Morbidity
• Asymmetric fracture of interdental septum + gingival defect
Cureton SL, Cuenin M, AJODO, 1999
• 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 54
55. Clinical Implications
• If only transverse changes are needed
★ SARPE = Choice # 1
MC; tx:18m Ka.Ri. Tx: 103w
©Dr Sylvain Chamberland
samedi 17 mars 2012 55
56. SARPE may be indicated
• For very large transverse (>6 mm), AP and vertical
changes or periodontally compromised patients
©Dr Sylvain Chamberland (Personal opinion)
samedi 17 mars 2012 56
57. Retrospective look
Ka.Tr.271107
• 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
©Dr Sylvain Chamberland
Ka.Tr.210909
samedi 17 mars 2012 57
58. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 58
59. Case 1
• Class I ( cl III tendency)
• Mx constriction
• Moderate to severe crowding
• Heavily restored teeth
©Dr Sylvain Chamberland Ka.La.270510
samedi 17 mars 2012 59
60. • Moderate apnea, severe snoring
• Orthodontic Tx plan: exo 5's/5's
• Surgical Tx plan = Mx & Md advancement
©Dr Sylvain Chamberland
samedi 17 mars 2012 60
61. Progess reports
• Reassessment of bracket position
• Mx: 3 segments
• Md: finishing space closure
• Surgery in May
Ka.La.120312
©Dr Sylvain Chamberland
samedi 17 mars 2012 61
62. • Decompensation of the dentition is done
• Surgical tx plan will focus on skeletal changes
©Dr Sylvain Chamberland
samedi 17 mars 2012 62
63. Case 2
• Class III
• Severe Mx constriction Ω
• Could this case be treated 37,12
in 1 phase surgery?
✦ YES. (exo 15, 24 / non ex) 33,52
St.Gi.191009
©Dr Sylvain Chamberland
samedi 17 mars 2012 63
64. • Retrusive maxilla
• Retroclined /1
• Md laterodeviation to the left
©Dr Sylvain Chamberland
samedi 17 mars 2012 64
65. • Pre-surgical
✦ Segmented Le Fort 1: to constrict!
✦ Md set back and laterodeviation 41,26
✦ Surgery tomorrow...
43,85
St.Gi.221111
©Dr Sylvain Chamberland
samedi 17 mars 2012 65
66. St.Gi.221111
• /1: proclined by 12°
• 1/: retroclined by 10°
©Dr Sylvain Chamberland
samedi 17 mars 2012 66
67. 29 days post surgery
St.Gi.211211;
St.Gi.061211;
14 days post surgery
©Dr Sylvain Chamberland
samedi 17 mars 2012 67
68. St.Gi.130212
St.Gi.120312
• Finishing stages
• Tooth mass discrepancy may help to explain the cl II canine
relationship
• Significant arch width improvement
St.Gi.191009 St.Gi.221111 St.Gi.130212
43,85 40,07
33,52
©Dr Sylvain Chamberland
samedi 17 mars 2012 68
69. Case 3
• Class III
• Mutilated dentition
• Moderate Mx constriction
• Overerupted UL6
Hé.Ar.030909
©Dr Sylvain Chamberland
samedi 17 mars 2012 69
70. • Retrusive maxilla
• Proclined 1/
• Retroclined /1
©Dr Sylvain Chamberland
samedi 17 mars 2012 70
71. • TADs
✦ Mx: to intrude UL6
✦ Md: to get some protraction of LL8
©Dr Sylvain Chamberland
samedi 17 mars 2012 71
72. Pre-Surgical
• Edentulous space prepared
• Surg. Plan:
✦ Mx: Le Fort 1 advancement
✦ Bone graft at implant site
Hé.Ar.171111
©Dr Sylvain Chamberland
samedi 17 mars 2012 72
73. • Mx: Le Fort 1 to advance
• Md: Genioplasty to correct the chin
déviation
©Dr Sylvain Chamberland
samedi 17 mars 2012 73
74. • 17 days post surgery
Hé.Ar.160511
©Dr Sylvain Chamberland
samedi 17 mars 2012 74
75. At 121 weeks
• Crowns are scheduled next month
• Operative dentistry will follow
Hé.Ar.250112
©Dr Sylvain Chamberland
samedi 17 mars 2012 75
76. • Bridge and crown placed today
• Total Tx time 128 weeks
Hé.Ar.120312
©Dr Sylvain Chamberland
samedi 17 mars 2012 76
77. Class 4
• Anterior open bite
• Moderate crowding
Ma-Je.Be210808
©Dr Sylvain Chamberland
samedi 17 mars 2012 77
78. Ma-Je.Be210808
• Slight vertical maxillary excess
• Bimaxillary protrusion
• Lip incompetency
©Dr Sylvain Chamberland
samedi 17 mars 2012 78
79. 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 79
80. At 85 weeks
• Normal OJ & OB
• Class I molar and canine relationship
• Midline coincident
Ma-Je.Be300410
©Dr Sylvain Chamberland
samedi 17 mars 2012 80
81. • Retracting and uprighting the incisors helped to
close the bite
• Slight maxillary excess
©Dr Sylvain Chamberland
samedi 17 mars 2012 81
82. Ma-Je.Be210808
At 109 weeks
20 weeks post surgery
• Class I occlusion is achieved
Ma-Je.Be131010
©Dr Sylvain Chamberland
samedi 17 mars 2012 82
83. • Mx: Le Fort 1: superior
repositionning &
advancement
• Md: BSSO & genio
©Dr Sylvain Chamberland
samedi 17 mars 2012 83
85. Case 5
• Narrow maxillary arch
• Cl II div 1, open bite
• Avulsion 22, fractured 11, 21
• Exfoliation 74, missing 35
Lu.Mo.030708
©Dr Sylvain Chamberland
samedi 17 mars 2012 85
86. • Retrognathic mandible
• Bimaxillary protrusion
• Lip incompetency
©Dr Sylvain Chamberland
samedi 17 mars 2012 86
87. 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?
©Dr Sylvain Chamberland
samedi 17 mars 2012 87
88. Tx Plan
• Exo of 5's & E
• Mx Le Fort 1
✦ Impaction, advancement, expansion
• Md: BSSO
• Genio advancement
©Dr Sylvain Chamberland
samedi 17 mars 2012 88
89. Lu.Mo.200409
At 36 weeks
Mx: Step distal to the canine. Prothetic tooth bonded to a bracket
Md: En masse retraction
Lu.Mo.010410
At 85 weeks
Mx: 3 segments
Md: Spaces closed
•Surgery in June
©Dr Sylvain Chamberland
samedi 17 mars 2012 89
90. • Incisors were retracted, no extrusion
©Dr Sylvain Chamberland
samedi 17 mars 2012 90
91. Presurgical models
• Selective grinding to maximize toot contact
• Left posterior Xbite noted
✦ Expansion needed
©Dr Sylvain Chamberland
samedi 17 mars 2012 91
92. • Surgery at 96 weeks Lu.Mo.010710
✦ 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
©Dr Sylvain Chamberland
samedi 17 mars 2012 92
93. Osteotomy half way between
apices of the teeth and
infraorbital nerve
Osteotomy sites filled
with bone from the
slice removed at the
symphysis
Rigid fixation to the piriform
rim & zygomatic buttress
buttress
DL 130312
©Dr Sylvain Chamberland
Courtesy Dr Carl Bouchard
samedi 17 mars 2012 93
94. BSSO
Bicortical screw
Genioplasty
Pre-bended 6 mm monocortical plate
©Dr Sylvain Chamberland Courtesy Dr Carl Bouchard
samedi 17 mars 2012 94
95. • Tx time = 123 weeks
• Implant #22 was placed
Lu.Mo.201210
©Dr Sylvain Chamberland
samedi 17 mars 2012 95
96. • Nice profile
• Lips are competent
©Dr Sylvain Chamberland
samedi 17 mars 2012 96
97. Lu.Mo.070711
• At 28 weeks into retention
✦ Crown is placed on #22
Lu.Mo.130112
• At 60 weeks into retention
✦ Note some midline deviation to the right and slight cl II
©Dr Sylvain Chamberland
samedi 17 mars 2012 97
98. • Recall at 60 weeks
©Dr Sylvain Chamberland
samedi 17 mars 2012 98
99. Why I don't like rigid fixation
for a genioplasty
Lu.Mo.010710 Lu.Mo.130212
Apposition zone Screw Embed
Screw in the
resorptive zone
Screw
Poor contact between distal prominent
Note bone formation over superior
& proximal segment portion of fixation device and
resorption in area of inferior
portion of fixation device
©Dr Sylvain Chamberland
samedi 17 mars 2012 99
100. Why do I prefer
osteosynthesis?
Apposition
zone
R: Remodeling
A: Apposition Courtesy Dr Dany Morais
Resorptive
Note complete coverage of fixation
zone
wires by bone and smooth labial Resorptive zone
Improved contact between proximal and cortical bone of anterior manbible
distal segment
De.Le060608 De.Le130410
©Dr Sylvain Chamberland
Precious D., Armstrong J., Morais D., Anatomic placement of fixation device in genioplasty, OOO 1992,; 73-2-8
samedi 17 mars 2012 100
101. Why I don't like posterior
openbite after orthognathic
surgery?
Pressure Condyle resorb
• Lack of posterior occlusion
may increase pressure at the
condyle and cause
non-physiologic remodeling
or condylar resorption
Screwed Setting Jam-packed Slight progressive
occlusion retrusion The bite open
©Dr Sylvain Chamberland
samedi 17 mars 2012 101
102. Distinguished Attendees
Thank you
www.slideshare.net/sylvainchamberland
www.sylvainchamberland.com
samedi 17 mars 2012 102
103. • Mx: segmented Le Fort 1
✦ Advancement
✦ Anterior elongation
✦ Expansion
• Md: BSSO + genio
©Dr Sylvain Chamberland
samedi 17 mars 2012 115