7/10/2013 - 258413772373414384.s3. · pdf filelip length: 24mm lip ... prepare & build-up...

7/10/2013

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Surgically Facilitated Orthodontic Therapy: The New Frontier in Interdisciplinary

Dentofacial Therapy

Brian S. Vence, DDS

David P. Forbes, DDS, PhD

George A. Mandelaris, DDS, MS

Brian S. Vence, DDS Restorative Dentistry

David P. Forbes, DDS, PhD Orthodontist

George A. Mandelaris, DDS, MS Periodontist

The speakers haven’t received any compensation or corporate support for the material or concepts presented in the following presentation.

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Interdisciplinary Approach

David P Forbes, DDS, PhD

Resto

rativ

e D

entis

try &

Orth

odo

ntic

s

Brian S. Vence, DDS

Intr

oductio

n



Surg

ical &

Perio

do

nta

l Medic

ine

Alan Rosenfeld, DDS, MS

Intr

oductio

n


Denta

l Techno

logis

t

Tadanori Tanaguchi, MDT

Intr

oductio

n

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Mo

vem

ent o

f Lig

ht

Pre

para

tion D

esig

n

Mo

vem

ent o

f Lig

ht

Refra

ctio

n &

Refle

ctio

n

SPACE APPROPRIATION SPACE APPROPRIATION

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Clin

ical C

row

n

Aff

ecte

d S

tructu

res

Lack of Space to Restore Natural Coronal Tooth Morphology

Clin

ical C

row

n

Aff

ecte

d S

tructu

res

Lack of Space to Restore Natural Coronal Tooth Morphology

To

oth

Mo

rpho

logy &

Dim

ensio

ns

Aff

ecte

d S

tructu

res

Average: 10.5mm Range: 9.0mm-12.0mm

Average Length of Central Incisor

Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Quintessence Publishing Co. Inc. Chicago, IL, 1993

SPACE APPROPRIATION

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To

oth

Mig

ratio

n

Aff

ecte

d S

tructu

res

Sterrett JD, et. al., “Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man.” J Clin Periodont 1999; Mar; 26(3):153-157

Width / IP= Length

ROOT PROXIMITY

Ste

pped O

cclu

sal P

lane

Aff

ecte

d S

tructu

res

Uneven Tooth Wear & Erosion S

tepped O

cclu

sal P

lane

Aff

ecte

d S

tructu

res

Uneven Tooth Wear & Erosion

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To

oth

Ero

sio

n

Aff

ecte

d S

tructu

res

Lack of Space to Restore Ideal Tooth Morphology

Dia

gno

stic

Pro

vis

ional D

iagno

stic W

ax U

p

Space Restitution E

sth

etic

s &

Functio

n

Fa

cia

l E

sth

etics

Definitive Restorations

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Bio

logic

Health

Fo

rm &

Co

nto

ur


Occlu

sal M

orp

ho

logy O

cclu

sio

n &

Functio

n

Definitive Restorations A

nte

rior P

rote

cte

d A

rticula

tion H

ori

zo

nta

l &

Ve

rtic

al O

ve

rla

p


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Ste

pped O

cclu

sal P

lane In

cis

al &

Occlu

sa

l P

lane


To

oth

Pro

po

rtions v

s O

cclu

sal P

lane

Incis

al &

Occlu

sa

l P

lane

Provisional & Definitive Restorations 2 - D

imensio

nal

Pre

vio

us P

ers

pe

ctive

Intra-arch & Inter-arch

Masticatory System

Mechanical

Regional

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3 - D

imensio

nal

Curr

ent

Pe

rspe

ctive

Craniomandibular

Stomatognathic System

Biological

Global

Mutila

ted D

entitio

n P

ristine

De

ntitio

n

? A

ttrition $

Ero

sio

n

Dia

gno

sis

The Bruxism Triad

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PSG PolySomnoGram

Pes Esophageal Pressure Decreased Esophageal pH

Miyawaki Sh, Tanimoto Y, Araka Y, Katayama A, Imai M, Takano-Yamamoto T “Relationships amoung nocturnal jaw muscle

activities, decreased esophageal pH, and sleep positions.” Am J Orthod Dentofacial Orthop 2004; 126:615-9

Sto

mato

gnath

ic

Ma

stica

tory

Mastication, Deglutination & Respiration Id

eal T

oo

th S

ize &

Mo

rpho

logy

Fa

cia

l E

sth

etics

Ideal Space Appropriation

We may position teeth ideally in a

patient’s face with a denture, but...

natural teeth have roots and

need available bone to support

the roots in the ideal position.

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Mack MR. Vertical dimension: a dynamic concept based on facial form and oropharyngeal function. J Prosthet Dent 1991;66: 478-485

Po

sitio

n &

Co

nditio

n

Dia

gno

sis

Ideal Space Appropriation

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Relationship of Mandibular Teeth to Maxillary Teeth

Joint Position & Condition

Anterior Articulation

Maxillary Incisor Position & Condition

Occlusal Vertical Dimension

Space Appropriation

Structures to Modify in Complex Cases

Coronal Morphology

Root Position

Dentoalveolar Bone

Least P

lastic

– M

ost P

lastic

Esth

etics &

Functio

n

Paradigm Shift

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Space Appropriation

Insuffic

ient F

acia

l Bo

ne

Functio

n

Anterior Protected Articulation

Space Appropriation

Insuffic

ient F

acia

l Bo

ne

Functio

n


Space Appropriation

Insuffic

ient F

acia

l Bo

ne

Functio

n


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MP2

MP1

Typically, lack of facial bone is only a

problem when we want to intervene!

Nowzari H, Molayem S, Chiu C, Rich SK. Cone Beam Computed Tomographic Measurement of Maxillary Central

Incisors to Determine Prevalence of Facial Alveolar Bone Width 2mm. Clin Imp Dent Rel Res; 2012:14(4): 595-602

Restorative, Orthodontic & Surgical

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“Classification System for Crestal and Radicular Dentoalveolar Bone Phenotypes”

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Initial Consultation 10/12/2009

Patient Age: 60 years old at consultation

To

oth

Po

sitio

n &

Gin

giv

al D

ispla

y

Case S

tudy

Esthetic Evaluation

Repose -1mm

Lip Length: 24mm

Lip Mobility: 6mm

Tooth Display

Arra

ngem

ent C

onto

ur C

olo

r

Case S

tudy

Gingival Levels: Uneven

Tooth Proportions W/L: Square

Tooth Length: Short

Tooth CEJ: YES

Tooth Condition & Position

Esthetic Evaluation

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Case S

tudy

Arra

ngem

ent C

onto

ur C

olo

r

Arrangement: Overlapping

Color: A4

Esthetic Evaluation

Tooth Position

Case S

tudy

Attritio

n &

Ero

sio

n

Occlusion & Function

Case S

tudy

Occlusal Factors

Erosion and Attrition

Tooth Migration

No Anterior Protected Articulation

Decreased OVD

Masked Angle Cl II Occlusion

Missing Teeth


Pro

ble

m L

ist

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Case S

tudy

Ante

rior A

rticula

tion &

OV

D


Case S

tudy

CB

CT

for H

ard

Tis

sue


Joint Based Occlusion

Case S

tudy

MR

I for S

oft T

issue

R TMJ LATERAL POLE L TMJ LATERAL POLE

L TMJ MEDIAL POLE R TMJ MEDIAL POLE

Piper IIIa Piper IVb

Joint Based Occlusion


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Co

nditio

n o

f Enam

el C

ap?

Case S

tudy

Structural Integrity

Pro

ble

m L

ist

Case S

tudy

Structural Integrity

Dentition

Color: Vita A4

Missing teeth 1, 16, 17, 18, 20, & 32

Existing PFM crowns teeth #3, 4, 5,19 & 30.

Amalgam restorations teeth #2, 14, 15,& 29.

Class V composite # 9.

Tooth #29 has a cusp fracture.

Teeth 13, 14, & 29 defective margins &

recurrent caries.

Extensive attrition and erosion teeth #2, 6-15,

21-28.

Contours: Altered intrinsic proportions

Arrangement: anterior crowding

Initia

l Radio

gra

phs

Case S

tudy

Biologic Health Radiograp

hs

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Biologic Health

Initia

l Perio

do

nta

l Pro

bin

gs

Case S

tudy

Biologic Health P

ulp

Perio

do

nta

l Airw

ay

Case S

tudy

Mounted Diagnostic Casts

Pre

-Op

Fully

Seate

d C

ondyla

r Po

sitio

n

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Recurre

nt C

arie

s #

5 C

ase S

tudy

2. 02/15/10 Equilibration in FSCP 3. 03/02/10 after equilibrating the patient, the crowns on teeth #4 &

5 come off when placing the rubber dam clamp to isolate teeth #6-11 for incisal composites. The teeth had recurrent caries under the restorations that was not evident on the radiographs. The caries was removed, the crowns were re-cemented with a resin glass ionomer cement until a final treatment decision was made .

Phase II: Interim Treatment Review

Fra

ctu

red #

12

Case S

tudy

4. 05/27/10 tooth #12 fractured while eating a hamburger. The tooth was extracted and the site preserved with a bone graft.

Phase II: Interim Treatment Review E

xtensiv

e W

ear

Irre

gula

r C

hew

ing C

ycle

s


Gibbs C, Messerman T, Reswick J, Derda H “Functional movements of the mandible”. J Prosthet Dent 1971,26:604

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Sle

ep D

iso

rdere

d B

reath

ing

Impaired S

wallo

win

g R

eflex

Teramoto S, Sudo E, Matsuse T, Ohga E, Ishii T, Ouchi Y, Fukuchi Y. “Impaired swallowing reflex in patients with obstructive sleep apnea syndrome”. Chest 1999;116:17-21.

Respiration, Mastication & Deglutination

...Patients with OSA are likely to exhibit an impaired swallowing reflex, probably

due to the perturbed neural and muscular function of the upper airway.

They demonstrate a longer time to initiate a swallow and shorter switching

mechanism from deglutination apnea and breathing.

Esth

etic

s &

Functio

n

Case S

tudy

1. Orthodontic set up and diagnostic wax-up.

Phase III: Establish Crestal Bone (Dr. Rosenfeld- Periodontist)

Pro

vis

ional S

hells

Case S

tudy

2. Fabricate preparation guides and provisional shells from wax –up of posterior teeth.


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Cre

sta

l Bo

ne

Case S

tudy

3. Removal of mandibular exostoses. Surgical ext #30 & site preservation. (12/02/11)


Pre

para

tion P

ara

mete

rs D

efin

e M

arg

in

Case S

tudy

4. Prepare & build-up posterior teeth ideally for occlusal reduction & prep height for retention.

Posterior provisionalization based on diagnostic wax up. (Max 01/06/11 & Mand 01/12/11)

Phase III: Establish Crestal Bone (Dr. Vence- General Dentist)

Re-e

sta

blis

h D

ento

gin

giv

al C

om

ple

x

Case S

tudy

5. Periodontal surgery to develop biologic width by altering crestal bone

position based on preparation margin generated from restorative needs- occlusal reduction and prep height for retention. Biologic root shaping based

on root proximity, tooth emergence form and to simplify orthodontic treatment.


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Impla

nt P

lacem

ent

Case S

tudy

6. Placement of implants after crestal bone position is

established during surgery. (Max 01/17/11 & Mand 04/11/11)


7. Transitional bonding teeth #6-11 to improve tooth

proportions and facilitate orthodontics. (05/16/11)

Case S

tudy

Tra

nsitio

nal B

ondin

g

Phase III: Establish Crestal Bone (Dr. Vence- General Dentist)

Case S

tudy

1. Three months of healing from crestal periodontal surgery.

2. Corticotomies and alveolar decortication to alter dentoalveolar bone with

therapeutically induced osteopenia to faclitate tooth movement. (07/08/11)

Surg

ically

Facilita

ted O

rtho

do

ntic

Thera

py

Phase IV: SFOT (Drs. Mandelaris- Periodontist;

ForbesOrthodontist)

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Decortication

Case S

tudy

3. One week after surgery, initiate SFOT for ideal tooth root position to

gain space for natural tooth morphology.

4. Modify transitional bonding once space is over corrected to alter tooth contours teeth #6-11 & 22-27.

Phase IV: SFOT (Drs. Mandelaris- Periodontist; Forbes-

Orthodontist)

Surg

ically

Facilita

ted O

rtho

do

ntic

Thera

py

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SFOT LITERATURE

Roblee RD. Interdisciplinary dentofacial therapy. Chap 2. pg. 24. In:

Roblee RD. Interdisciplinary dBolding SL, Roblee RD. Optimizing orthodontic therapy with dentoalveolar distraction osteogensis. In:

Wilcko WM, Wilcko MT, Bouquot JE, Ferguson DJ. Rapid

orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent 2001 (21(1):9-19.

Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE.

Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar

augmentation. J Oral Maxillofac Surg 2009; 67(10):2149-2159

Roblee RD, Bolding SL, Landers JM. Surgically facilitated

orthodontic therapy: a new tool for optimal interdisciplinary results. Compend Contin Educ Dent 2009: 30(5):264-275.

Bell WH, Guerrero C. eds. Distraction osteogenesis of the

facial skeleton. Hamilton, Ontario: BC Decker; 2007; 167-186.entofacial therapy. A comprehensive approach to

optimal patient care. Chicago: Quintessence; 1994.

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Case S

tudy

5. Finalize orthodontics for ideal esthetics and function. (05/31/12)

Phase IV: SFOT (Drs. Mandelaris- Periodontist; Forbes-

Orthodontist)

Surg

ically

Facilita

ted O

rtho

do

ntic

Thera

py

5 Weeks Post SFOT

Case S

tudy

Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)

Esth

etic

Evalu

atio

n

Case S

tudy


To

oth

Mo

rpho

logy

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Case S

tudy


Functio

n

2. Fabricate silicone index to fabricate reduction guides and provisionals.

1. Diagnostic casts and wax-up.

Case S

tudy


Facia

l Esth

etic

s &

Sm

ile D

esig

n

3. Refine preparations and fabricate diagnostic provisionals. (Max 06/21/12 & Mand 06/28/12)

Facia

l Esth

etic

s &

Sm

ile D

esig

n

Case S

tudy


Functio

n &

So

ft Tis

sue G

roo

min

g

4. Soft tissue grooming and trial therapy with provisionals including occlusal refinement to

coordinate neuromuscular, dental and parafunctional envelopes of function.

Functio

n &

So

ft Tis

sue G

roo

min

g

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Case S

tudy


Impre

ssio

n M

akin

g

5. Final impressions of tooth preparations and emergence profiles developed

with provisionals for fabricating definitive restorations. (07/19/12)

Preop & Post SFOT Comparison


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Case S

tudy

Dia

gno

stic

Pro

vis

ionals

6. Impressions of provisionals and interocclusal records for cross mounting

including condylar inclination and a custom incisal guide table. (07/03/12)


Case S

tudy

Tra

nsfe

r Esth

etic

& F

unctio

na

l Info

rmatio

n

7. Communication for laboratory procedures to fabricate definitive restorations

that follow provisionals used in trial therapy for esthetics and function.


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Case S

tudy

Cro

ss M

ountin

g &

Custo

m G

uid

e T

able

7. Communication for laboratory procedures to fabricate definitive restorations

that follow provisionals used in trial therapy for esthetics and function.


Case S

tudy

Defin

itive R

esto

ratio

ns

8. Try-in of definitive restorations to confirm esthetics and function.


Case S

tudy

Defin

itive R

esto

ratio

ns

9. Delivery of definitive restorations. (09/19/12)


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Arra

ngem

ent C

onto

ur C

olo

r

Case S

tudy

Esthetic Evaluation

Tooth Condition & Position

Case S

tudy

Po

st T

reatm

ent R

adio

gra

phs

9. Delivery of definitive restorations. (09/19/12)


Case S

tudy

Defin

itive R

esto

ratio

ns

Phase V: Definitive Restorative Treatment (Brian S. Vence, DDS General Dentist)

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34


Surgically Facilitated Orthodontic Therapy: The New Frontier in Interdisciplinary

Dentofacial Therapy

Brian S. Vence, DDS

David P. Forbes, DDS, PhD


Thank You

Brian S. Vence, DDS Restorative Dentistry

David P. Forbes, DDS, PhD Orthodontist

George A. Mandelaris, DDS, MS Periodontist

7/10/2013

35

[email protected]

7/10/2013 - 258413772373414384.s3. · pdf filelip length: 24mm lip ... prepare & build-up...

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