J. Sugawara (Final) のコピー - AAO...Point-Counterpoint: Surgery-First Orthodontics Point - The...
Transcript of J. Sugawara (Final) のコピー - AAO...Point-Counterpoint: Surgery-First Orthodontics Point - The...
Point-Counterpoint: Surgery-First Orthodontics
Point - The Case for Surgery-First Orthodontics
Junji SUGAWARASendai, Japan
2014 Winter ConferenceFebruary 7-9, 2014 Las Vegas, Nevada
~1950 1960 1970 1980 2000 20101990
Surgery- First
Orthodontics
Prosthodontics
Dental / OralImplantology
TADs (SAS)
Surgical Orthodontics
Minimum Pre-Surgical Orthodontics
OrthognathicSurgery
Oral Maxillofac / Plastic Surgery
NoPre-surgicalOrthodontics
NoPre-surgicalOrthodontics
Pre-surgicalOrthodontics
Sugawara 2014
How We Got Here
Why Surgery-First?Conventional
Surgical Orthodontics
Initial Imm. before OGSPresurgical Orthodontic Treatment
At debondingOrthognathic
Surgery(LF1 + BSSO)
•The worsening facial profile, some masticatory discomfort during presurgical orthodontics, and long-term low QOL were cited as problems. (Proffit, White, Sarver 2003)
•Presurgical orthodontic treatment was time-consuming, taking as long as 24 months. (Luther, Morris, Hart 2003)
•Overall treatment duration was longer than commonly expected, with a mean length of 32.8 months. (O’Brien et al. 2009)
What are the Problems?
Imm. after surgery At debondingInitial
PostsurgicalOrthodontics
(SAS)
OrthognathicSurgery(BSSO)
Surgery-First
Styles of Surgery-First
Surgery-DrivenTo solve both skeletal and
dental problems using OGS (Baek et al. 2010, Liou et al. 2011,
Hernández et al. 2011, Kim et al. 2012)
Ortho-DrivenTo solve skeletal problems
with OGS and dental problems using SAS
(Nagasaka et al. 2009, Villegas et al. 2010, Faber 2010, Sugawara et al. 2010)Surgery-
First
Facial Types of Our Surgery-First Cases (N=162)
87%
5%8%
Class III (141)Class II (13)Class I (8)
As of December 31, 2013
Class III patients seem to benefit more from the
Surgery-First than Class II cases.
(Kim, Mahdavie, Evans 2012)
A Recent Surgery-First Case Ortho-Driven
Indications of Surgery-First: Most jaw deformities are indications except for a few specific types of cases.
(Sugawara 2012)
Point 1: Case SelectionSurgery-Driven
Indications of Surgery-First:1) Crowding: no~mild2) Curve of Spee: no~mild3) U1 and L1: normal~mild4) Asymmetry: no~mild
(Liou et al. 2011)
YI 20-04 Initial (Sep 30, 2011)
Ceph Analysis
1. CDS Analysis2. Wits Appraisal (-24.0 mm)Patient
Norm
10 mm
Ceph Prediction
5 mm
InitialImm. after OGS
Mx advance: 5 mmMn setback: 10mm
PatientNorm
A InitialAt debondingC
Ceph Prediction
4
7
52
Imm. after OGSAt debondingB
Point 2: Ceph Prediction
There is absolutely no difference in the way to make cephalometric
predictions between the conventional approach and the Surgery-First. Only the order of
the procedures is different.
Model Prediction for OGS
Class II denture with open bite reveals the true extent of decompensation.
(No overcorrection)
10.5 mm
5 mm
Point 3: Model PredictionSurgery-Driven
Occlusion after OGS should be setup for “a treatable
Class I malocclusion” with tripod occlusal contact.
(Liou et al. 2011)
Ortho-DrivenOcclusion after OGS should be setup to reveal the true extent of decompensation based on ceph prediction.
(Nagasaka et al. 2009)
Bonding Brackets(.022” slots)
Passive Surgical Wires
(.016”x.022” SS)
The passive surgical wires were prepared by a dental technician in a laboratory.
OGS and SAS
SAS miniplates
LF1BSSOLF1 + BSSO
11 days after OGS (Aug 27, 2012)
Ortho-DrivenThe use of the skeletal
anchorage system using miniplates or miniscrews is indispensable in the post-
surgical orthodontics of SF.(Nagasaka et al. 2009, )
Point 4: TADsSurgery-DrivenSince skeletal and dental
problems are solved surgically, the application of
TADs is not necessarily required.
11 days after OGS (Aug 27, 2012)
Immediately after OGS Treatment Progress (1)
0.9 months after OGS (Sep 12, 2012)
3.1 months after OGS (Nov 16, 2012)
Treatment Progress (2)
3.8 months after OGS (Dec 07, 2012)
5.2 months after OGS (Jan 17, 2013)
Treatment Progress (3)
8.3 months after OGS (Apr 19, 2013)
9.4 months after OGS (Jun 11, 2013)
YI 22-02 At debonding (Jul 11, 2013)
Ceph Superimposition
InitialAt debonding
Facial Changes
At debondingInitial Imm. after surgery Treatment Goal
Evaluation of End Result
End result
Ceph Analysis
1. CDS Analysis2. Wits Appraisal (-2.5 mm)
PatientNorm
At debonding
Comparison Pre and Post
AfterBefore
Total Treatment Time: 12.0 months
Benefits and Problems
Benefit 1The timing of OGS is entirely up to
the patient.Since the OGS precedes orthodontic
treatment, the patient has the opportunity to choose the timing of surgery to allow
for the postoperative healing period.(Kim, Mahdavie, Evans 2012)
Facial deformity is immediately corrected.
In Surgery-First, patients can avoid the exacerbation of their profiles and
occlusions.
Benefit 2Decompensation can be performed
effectively and efficiently.(Nagasaka et al. 2009)
Benefit 3
Increased tone of the upper lip to maxillary incisorsIncreased tone of the tongue to mandibular incisors
The total treatment time is much shorter than in the conventional approach.
Benefit 4
0
5
10
15
20
25
~9 9~12 12~15 15~18 18~21 21~24 24~27 27~30 30~33 33~36 36~39 39~42 42~45 45~
Total Treatment TimeSF
12.7 mos(7.5~24.9)
N=53
COF33.7 mos
(19.2~51.5)N=47
months
Num
ber
of P
atie
nts
p<0.001
Sugawara et al. (in press)
Imm. after surgery At debonding
Short Group (8.7 mos)
Initial
Imm. after surgery At debondingInitial
Long Group (18.7 mos)
Tooth movement may be accelerated after OGS.
Benefit 5
“OGS triggers a 3- to 4-month period of higher osteoclastic activities and
metabolic changes in the dentoalveolus postoperatively.” (Liou et al. 2011)
Benefit 6In Ortho-Driven style, the range of indications for one-jaw surgery is
significantly expanded.
Imm. after surgery At debonding
One-Jaw Surgery (BSSO)
Initial
Benefit 7In the Surgery-First approach, the unlikely event of a surgical error
and a possible post-surgical relapse can be compensated during
the post-surgical orthodontics.
Initial Imm. after surgery
After removal of splint At debonding
Recover from Surgical Error
The ProblemWithout pre-surgical orthodontics,
it is difficult to obtain a stable occlusion immediately after OGS.
Surgical Splint
Benefits
ProblemsBenefits
Problems
Conclusion
Although there are two different styles of the Surgery-First approach. Clearly, the benefits of both styles
substantially outweigh the problems associated with them. It must be noted that orthodontists and
surgeons must be experienced to predictably achieve the desired outcome.
Tohoku Univ. Prof. H. Kawamura Prof. H. Nagasaka Prof. S. Goto Prof. T. Takahashi
UCONN Prof. R. Nanda Prof. F. Uribe
SAS Centre Dr. H. Momono Dr. S. Yamada