Section of Orthodontics

A A R H U S U N I V E R S I T E T

Paolo M. Cattaneo

Department of Dentistry, HEALTH

Aarhus University - Denmark

Akila Aiyar

Aarhus

Denmark

• Postgraduate residents: 16

• Education duration: 3 years full-time

• Clinical Instructors: 8 (+2)

• Scientific staff: 5

Facilities:

• 16 dental chairs (+6 in specialized clinic)

• CBCT-scanner

• Digital models & Intra-oral scanner

• 3D camera

• 3D Virtual surgery

Postgraduate program in ORTHODONTICS

Head of Section & Course Director: Marie Cornelis

Lene & Morten Susanna & Anne

Vibeke & Bo Thomas & Annelise

Lill & Tine

5 days of clinic per week – clinical instructors

Marie

ResearchResearch Coordinator: Paolo M. Cattaneo

Scientific Staff:

• Marie Cornelis – Associate Professor

• Michel Dalstra – Associate Professor

• Peter Stoustrup – Assistant Professor

• Thomas Klit Pedersen – Professor MSO

• Paolo M. Cattaneo – Associate Professor

• Intensive theoretical and clinical insight in orthodontics

• Academic-based teaching

• Targets both dentists and orthodontists

• Speakers: international speakers & former Aarhus residents

• 3 months (September to November), 8h/day

• First part of the program for the postgraduate residents

International Short-Term courseCourse Director: Susanna Botticelli

The residents’ routine at the Orthodontic Section

// 8:00-9:00 // Seminar //

Every day one of us presents a seminar on a selected topic

// 9:00-14:00 // Work in the clinic //

Each resident has his/her own chair and starts at least 50 patients

// 14:00-16:00 // After clinic //

Treatment planning with clinical instructors and research meetings

//16:00-? // Work in the office // Research //

….

Class III malocclusions

• Patient treated at Aarhus Dental Institute

and Aarhus university hospital.

• Age at start of treatment 18 years.

• Treatment planning: plaster surgery

• Supervisor: Annelise Küseler

Akila Aiyar ; Aarhus University

,Denmark9

Case Summary

AGE 18 years and 7 months

DENTAL STAGE DS4 M2

DESCRIPTION OF MALOCCLUSION Skeletal open bite, Angle Class I, peg shaped 12 and 22

TREATMENT APPROACH Full fixed appliance, segmented approach, Le fort 1 3

piece and autorotation of mandible, interdisciplinary

case

TREATMENT STARTED 20.02.2014

TREATMENT COMPLETED 06.04.2016

TREATMENT TIME 2 years and 2 months (26 months)

RETENTION PROTOCOL Fixed retainers and Essix full time in upper arch

Anamnesis

CHIEF COMPLAINT Patient is unhappy with his appearance – has difficulty in

breathing , mastication and speech.(Lisping)

GENERAL HEALTH (ALLERGY) Autistic and diagnosed for hay fever.

RESPIRATORY DISORDER Occasional snoring and mouth breather

TONSILS/ADENOIDS Nothing to report

TRAUMA Nothing reported.

SYMPTOMS OF TMD No

PARAFUNCTION No

EARLIER ORTHODONTIC TX Was offered OR treatment in community system, a removable

plate to correct inverted upper incisor.

FAMILY‘S ORTHO HISTORY Both parents have no history of orthodontic treatment.

GROWTH/MATURATION

(menarche)

Patient is adult and growth is considered completed

ATTITUDE TOWARDS TREATMENT Very positive

AnamnesisREFERRAL The patient is referred by Aarhus Kommunale tandpleje

CHIEF COMPLAINT Patient is unhappy with his appearance – has difficulty in breathing ,

mastication and speech.(Lisping)

GENERAL HEALTH (ALLERGY) Autistic and diagnosed for hay fever.

RESPIRATORY DISORDER Occasional snoring and mouth breather

TONSILS/ADENOIDS Nothing to report

TRAUMA Nothing reported.

SYMPTOMS OF TMD No

PARAFUNCTION No

EARLIER ORTHODONTIC TX Was offered OR treatment in community system, a removable plate

to correct inverted upper incisor.

FAMILY‘S ORTHO HISTORY Both parents have no history of orthodontic treatment.

GROWTH/MATURATION (menarche) Patient is adult and growth is considered completed

ATTITUDE TOWARDS TREATMENT Very positive

Initial photos - extraoral

Clinical examination – extraoral

En Face

Face is asymmetric due to an asymmetric mandibular projection.

Lower face canting.

Eyes are at the same level (bipupilar line is parallel to the

floor)(caution – picture rotated slightly on z axis)

Nose is slightly off to the left and everted

Chin is deviated to the right

Ramus on the right side seems shorter than the left side (caution –

picture rotated slightly on z axis)

Proportions in the transversal are slightly larger on the right side

compared to the left (caution - skew picture)

Upper midline to facial midline On

Radiographic examination -

NEWTOM

Minor asymmetry:left gonion is slightly higher positioned than right

and left ramus slightly shorter.Chin is centered.

39%

61% 28%

72%

Clinical examination – extraoralProfile

Facial profile is slightly convex due to more posterior

positioned nasion.(mesocephalic)

Lower anterior facial height is increased

(LAFH= 61% TAFH)(55% ± 2% Eastman normal value, Mills;1982)

Nasolabial angle is increased (132º)(Caucasian norm:114° ± 10°, Fitzgerald et al., 1992)

Sulcus mento-labialis is shallow(flattened)

Chin- and mandibular projection is reduced.

Initial photos -

intraoral

Occlusion

OCCLUSION Angle Class I with subdivision

SAGITTAL()=from lingual

Anterior Overjet: 2 mm

Molars Right 1/4D (1 N) Left 1/4M (N)

Canines - -

VERTICAL Anterior Overbite: 5,5 mm

Posterior Open bite from 5+ til +5

TRANSVERSAL Anterior Upper midline to facial midlineLower midline to facial midline

On½mm to right

Posterior Edge to edge at molars

Lingual view

Lingual

view

Radiographic examination - Intraoral

ROOT LENGTH normal

ROOT MORPHOLOGY Roots appear more curved. Distal bending of 21,23

Radiographic examination - OPG

TEETH PRESENT All teeth except third molars

CARIES -

BONE LEVEL, APICAL SITES Normal bone level, Dense bone islands(enostosis)

ABNORMALITIES IN BONE Right sinus seems to be filled with polyps (retention psuedocyst) (signs of sinusitis)

CONDYLES Condyles appear well defined in this radiographic projection

Radiographic examination TMJ

Pretreatment

Condyles seem normal in length and with a normal morphology. Well seated in

the fossa on the right side and left side. Both joints have well-defined cortical

bone of both condyles and articular fossa.

LR

Initial cephalometric analysis

Decreased sagittal jaw relation with reduced maxillary prognathism.

Increased vertical jaw relations due to increased mandibular inclination.

Decreased Wits.

Akila Aiyar ; Aarhus University

,Denmark22

Skeletal Class I with

Skeletal open bite

Problem List

SUBJECTIVE Patient is unhappy with his appearance – feels that his face is asymmetric with open bite and has

problem with chewing and breathing.

OBJECTIVE Angle Class I, subdivision, Skeletal open bite, peg shaped 12 and 22

APPEARANCE Straight facial profile(slightly convex), Anterior open bite, dark buccal corridors

FUNCTION Tongue thrust , oral breathing, lisping

ORAL HEALTH -

DENTITION Peg shaped 12 and 22

Some rotations and tippings

Severe crowding in upper (-8 mm) and lower (-5 mm) arches

Increased anterior ratio(86,3%)

OCCLUSION Angle class I, subdivision. occlusal plane tilting downwards

VOB: -5,5 mm, HOB: - 2 mm

OTHER Autistic and Hay fever

Treatment options

Surgical Advantage Disadvantage

Non Surgical

Transverse expansion

Intrusion of upper and lower

molars with miniscrews

No need for orthognatic surgery

Extractions could ease the closure of open

bite(extrusion of anterior teeth)

Less risk of morbidity.

-Camouflage treatment

-Uncertain treatment result

-Doubtful if bite can be closed sufficiently as

openbite is 5,5mm

Surgical: Single procedure

LeFort I, 3 piece osteotomy with

impaction posteriorly, lowering

anteriorly, advancement in total

and autorotation of the mandible)

-Eliminates openbite

-Control of upper and lower front

inclinations

-Optimal aesthetic outcome

Risk of morbidity with surgery

Surgical: Double procedure

LeFort I, 3 piece osteotomy with

impaction posteriorly, lowering

anteriorly, advancement in total

with BSSO in mandible

Eliminates open bite

Less movement in one jaw

Improves profile and airways

Risk of morbidity with surgery and more

invasive compared to one jaw surgery

Treatment principles

TOOTH MOVEMENT Full fixed appliance

SURGERY/EXTRACTION Le Fort I (3-pieces) and auto rotation of mandible

FUNCTIONAL ADAPTATION/GROWTH EFFECT

-

PROSTHODONTIC Build up 12 and 22, after treatment evaluate need for implants.

Treatment phasesPHASE GOALS MECHANICS

I Level and align in three segment,

prepare for orthognathic surgery.

Obtain space between roots 3,2+

and +2,3

Br. 5,4,3,2,1+1,2,3,4,5. Tubes 7+7.

Three segments with braided wires.

V bends at 3,2+2,3.

End in rectangular 0,018”x 0,025” SS wires.

Optimize anchorage with TPA.

II Levelling of lower arch Work up to 0.019x0.025 SS wires

III Decrease vertical relation.

Obtain consonant smile arch.

Surgery: Correct in both vertical,

transversal, and sagittal planes of

space

3-piece maxilla with osteotomies distal of 12, 22.

Individual movements for the three segments

and further autorotation of the mandible

IV Arch coordination

Post surgical finishing

Decrease wire size. Individual bends and leveling

of occlusal planes. Intra-maxillary elastics

Date: 05.12.14

Months in TX: 10

Date: 10.04.15

Months in TX: 14

Surgical plan

Date: 23.05.13

Months in TX: 15

Le fort 1 with 3 piece between

3,2+2,3

Anterior segment advanced,extruded

Posterior segment impacted and

expanded

Advancement in total.

Anterior rotation of mandible

Auto-rotation

4 mm 3,5 mm

Before

After

Presurgical registrations

Date: 24.04.15

Months in TX: 15

Presurgical registrations

Date: 24.04.15

Months in TX: 15

Date: 19.06.15

Months in TX: 17

With surgical wafer( 2 weeks

post surgical)

Date: 04.09.15

Months in TX: 20

Date: 26.02.16

Months in TX: 25

Final photos

Date: 05.04.16

Months in TX: 28

After build ups of 12,22

Date: 27.05.16

Months in TX: 27

Initial vs. Final: Extraoral

Initial vs. Final: Extraoral

Initial vs. Final: Intraoral

Final radiographic examination

Intraoral

Minor root blunting - mild (grade 0) according to classification (0-4) (Levander and Malmgreen, 1988)

Before

Final radiographic examination - OPG

Acceptable root parallelism and interradicular spacing.

Enostosis still visible and right sinus cleared with few persistent polyps.

Final radiographic examination

Lateral cephalogram

Sagittal and vertical jaw relations improved.

Wits improved.

Upper and lower incisor inclinations improved.

A B C M sd A B C M sd

Den

toalv

eo

lar

OK alv. prognathism Pr-N-Ss Max. incisor to upper lip (vertical) 8.7 12.9 +++/+

++

2 2

2.3 2.3 2 1 Mand. incisor to A-Pg 0.9 2.3 1 2

UK alv. prognathism CL/ML Nasolabial angle 132.2 109.4 +++/ 102 8

56.8 57,6 --/-- 70 6 Wits appraisal (♂/♀) -6.0 -1.6 ---/ -1/0 1.9/1.8

OK inc. inclination Ils/NL

100.5 110.6 -/ 110 6 Lower lip to E-plane -2.8 1.8 /+ -2 2

UK inc. inclination Ili/ML Facial contour angle (facial convexity) 20.9 19.9 ++/+ 12 4

77.7 92.1 --/ 94 7 G-Sn/Sn-Me (Lower face height) 0.4 0.5 1:1

A B C M sd A B C M Sd

Sk

ele

tal

Sag. jaw relation Ss-N-Pg Max. prognathism S-N-Ss Basis Cranii N-S-Ar

-0.1 2.3 2 2.5 78.3 84.5 -/ 82 3,5 125.7 123.3 124 5,0

Sag. jaw relation Ss-N-Sm Mand. prognathism S-N-Pg Basis Cranii N-S-Ba

1.1 4.4 3 2.5 78.4 82.2 80 3,5 140.6 133.8 +++/ 131 4,5

Den

to-

alv

ela

r OK-zone NL/Ols Max. inclination NSL/NL Beta angle

6.5 11.7 10 4 6.8 12.1 /+ 8 3,0 19.1 19.8 19 2,5

UK-zone Oli/ML Mand. inclination NSL/ML Jaw angle

Sk

ele

tal 17.6 16.6 20 5 44.1 38.8 +/ 33 6,0 124.5 123.3 -- 126 6,0

Vert. jaw relation NL/ML

37.3 26.7 ++/ 25 6

Horizontal Overjet Vertical Overbite

0.2/2.5 -6,1/0.9

NEWTOM – Post treatmentBefore

Before

Treatment evaluation

ROOT RESORPTION

Minor root bluntings (> 2 mm) are present in the upper front.

RETENTION Fixed retainer 43 to 33 and 12 to 22.

Removable Essix retainer worn full-time

PROGNOSIS If the prescribed retention protocol is followed the prognosis is good, but it must be clear for the patient that retention is needed life-long

ADDITIONAL

COMMENTS

See next slide

Additional comments to the

treatmentSubjective: The patient is satisfied with the treatment outcome - both the functional and the

esthetical improvements are appreciated.

Objective:

The open bite was resolved and thereby improving the function and speech.

12,22 was not affected during surgery, hence good prognosis with prosthetic restorations.

The restorations could be better. Inclination of canine on left side could be improved.

The patient was diagnosed for autism. It was stated that he has remarkably improved his self

esteem.

After a month of retention the occlusion seems stable and there is improved settling

observed in the both sides.

Post treatment models

AU Aarhus University

Section of Orthodontics

odont.au.dk/postgraduate

AARHUS INTERNATIONAL

SHORT-TERM COURSE

IN ORTHODONTICS

AARHUS UNIVERSITY

POSTGRADUATE PROGRAM

IN ORTHODONTICS