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Treatment of Severe
Maxillary and Mandibular
Constriction
SARPE & MSDO
AAO 118th Annual Session
©sylvainchamberland.com
Bi...
©sylvainchamberland.com
Treatment of Severe Maxillary and
Mandibular Constriction
•Review of the technique of SARPE and MS...
©sylvainchamberland.com
Covariables
•Low correlation between skeletal and dental changes: r = .36; r2 = 0.13
•Low correlat...
©sylvainchamberland.com
MSDO. Early reports
•Tooth anchor expansion device
✦ Force is applied above C/R of Md
•Activation ...
©sylvainchamberland.com
Lessons from the Past
• Constricted maxilla
• Significant ALD
• Crossbite #22, #15
• Slight CO/CR d...
©sylvainchamberland.com
Follow Up
• Mx: .33 mm/day
• Md: 0,5 mm/day • 3 days into expansion
✓ Sequestra between 31-41
✓ Gr...
©sylvainchamberland.com
Parodontal Assessment
• Root surfacing was
required
April 2002
©sylvainchamberland.com
Outcome
• C...
©sylvainchamberland.com
Superposition
• Md forward??
• /1-MP = maintained
• 1/-FH increased
©sylvainchamberland.com
RM 24
...
©sylvainchamberland.com
Missed Opportunity
©sylvainchamberland.com
3e rang Est

St-Gervais
©sylvainchamberland.com
Bologna...
©sylvainchamberland.com
•q
Inferior plates of the distractor are bent
and adjusted to the form of the mandible
Distractor ...
©sylvainchamberland.com
Distraction Protocol
•Latency period of 7-8 days
✦ Critical to allow time for a callus of good qua...
©sylvainchamberland.com
Rte 279 intersection 3e rang
Est, St-Gervais-St Lazare ©sylvainchamberland.com
Case 2
•Class I
•Co...
©sylvainchamberland.com
1 m Postdistraction
• Latency period was 7 days.
Expansion monitored every
week
• Activation perio...
©sylvainchamberland.com
•Transverse dimension improved
•1st, 2nd & 3rd order movement needed for lower and upper
anteriors...
©Dr Sylvain Chamberland
• Osteogenesis of distraction site
• Root surfacing was done mesial of #43 during tx.
• Root paral...
©sylvainchamberland.com
Risk and Complication
• Case from a netsurfer who lives
in France
•Oronasal communication
•Open co...
©sylvainchamberland.com
Outcome
•Final occlusion
Prior phase 2 surgery
Courtesy of Dr Dany Morais & Dr Claude Gariepy
©syl...
©sylvainchamberland.com
Rang St-Joseph,
Armagh, Bellechasse ©sylvainchamberland.com
•Class I
•Missing 42, 41
•Maxillary an...
©sylvainchamberland.com
•Osteotomy on the midline turning to the right between diverging roots of
43 - 31.
•Problems
✦ Com...
©sylvainchamberland.com
Complication
Oct. 16 Nov. 12 Nov. 17

Patient noted that the
screw seems to unscrew
Nov. 24: react...
©sylvainchamberland.com
19 weeks
•Osteogenesis at
distraction site
•Bonding md teeth
NiBo260115 ©sylvainchamberland.com
At...
©sylvainchamberland.com
Bone Grafting
•Follow up 2 months post grafting
NiBo241115
©sylvainchamberland.com
•Baseline June ...
©sylvainchamberland.com
82 weeks
•Implant placement with a surgical guide
©sylvainchamberland.com
94 weeks
NiBo07072016
©s...
©sylvainchamberland.com
Follow up 61 weeks into retention
•Good osteogenesis
•Increase oropharynx airway
NiBo05092017NiBo0...
What is New About
Maxillary Expansion?
New Hybrid Superscrew Device
MARPE
3e rang Est

St-Gervais ©sylvainchamberland.com
...
©sylvainchamberland.com
Hybrid Hyrax
•Early cases
✦ TADs too short (8 mm)
✦ 10-12 mm recommended
to engage both palatal &
...
©sylvainchamberland.com
MARPE Skeletal Changes vs SARPE
•MARPE Center of Rotation higher than SARPE
•MARPE
✦ Maxilla move ...
©sylvainchamberland.com
Skeletal Change
•More expansion anteriorly than
posteriorly
•More expansion inferiorly than
superi...
©sylvainchamberland.com ©sylvainchamberland.com
Conclusion
•My next case
✦ Cl II div 2
✦ Right buccal Xbite
✦ Missing LR4
...
©sylvainchamberland.com
MSE & MSDO
• Correct the Mx expansion with MSE device or Hybrid device
• Mandibular Symphyseal Dis...
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Mandibular Symphyseal Distraction Osteogenesis and SARPE aao 2018 Washington DC ©sylvain chamberland

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SARPE and Mandibular Symphyseal Distraction Osteogenesis

Transverse skeletal deficiency is a common clinical problem associated with narrow basal and dentoalveolar bone. Bimaxillary transverse distraction osteogenesis for correction of OSA was first reported by Conley & Legan (2006). Mandibular symphyseal distraction osteogenesis (MSDO) evolve form tooth anchor device to bone anchor device for a better control of the distraction segment in the 3 planes of space. Its success depends on good collaboration between the orthodontist and the surgeon, and on strict patient selection. Throughout case reports, we will review the diagnosis, orthodontic and surgical treatment planning considerations to achieve clinical success.

Learning objective:
After this lecture you will be able to
1-Diagnose patient with transverse mandibular deficiency
2-Understand the distraction protocol
3-Manage the postdistraction orthodontic movement

Publié dans : Santé & Médecine
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Mandibular Symphyseal Distraction Osteogenesis and SARPE aao 2018 Washington DC ©sylvain chamberland

  1. 1. Treatment of Severe Maxillary and Mandibular Constriction SARPE & 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 ©sylvainchamberland.com 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 ©sylvainchamberland.com 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 asebaugh@aaortho.org with questions. AAO Donated Orthodontic Services (DOS) Program
  2. 2. ©sylvainchamberland.com 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 ©sylvainchamberland.com = FrDeMa020412 NiBo040614 Case Report ©sylvainchamberland.com Mandibular Constriction Not so constricted Constricted Very constricted ©sylvainchamberland.com •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
  3. 3. ©sylvainchamberland.com 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 T5 Diastema changes / 1st Molar 0.69 0.22 Screw changes / 1st Molar 0.93 0.38 Screw changes / Skeletal changes 0.41 0.47 Skeletal changes / Dental changes 0.36 0.03 Expansion / relapse 0.01 ©sylvainchamberland.com •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 Expansion A B C C Chamberland S, Proffit WR, Short-term and long-term stability of surgically assisted rapid palatal expansion revisited AJODO 2011; 139:815-22 Koudstaal 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. ©sylvainchamberland.com •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 ©sylvainchamberland.com How Much Wide? •3-4 mm wide
  4. 4. ©sylvainchamberland.com 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 proclination Santo M., Guerrreo C., Bushang P.H., et al. Long-term skeletal and dental effects of mandibular symphyseal distraction osteogenesis AJODO 2000;118:485-93 Santo M., English Jd, Wolford L et al, Midsymphyseal distraction osteogenesis for correcting transverse mandibular discrepancies AJODO 2002; 121: 629-638 ©sylvainchamberland.com 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 ©sylvainchamberland.com 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. ©sylvainchamberland.com 3e rang Est
 St-Gervais
  5. 5. ©sylvainchamberland.com Lessons from the Past • Constricted maxilla • Significant ALD • Crossbite #22, #15 • Slight CO/CR discrepancy • Gingival recession ©sylvainchamberland.com •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 ©sylvainchamberland.com Tx Option • Non-surgical, extraction of 4 premolars (5’s) • SARPE + MSDO ©sylvainchamberland.com Tx Plan • SARPE and MSDO May-2001 Mei-Ra May-2001
  6. 6. ©sylvainchamberland.com 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 surgery May 25 June 6 ✓ 21 days post surgery ©sylvainchamberland.com End of Distraction • Expansion is slightly larger at the dental level than the mandibular border June 11 ©sylvainchamberland.com 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 ©sylvainchamberland.com At 10 Months •Mx & Md: .016 X .022 cnt ★Elastomeric chain 42 to 32 ★2nd molars were not engaged March 02
  7. 7. ©sylvainchamberland.com Parodontal Assessment • Root surfacing was required April 2002 ©sylvainchamberland.com Outcome • Class I occlusion was achieved • Slight anterior guidance • Slight curve of Spee maintained • Gingival recession B 31-41 ©sylvainchamberland.com Dental Changes •At 1st molars ✦ Mx: + 4,06 ✦ Md: + 6,58 43.48 50.06 +6.58 38.15 42.21 +4.06 ©sylvainchamberland.com Tx time: 22 months • No TMJ symptoms • Maximum interincisor opening 46 mm
  8. 8. ©sylvainchamberland.com Superposition • Md forward?? • /1-MP = maintained • 1/-FH increased ©sylvainchamberland.com RM 24 • Parodontal status maintained or improved • Root parallelism improved, except 21 & 22 ©sylvainchamberland.com Follow up at 31 months ©sylvainchamberland.com 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
  9. 9. ©sylvainchamberland.com Missed Opportunity ©sylvainchamberland.com 3e rang Est
 St-Gervais ©sylvainchamberland.com 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 ©sylvainchamberland.com •Fissure bur •Osteotomy cut deviated to the right where there is more room between roots of 42-43.
  10. 10. ©sylvainchamberland.com •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 ©sylvainchamberland.com Osteotomy site Precise 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
  11. 11. ©sylvainchamberland.com 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 bid Conley R., Legan H., Mandibular Symphyseal Distraction Osteogenesis:Diagnosis and Treatment Planning Considerations, Angle Orthod 2003;73:3–11 ©sylvainchamberland.com 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 31 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. ©sylvainchamberland.com Complications •Cellulitis ✦ 1 patient required antibiotic therapy + marsupialisation •Hardware problems: ✦ If the surgeon break the thread of the screw or if you 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
  12. 12. ©sylvainchamberland.com Rte 279 intersection 3e rang Est, St-Gervais-St Lazare ©sylvainchamberland.com Case 2 •Class I •Constricted dental arches •Moderate ALD FrDeMa020412 ©sylvainchamberland.com •Orthognathic profile •But slight retrusion of Mx & Md •Mouth breather FrDeMa020412 ©sylvainchamberland.com 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
  13. 13. ©sylvainchamberland.com 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 ©sylvainchamberland.com •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 ©sylvainchamberland.com •At 20 weeks ✦ Mx: .016 x .022 CNT ✦ Md: .016 CNT De-Ma, Fri 16-09-2013 ©sylvainchamberland.com •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
  14. 14. ©sylvainchamberland.com •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 ©sylvainchamberland.com At 76 weeks •Finishing stages De-MaFr16-10-2014 ©sylvainchamberland.com Final outcome •Tx time 85 weeks •Class I fonctionnal occlusion FrDeMa161214 ©sylvainchamberland.com •Improvement of interincisal relationship ✦ 1/ retroclined 10°, /1 maintained 93° •Profil maintained or improved
  15. 15. ©Dr Sylvain Chamberland • Osteogenesis of distraction site • Root surfacing was done mesial of #43 during tx. • Root parallelism obtained (except 34) FDM_Jan-28-2014 ©Dr Sylvain Chamberland 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 ©sylvainchamberland.com 3e rang Est
 St-Gervais
  16. 16. ©sylvainchamberland.com Risk and Complication • Case from a netsurfer who lives in France •Oronasal communication •Open communication mesial to #31 •This case is…POORLY manage ©sylvainchamberland.com Risk and Complication •Follow up ~ 1 year •Lack of bone between central incisors •Hyperplasia right concha ©sylvainchamberland.com ©sylvainchamberland.com Mx & Md Constriction End of SARPE End of MSDO Midline osteotomy cut is where there is space available Courtesy of Dr Dany Morais & Dr Claude Gariepy
  17. 17. ©sylvainchamberland.com Outcome •Final occlusion Prior phase 2 surgery Courtesy of Dr Dany Morais & Dr Claude Gariepy ©sylvainchamberland.com •Class I •Severe bimax constriction Courtesy of Dr Sandra Labbé JeDu Aprl 2017 JeDu Aprl 2017 ©sylvainchamberland.com JeDu Aprl 2017 JeDu January 2018 Courtesy of Dr Sandra Labbé ©sylvainchamberland.com End of Distraction •Inward rotation of hemimaxilla •Parallel md expansion ✦ Expansion device || occlusal plane Courtesy of Dr Sandra Labbé JeDu 23 octobre 2017
  18. 18. ©sylvainchamberland.com Rang St-Joseph, Armagh, Bellechasse ©sylvainchamberland.com •Class I •Missing 42, 41 •Maxillary and mandibular constriction •ENT specialist referred for snoring and apnea NiBo040614 ©sylvainchamberland.com •Mx et Md Retrusion •Class I skeletal relationship •Proclined 1/ (121°) •Retroclined /1 (79°) ©sylvainchamberland.com •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
  19. 19. ©sylvainchamberland.com •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 ©sylvainchamberland.com •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 ©sylvainchamberland.com End of Distraction at 30 days post op NiBo161014 • Distractor canted to the left ©Dr Sylvain Chamberland 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.
  20. 20. ©sylvainchamberland.com Complication Oct. 16 Nov. 12 Nov. 17
 Patient noted that the screw seems to unscrew Nov. 24: reactivation completed + ligature Dec.17: Bond Mx teeth 11,5 mm 10,4 mm 10,8 mm ©sylvainchamberland.com •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 ©sylvainchamberland.com •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 ©sylvainchamberland.com What Happens if 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
  21. 21. ©sylvainchamberland.com 19 weeks •Osteogenesis at distraction site •Bonding md teeth NiBo260115 ©sylvainchamberland.com At 5½ months •Wide BL width of the distraction site NiBo090315 ©sylvainchamberland.com 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
  22. 22. ©sylvainchamberland.com Bone Grafting •Follow up 2 months post grafting NiBo241115 ©sylvainchamberland.com •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 32,78 24,32 10,52 +8,34 +10,01 +8,05 +8,31 +15,12 +11,9 ©sylvainchamberland.com 69 weeks NiBo12012016 ©sylvainchamberland.com Mx width 59,6 Mx width 65,5+5,9 mm
  23. 23. ©sylvainchamberland.com 82 weeks •Implant placement with a surgical guide ©sylvainchamberland.com 94 weeks NiBo07072016 ©sylvainchamberland.com 94 weeks ©sylvainchamberland.com Follow up 61 weeks into retention NiBo05092017
  24. 24. ©sylvainchamberland.com Follow up 61 weeks into retention •Good osteogenesis •Increase oropharynx airway NiBo05092017NiBo05092017 ©sylvainchamberland.com Airways •Oropharynx widened •Hyoïd bone moved up •Epiglottis opened ©sylvainchamberland.com 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 ©sylvainchamberland.com Corticotomy & Grafted Freeze Dried Bone • Mx dentoalveolar expansion • Md dentoalveolar expansion
 into grafted bone • Increase airway (?????) ✦ Buccal proclination ✦ Md forward position • NO BASAL WIDTH CHANGE Evans M. et al, 3D guided comprehensive approach to mucogingival problems in orthodontics , Semin Orthod 2016;22:52– 63.
  25. 25. What is New About Maxillary Expansion? New Hybrid Superscrew Device MARPE 3e rang Est
 St-Gervais ©sylvainchamberland.com 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 ©sylvainchamberland.com •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-10-12-15 Lar-Lav Ste-10-12-15 ©sylvainchamberland.com •Larger skeletal expansion
  26. 26. ©sylvainchamberland.com 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 ©sylvainchamberland.com 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 ©sylvainchamberland.com 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 Skeletal 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} After Expansion B CR CR SARPE Blue picture Courtesy Dr Won Moon
  27. 27. ©sylvainchamberland.com MARPE Skeletal 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} After Expansion B CR CR SARPE ©sylvainchamberland.com MARPE Skelettal Changes •Disengagement of palatal bones ✓ Bending of vertical process (sphenoïd) •Hemimaxillae: quasi parallel expansion ✦ Posterior part bend medially •Maxilla move laterally ✦ Downward ✦ Forward Plan horizontal Plan coronal • 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 } ©sylvainchamberland.com MARPE Skelettal Changes •Center of rotation frontal and occlusal From Dr Moon lecture ©sylvainchamberland.com MARPE Skelettal Changes •Disengagement of palatal bones ✓ Bending of vertical process (sphenoïd) •Hemimaxillae: quasi parallel expansion ✦ Posterior part bend medially Plan horizontal Plan coronal • 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.
  28. 28. ©sylvainchamberland.com Skeletal Change •More expansion anteriorly than posteriorly •More expansion inferiorly than superiorly ∆ Zygomatic area MSE ∆ Zygomatic area Hyrax From Dr Moon lecture • 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. ∆ Maxilla area Hyrax ∆ Maxilla area MSE ©sylvainchamberland.com Airway Changes •Decrease nasal resistance •Increase airflow ∆ Zygomatic area MSE ∆ Zygomatic area Hyrax From Dr Moon lecture • Hur JS, Kim HH, Choi JY, Suh SH, Baek SH. Investigation of the effects of miniscrew-assisted rapid palatal expansion on airflow in the upper airway of an adult patient with obstructive sleep apnea syndrome using computational fluid-structure interaction analysis. Korean J Orthod 2017;47:353-364 • 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 Dental Expansion 38,3 45,7 +7,4 45,3+7 ©sylvainchamberland.com Skeletal Expansion •Mx: 5,7 mm •NC: 5,3 mm •1stM: 7 mm
 
 
 •Sk/Dt : 81%
  29. 29. ©sylvainchamberland.com ©sylvainchamberland.com Conclusion •My next case ✦ Cl II div 2 ✦ Right buccal Xbite ✦ Missing LR4 ©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 ©sylvainchamberland.com 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
  30. 30. ©sylvainchamberland.com 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 you Do you have questions? 2e Rang St-Gervais, Bellechasse ©sylvainchamberland.com •Thanks for you attention Vanessa lived 10 004 days. 
 It seemed like a moment. The next 10 000 days that I, Carole, Pier-Eric and Richard will live will be an eternity.
 I am 558 days into eternity Who blocks my chest I can not breath anymore It prevents me from singing My dear parents, I'm leaving I love you but I'm leaving You’ll have no more children Tonight I do not run away I fly Understand I'm flying Without Smoke, without alcohol I fly lalalala lalalala lalalala I fly, I fly

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