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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
Interdisciplinary Approach
George A. Mandelaris, DDS, MS
Surg
ical &
Perio
do
nta
l Medic
ine
Alan Rosenfeld, DDS, MS
Intr
oductio
n
Interdisciplinary Approach
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
Definitive Restorations
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
Definitive Restorations
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Ste
pped O
cclu
sal P
lane In
cis
al &
Occlu
sa
l P
lane
Definitive Restorations
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
Anterior Protected Articulation
Space Appropriation
Insuffic
ient F
acia
l Bo
ne
Functio
n
Anterior Protected Articulation
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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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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
Occlusion & Function
Pro
ble
m L
ist
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Case S
tudy
Ante
rior A
rticula
tion &
OV
D
Occlusion & Function
Case S
tudy
CB
CT
for H
ard
Tis
sue
Occlusion & Function
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
Occlusion & Function
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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
Occlusion & Function
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.
Phase III: Establish Crestal Bone (Dr. Rosenfeld- Periodontist)
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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)
Phase III: Establish Crestal Bone (Dr. Rosenfeld- Periodontist)
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.
Phase III: Establish Crestal Bone (Dr. Rosenfeld- Periodontist)
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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)
Phase III: Establish Crestal Bone (Dr. Rosenfeld- Periodontist)
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
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
To
oth
Mo
rpho
logy
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Case S
tudy
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
Functio
n
2. Fabricate silicone index to fabricate reduction guides and provisionals.
1. Diagnostic casts and wax-up.
Case S
tudy
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
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
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
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
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
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
Preop & Post SFOT Comparison
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Preop & Post SFOT Comparison
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)
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
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.
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
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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.
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
Case S
tudy
Defin
itive R
esto
ratio
ns
8. Try-in of definitive restorations to confirm esthetics and function.
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
Case S
tudy
Defin
itive R
esto
ratio
ns
9. Delivery of definitive restorations. (09/19/12)
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
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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)
Phase V: Definitive Restorative Treatment (Mr. Tanaguchi- Technologist)
Case S
tudy
Defin
itive R
esto
ratio
ns
Phase V: Definitive Restorative Treatment (Brian S. Vence, DDS General Dentist)
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Anterior Protected Articulation
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
Thank You
Brian S. Vence, DDS Restorative Dentistry
David P. Forbes, DDS, PhD Orthodontist
George A. Mandelaris, DDS, MS Periodontist