Biography Maxillary and Mandibular Constriction · •During distraction, the hybrid distractor effected more parallel expansion of basal and alveolar bone than did the tooth-borne

Treatment of Severe Maxillary and Mandibular

ConstrictionSARPE & MSDO

AAO 118th Annual Session

©sylvainchamberland.com

Biography Sylvain Chamberland

•D.M.D. (Docteur en Médecine Dentaire), University Laval, 1983

•Private practice, general dentistry 1983-1988

•Certificate in Orthodontics, University of Montreal, 1990

•M.Sc. in Dental Science, University Laval, 2008

•Private practice in orthodontics since 1990

•Publications

✦Closer look at SARPE, JOMS 2008

✦Short-term and long-term stability of SARPE revisited, AJODO 2011

✦Long-term dental and skeletal changes following SARPE, letter to editor, OOOO 2013

✦Functional genioplasty in growing patients, AO 2015,

✦Response to : Functional geniolasty in growing patients by Chamberland et al, AO 2015,;85, 6: p1083

•Lecturer in several graduate program and scientific meeting in USA, Canada, Europe


Conflict of Interest Declaration

•I declare that neither I nor any member of my family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing education presentation, nor do I have a financial interest in any commercial product(s) or services I will discuss in this presentation


All that is missing is You!

• Introduced in 2009, the DOS program provides access to care for children in need. Access to quality orthodontic care is missing in many children’s lives. The AAO DOS program mission is to serve indigent children without insurance coverage or that do not qualify for other assistance in their state of residence.

• The program has expanded and offers care to children nationwide in addition to the recognized state programs in Illinois, Indiana, Kansas, Michigan, New Jersey, North Carolina, Rhode Island, Tennessee, Texas and Virginia.

• In order to expand further, we need you to help us by volunteering to serve as a provider orthodontist or help identify orthodontists willing to lead efforts to establish a DOS chapter in your state.

• Stop by the DOS booth here in San Diego to learn more about the program or contact Ann Sebaugh at [email protected] with questions.

AAO Donated Orthodontic Services (DOS) Program


Treatment of Severe Maxillary and Mandibular Constriction

• Review of the technique of SARPE and MSDO

• Case reports of combined treatment

• New approach to maxillary expansion

• Conclusion


Mandibular Constriction

Not so constricted Constricted Very constricted


•Skeletal Expansion ★ Mx & Nasal cavity (p < 0.0001)

★ STABLE: NS ∆ (p=0,1166)

•Dental Expansion (7,6± 1,6mm) ★Sig.Relapse: 24% (1,8±1,8mm) at 15

months post SARPE

★Follow up 24m: Relapse 1.1 mm➔ 38% of total expansion

•46% Sk/Dt at 6 m

•65% Sk/Dt at 23,6 m

Changes in the Dental and Skeletal Dimensions Over Time after SARPE


Covariables•Low correlation between skeletal and dental changes: r = .36; r2 = 0.13

• Low correlation between screw changes and skeletal change: r = 0.41; r2 = 0.17

✦ Hemimaxillae do not expand in parallel

✓ Lateral rotation & alveolar bending

• It explains why skeletal expansion is 47% of maximal dental expansion (T3)r T3 r T5Diastema changes / 1st Molar 0.69 0.22Screw changes / 1st Molar 0.93 0.38Screw changes / Skeletal changes 0.41 0.47Skeletal changes / Dental changes 0.36 0.03Expansion / relapse 0.01


•No parallel expansion of hemimaxillae in coronal view

•Rotation of hemimaxillae

✦ Inward movement of alveolar border under the osteotomy cut (C, A)

✦Palatal depth decrease (B)

Before Expansion After ExpansionA

B

CC

Chamberland S, Proffit WR, Short-term and long-term stability of surgically assisted rapid palatal expansion revisited AJODO 2011; 139:815-22Koudstaal MJ, Smeets JB, Kleinrensink GJ, Schulten AJ, van der Wal KG. Relapse and stability of surgically assisted rapid maxillary expansion: an anatomic biomechanical study. J Oral Maxillofac Surg 2009;67:10-4.Chamberland S, Proffit WR. Closer look at the stability of surgically assisted rapid palatal expansion. J Oral Maxillofac Surg 2008;66: 1895-900. Landes CA, Laudemann K, Schubel F, Petruchin O, Mack M, Kopp S, et al. Comparison of tooth- and bone-borne devices in surgically assisted rapid maxillary expansion by three-dimensional computedtomography monitoring: transverse dental and skeletal maxillary expansion, segmental inclination, dental tipping, and vestibular bone resorption. J Craniofac Surg 2009;20:1132-41.Zemann W, Schanbacher M, Feichtinger M, Linecker A, Karcher H. Dentoalveolar changes after surgically assisted maxillary expansion: a three-dimensional evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:36-42.


•No escape when hemimaxillae are expanded if the cut is not widened at the zygoma

•Obvious inward displacement upon appliance activation per op. This has been proven by Chamberland& Proffit AJODO2011

•As bone contact, resistance may be similar to non-cut bone


How Much Wide?

• 3-4 mm wide


MSDO. Early reports• Tooth anchor expansion device

✦ Force is applied above C/R of Md

• Activation 1 mm /days

• Concerns:

✦ Disproportional widening of the dento-osseous segments (alveolar bone was expanded more than basal bone)

✦ Lower incisor proclinationSanto M., Guerrreo C., Bushang P.H., et al. Long-term skeletal and dental effects of mandibular symphyseal distraction osteogenesis AJODO 2000;118:485-93Santo M., English Jd, Wolford L et al, Midsymphyseal distraction osteogenesis for correcting transverse mandibular discrepancies AJODO 2002; 121: 629-638


Tooth-borne Versus Hybrid Devices for MSDO

• Greater skeletal expansion was achieved with a hybrid distractor.

• Greater dental expansion was achieved with a tooth-borne distractor

• During distraction, the hybrid distractor effected more parallel expansion of basal and alveolar bone than did the tooth-borne distractor

Skeletal and dental effects of tooth-borne versus hybrid devices for mandibular symphyseal distraction osteogenesis, Niculescu, Julia A, John W King, and Steven J Lindauer. Angle Orthod. 2014;84:68–75 doi:10.2319/022213-154.1


Long-Term Skeletal & Dental Stability• Follow-up 6-7 years post distraction

✦ T5-T4 Skeletal change: Stable

✦ T5-T4 Dental change:

✓ NS slight increase 1st molar

King JW, Wallace JC, Winter DL, Niculescu JA. Long-term skeletal and dental stability of mandibular symphyseal distraction osteogenesis with a hybrid distractor. Am J Orthod Dentofacial Orthop 2012;141:60-70.

Durham JN, King JW, Robinson QC, Trojan TM. Long-term skeletodental stability of mandibular symphyseal distraction osteogenesis: Tooth-borne vs hybrid distraction appliances. Angle Orthod 2017;87:246-253.


3e rang EstSt-Gervais ©sylvainchamberland.com

Lessons from the Past• Constricted maxilla

• Significant ALD

• Crossbite #22, #15

• Slight CO/CR discrepancy

• Gingival recession


•Bimax dentoalveolar protrusion

•Retrognathic profile

•No anterior guidance in protrusion

✦ Interferences on balancing side

✦ Bilateral TMJ clicking on opening

✦ Pain on palpation of both lateral pterygoïd


Tx Option

• Non-surgical, extraction of 4 premolars (5’s)

• SARPE + MSDO


Tx Plan

• SARPE and MSDO

May-2001

Mei-Ra May-2001


Follow Up

• Mx: .33 mm/day

• Md: 0,5 mm/day • 3 days into expansion ✓ Sequestra between 31-41 ✓ Granulation tissue B #11

May 28

✓ 7 days post surgeryMay 25 June 6

✓ 21 days post surgery


End of Distraction

• Expansion is slightly larger at the dental level than the mandibular border

June 11


At 4 months• Mx: .016 CNT

• Md: segment .016 CNT

• At 5 months ✦ Removal of both expander, bond molars ✦ Lower arch aligned in 3 segments


At 10 Months• Mx & Md: .016 X .022 cnt

★Elastomeric chain 42 to 32

★2nd molars were not engaged

March 02©sylvainchamberland.com

Parodontal Assessment• Root surfacing was

required

April 2002


Outcome• Class I occlusion was achieved

• Slight anterior guidance

• Slight curve of Spee maintained

• Gingival recession B 31-41


Dental Changes

• At 1st molars

✦ Mx: + 4,06

✦ Md: + 6,58

43.48

50.06+6.58

38.15

42.21+4.06


Tx time: 22 months

• No TMJ symptoms

• Maximum interincisor opening 46 mm


Superposition

• Md forward??

• /1-MP = maintained

• 1/-FH increased


RM 24

• Parodontal status maintained or improved

• Root parallelism improved, except 21 & 22


Follow up at 31 months


Epilogue• I said that I will never do that again…

• But…

✦ Bone anchor device:

✓ Malkoç et al Sem. Ortho. 2012; 18:152-161 et AJODO 2007; 132:769-75

✓ Conley RS., Legan HL AJODO 2006; 129:283-92


Missed Opportunity



Bologna Midline Distractor (KLS Martin)

• 1 activation 90° = 0,25 mm

• Screw parallel to occlusal plane

• Relief 2 mm buccal

• Upper connector 2-3 mm apical to gingival margin


• Fissure bur

• Osteotomy cut deviated to the right where there is more room between roots of 42-43.


• q

Inferior plates of the distractor are bent and adjusted to the form of the mandible

Distractor seated on abutment teeth to figure out plates adjustment

Stepped parasagittal cut to widest interradicular site

Bologna Distractor

Precise plates positioning to ensure stress-free fixation


Osteotomy sitePrecise plates positioning to ensure stress-free fixation

Precise adaptation & fixation Mobility check of bone fragment©sylvainchamberland.com

Precise adaptation & fixation Mobility check of bone fragment

Mucosa margin sutured2 mm expansion perop

©Dr Sylvain Chamberland

• EMRAC movie


Distraction Protocol•Latency period of 7-8 days

✦Critical to allow time for a callus of good quality to form

•Rate of distraction: 1 mm per day

✦ Too fast: can lead to poor bone quality, partial union, fibrous union

✦ Too slow: premature consolidation, inability to obtain the planned amount of expansion

•Rhythm of distraction: 0,25 mm qid or 0,50 mm bidConley R., Legan H., Mandibular Symphyseal Distraction Osteogenesis:Diagnosis and Treatment Planning Considerations, Angle Orthod 2003;73:3–11


Distraction protocol• Postdistraction orthodontic movement

✦ Should not begin until radiographic evidence of consolidation is observed

✦ Typically 2-3 months

• Removal of the distractor

✦ 6 months after the end of distraction

Conley R., Legan H., Mandibular Symphyseal Distraction Osteogenesis:Diagnosis and Treatment Planning Considerations, Angle Orthod 2003;73:3–11 ©sylvainchamberland.com

Complications• Irritation to labial mucosa

• Gingival inflammation

✦ Careful cleaning is mandatory

• Loss of interdental septum

✦ Mesial to 31Garreau É, Wojcik T, Rakotomalala H, Raoul G, Ferri J. Symphyseal distraction in the context of orthodontic treatment: A series of 35 cases, Int Orthod. 2015 Mar;13(1):81-95.


Complications• Cellulitis

✦1 patient required antibiotic therapy + marsupialisation

• Hardware problems:

✦ If the surgeon break the thread of the screw or forget to ligate, your are screwed…

Garreau É, Wojcik T, Rakotomalala H, Raoul G, Ferri J. Symphyseal distraction in the context of orthodontic treatment: A series of 35 cases, Int Orthod. 2015 Mar;13(1):81-95.

1 m post distraction 5 days later

©sylvainchamberland.comRte 279 intersection 3e rang Est, St-Gervais-St Lazare


Case 2• Class I

• Constricted dental arches

• Moderate ALD

FrDeMa020412©sylvainchamberland.com

• Orthognathic profile

• But slight retrusion of Mx & Md

• Mouth breatherFrDeMa020412


End of distraction•Mx: 0,25 mm bid

✦mx diastema: 8,6 mm

•Md: 0,5 mm bid (2 activations bid or 2 activations morning 1 activation evening)

✦0,75 to 1 mm per day

✦∆ intercanine= 5,4 mm, diastema ~ 6 mm

De-Ma, Fri 23-05-2013


1 m Postdistraction

• Latency period was 7 days. Expansion monitored every week

• Activation period: 14 days

• Note the parallelism of md segment

De-Ma, Fri 23-05-2013


• Bonding at 1 month post distraction

✦ Mx: .016 Supercable™ 15 to 25

✦ Md: .016 Supercable™ 42 to 33

• Careful cleaning and root surfacing at each visit

De-Ma, Fri 20-06-2013 De-Ma, Fri 05-08-2013


• At 20 weeks

✦ Mx: .016 x .022 CNT

✦ Md: .016 CNT

De-Ma, Fri 16-09-2013


• At 32 weeks

✦ Mx expansion device is removed

✦ Mx and Md arch are coordinated; .020x .020CNT / .016 X .022CNT

✦ Class I relationship is maintained

✦ Crowding is resolved

De-Ma, Fri 09-12-2013


• Transverse dimension improved

• 1st, 2nd & 3rd order movement needed for lower and upper anteriors

FrDeMa020412 De-MaFr09-12-2013FrDeMa200613 De-MaFr06-03-2014De-MaFr27-05-2014


At 76 weeks• Finishing stages

De-MaFr16-10-2014


Final outcome• Tx time 85 weeks

• Class I fonctionnal occlusion

FrDeMa161214


• Improvement of interincisal relationship

✦ 1/ retroclined 10°, /1 maintained 93°

• Profil maintained or improved


• Osteogenesis of distraction site

• Root surfacing was done mesial of #43 during tx.

• Root parallelism obtained (except 34)

FDM_Jan-28-2014


Dental Changes

33,77

25,47

30,43

24,51

24,34

42,44

32,99+7,52

+8,67

+8,72

+10,02

+2,24

39,15

34,53

26,58+23,62+21,56 ©sylvainchamberland.com

Follow up at 2 years

De-MaFr12-01-2017



Risk and Complication• Case from a netsurfer who lives

in France

• Oronasal communication

• Open communication mesial to #31

• This case is…POORLY manage


Risk and Complication• Follow up ~ 1 year

• Lack of bone between central incisors

• Hyperplasia right concha


Risk and Complication

• Follow up

✦ 16 months post MSDO + SARPE

• Bone graft has failed

• Redo is planned…

©sylvainchamberland.com ©sylvainchamberland.com

Mx & Md Constriction

End of SARPE End of MSDOMidline osteotomy cut is where there is space available

Courtesy of Dr Dany Morais & Dr Claude Gariepy


Outcome

• Final occlusion

Prior phase 2 surgery

Courtesy of Dr Dany Morais & Dr Claude Gariepy


•Class I

•Severe bimax constriction

Courtesy of Dr Sandra Labbé

JeDu Aprl 2017

JeDu Aprl 2017


JeDu Aprl 2017

JeDu January 2018



End of Distraction

• Inward rotation of hemimaxilla

• Parallel md expansion

✦ Expansion device || occlusal plane


JeDu 23 octobre 2017

©sylvainchamberland.comRang St-Joseph, Armagh, Bellechasse ©sylvainchamberland.com

• Class I

• Missing 42, 41

• Maxillary and mandibular constriction

• ENT specialist referred for snoring and apnea

NiBo040614


• Mx et Md Retrusion

• Class I skeletal relationship

• Proclined 1/ (121°)

• Retroclined /1 (79°)


• Similar case published by Conley et Legan

Conley RS., Legan HL., Correction of severe obstructive sleep apnea with bimaxillary transverse distraction osteogenesis and maxillomandibular advancement. AJODO 2006;129:283-92


•Osteotomy on the midline turning to the right between diverging roots of 43 - 31.

•Problems

✦ Complete separation should not be done before fixation of the distractor

✦ Distraction device should be more parallel to the occlusal plane

✦ Fitting of the plates could be improved


• Distraction starts 7 days post op

• Mx: activation ⅓ mm bid

• Md: 2 activations morning (0,5 mm) et 1 activation evening (0,25 mm)

NiBo230914


End of Distraction at 30 days post op

NiBo161014

• Distractor canted to the left


NiBo021014

Oct. 2 (+10 days) c-c = 15 mm

NiBo091014

Oct. 9 (+7 days) c-c = 16,7 mm

NiBo141014

Oct.14 (+5 days) c-c = 20,5 mm

NiBo161014

Oct 16 (+2 days) c-c = 22,5 mm

Latérodéviation mandibulaire gauche.


Complication

Oct. 16 Nov. 12 Nov. 17Patient noted that the screw seems to unscrew

Nov. 24: reactivation completed + ligature Dec.17: Bond Mx teeth

11,5 mm

10,4 mm10,8 mm


•Note

✦Chances are that thread of the screw were stripped when the surgeon adapted the plates of the device on the symphysis and it may explain the loss of expansion at 1 month post distraction, because there was some slack of the screw when activating.

✦Or it is because the screw was not ligate and immobilized at the end of distraction.

✦Advice: Always lock the screw with a ligature with such device.

17,5 mm

39,62 mm


• I accepted the loss of 1 to 2 mm expansion

• Because I had to reactivate 1 month after we had stopped distraction I was nervous to reactivate .

NiBo161014

NiBo171214

End of Distraction. October End of Distraction. December


What Happen You Don’t Ligate the Screw?

• You will likely learn the hard way that you should have ligate…

• Complete relapse in 2 months

• Call

JeDu January15 2018

JeDu 23 octobre 2017

JeDu March 12, 2018


19 weeks• Osteogenesis at

distraction site

• Bonding md teeth

NiBo260115 ©sylvainchamberland.com

At 5½ months• Wide BL width of the

distraction site

NiBo090315


At 7 Months • Removal Mx distractor Superscrew™

NiBo220415©sylvainchamberland.com

At 8 Months• Removal of the

Bologna Distractor

• Possible sequela of reactivation at 1 months

NiBo280515


Bone Grafting• Follow up 2 months post grafting

NiBo241115


•Baseline June 2014 on left

•Progress January 2016→ 12,42

17,66

33,69

40,17

24,83

25,2 33,54

34,84

48,22

42

32,7824,32

10,52

+8,34

+10,01

+8,05

+8,31

+15,12+11,9


69 weeks

NiBo12012016©sylvainchamberland.com

Mx width 59,6 Mx width 65,5 +5,9 mm


82 weeks

• Implant placement with a surgical guide


94 weeks

NiBo07072016


94 weeks


Follow up 61 weeks into retention

NiBo05092017


Follow up 61 weeks into retention

• Good osteogenesis

• Increase oropharynx airway

NiBo05092017NiBo05092017


Airways• Oropharynx

widened

• Hyoïd bone moved up

• Epiglottis opened


Orthodontic Pearls Controversies

• Such outcome CAN NOT be compare to bone augmentation completed with corticotomy and grafted freeze-dried bone allograft material

• SARPE or MARPE and MSDO is by far better IMHO


Corticotomy & Grafted Freeze Dried Bone

• Mx dentoalveolar expansion

• Md dentoalveolar expansioninto grafted bone

• Increase airway (?????)

✦ Buccal proclination

✦ Md forward position

• NO BASAL WIDTH CHANGEEvans M. et al, 3D guided comprehensive approach to mucogingival problems in orthodontics , Semin Orthod 2016;22:52– 63.

What is New About Maxillary Expansion?

New Hybrid Superscrew Device MARPE


What is New About Maxillary Expansion?

• Hy

Tooth-Borne device+ Le Fort 1 osteotomy

Hybrid device+ Le Fort 1 osteotomy

Bicortical TAD Non Surgical

Maxillary Skeletal Expansion


• Parallel expansion of buccal segment

✦ Note the step out at the osteotomy cut

• Mx width gain 8,6 mm

• Nasal cavity width gain 6,6 mm

Lar-Lav Ste-10-12-15Lar-Lav Ste-10-12-15


•Larger skeletal expansion


Hybrid Hyrax•Early cases

✦ TADs too short (8 mm)

✦ 10-12 mm recommended to engage both palatal & nasal cortex

•TADs should be place in the horizontal part of the palate

•Expansion device in line or posterior to 1st molars

DubPe30-09-15

Tomas pin EP 12 mm


Miniscrew Assisted Rapid Palatal Expansion (MARPE)

•4 mini-screw de 1,8mm X 11 mm

•MSE position: posterior palatal vault between 1st-2nd molars

•Rate of activation MSE II

✦Early teens: 6x/week (0,8 mm/Wk)

✦Teens: 2x/day (0,27 mm/ day)

✦Early to mid 20s: 4-6x/day (0,53-0,8 mm)

✦Adult (>25-30): 4-6X/day minimum

•After diastema: 2x/day (0,27 mm/day)

•Non rigid connector •Dégagement 2 mm


MARPE• Disengagement of pterygoïd plate /

pyramidal process

✦ 53% (16 sutures/30)

• Skeletal expansion

✦ 71% et 63% of the screw changes

✓ (SARPE: 46%)

71%

63%

A:Rupture bilatérale. B: Rupture unilatérale

• Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J et al. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed with a novel 3D method based on CBCT imaging. Prog Orthod 2017;18:34. ©sylvainchamberland.com

MARPE Skelettal Changes vs SARPE•MARPE Center of Rotation higher than SARPE

•MARPE

✦ Maxilla move laterally

✓ Downward

✓ Forward

✦ Hemimaxillae: quasi parallel expansion

✓ Posterior part bend medially• Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J et al. Changes

in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed with a novel 3D method based on CBCT imaging. Prog Orthod 2017;18:34.

✦ as a consequence of the rotation

as a consequenceof the rotation}

After Expansion

B

CR CR

SARPE


Dental Expansion

13,8 mm

38,3 45,7+7,4 45,3+7


Skelettal Expansion

•Mx: 5,7 mm •NC: 5,3 mm •1stM: 7 mm

•Sk/Dt : 81%

©sylvainchamberland.com ©sylvainchamberland.com

Conclusion• Mandibular symphyseal distraction osteogenesis

✦ Effective to alleviate md crowding and maintain /1 AP relationship

✦ Small advancement of the mandible could be explained by outward rotation of the condyle in the fossa

✦ May improve airways by permitting the tongue to have room between dental arches

• Monitoring expansion every week is mandatory. Every 3-4 days ideally


Conclusion• SARPE:

✦ Skeletal change is stable but account for only 46% at end of distraction

• MARPE

✦ Skeletal change is about 70% of the screw change

• MSDO

✦ Skeletal change is about 80% of the screw change. Relapse is NS

• Therefore one should aim for skeletal change because it is stable


MSE & MSDO

• Correct the Mx expansion with MSE device or Hybrid device

• Mandibular Symphyseal Distraction Osteogenesis

Bicortical TAD MARPE

De-Ma, Fri 23-05-2013

Hybrid Supercrew

Thank youDo you have questions?

2e Rang St-Gervais, Bellechasse

Documents

Biography Maxillary and Mandibular Constriction · •During distraction, the hybrid distractor effected more parallel expansion of basal and alveolar bone than did the tooth-borne