Download Szkeletális horgonylatok alkalmazása az állcsont

Szkeletális horgonylatok
szerepe az
állcsontorthopédiában
Dr. Nemes Bálint
Semmelweis Egyetem Gyermekfogászati és
Fogszabályozási Klinika
III. osztály
Le Fort I advancement
Konzervatív kezelés
Graber, Contemporary Orthodontics 2012. Ch 14. Optimizing Orthodontic and
Dentofacial Orthopedic Treatment Timing
RME + ARCMASZK
(Rapid Maxillary Expansion)
Alt-RAMEC + ARCMASZK
(Alternating Rapid Maxillary
Expansion and Constriction)
Liou EJ: Effective maxillary orthopedic protraction for growing Class III patients: a clinical application simulates distraction
osteogenesis.: Prog Orthod. 2005;6(2):154-71.
Masucci C1, Franchi L, Giuntini V, Defraia E.: Short-term effects of a modified Alt-RAMEC protocol for early treatment of Class
III malocclusion: a controlled study.: Orthod Craniofac Res. 2014 Nov;17(4):259-69. doi: 10.1111/ocr.12051. Epub 2014 Jul 7.
Minilemez + arcmaszk
Baek et al., 2010. Angle Orthodontist
Alt-RAMEC + arcmaszk + minilemez
15 patients with a mean skeletal age of 11.6 ±1.59 years undergoing 8
weeks of Alt-RAMEC followed by maxillary protraction, maxilla moved
forward by 2 mm
Kaya et al., 2011. Angle Orthodontist
Hybrid-hyrax + mentoplate
Wilmes et al., 2011. JCO
Hybrid Hyrax Alt-RAMEC
Wilmes et al. 2014
Bone Anchored Maxillary
Protraction (BAMP)
According to the present results,
TAD-anchored MP might have a
greater maxillary advancement effect
and might reduce skeletal and dental
side effects, compared with
toothanchored MP.
(Feng et al. Angle Orthod.
2012;82:1107–1114.)
The overall success rate of miniplate
anchorage in terms of stability was
97%. (De Clerck and Swennen 2011.
Angle Orthodontist)
Bone Anchored Maxillary
Protraction (BAMP)
De Clerck et al., 2010. J Oral Maxillofacial Surg
Remodeling of the glenoid fossa at the anterior eminence and bone resorption at the posterior wall
De Clerck et al. 2012. AJODO
II. osztály
Bilateral Saggital Split Osteotomy
Graber, Contemporary Orthodontics 2012. Ch 14. Optimizing Orthodontic and
Dentofacial Orthopedic Treatment Timing
Mandibular changes produced by
functional appliances in Class II
malocclusion: a systematic review.
• from January 1966 to January 2005 RCT-s and CCT-s with
untreated Class II controls. 22 articles qualified for the final analysis.
Four RCTs and 18 CCTs were retrieved.
• The amount of supplementary mandibular growth appears to be
significantly larger if the functional treatment is performed at the
pubertal peak in skeletal maturation.
• The Herbst appliance showed the highest coefficient of efficiency
(0.28 mm per month) followed by the Twin-block (0.23 mm per
month).
Cozza et al. AJODO, 2006 May;129(5):599.
Class II correction in patients treated with
Class II elastics and with fixed functional
appliances: A comparative study
In the Begg group, the maxilla moved forward 1 mm more than in the Herbst
group, and the mandible moved 1 mm more in the Herbst group than in the
Begg group. The skeletal improvement in the Herbst group exceeded the
changes in the Begg group by, on average, 2.0 mm (P < .01). The overjet
reduction in the Begg group was larger (2.1 mm; P < .01) than in the Herbst
group, mostly because of dental movements. The skeletal part of the
overjet reduction was 4% in the Begg group compared with 51% in the
Herbst group. The molar correction was similar in both groups, but in
the Begg group, the skeletal improvement was 10%, compared with
66% in the Herbst group. The overbite correction and the increase in the
anterior lower facial height and in the NSL/ML angle were larger in the Begg
group (P < .05). The conclusions of this study were that the changes
contributing to the Class II corrections in Begg and Herbst therapy were
skeletal and dental. The skeletal changes were, however, larger in the
Herbsttreated group. On the other hand, favorable and unfavorable
vertical changes were more pronounced in the group treated with
Class II elastics.
Nelson et al. Am J Orthod Dentofacial Orthop 2000;118:142-9
Correction of Class II malocclusion with
Class II elastics: a systematic review.
• Although Class II elastics have been widely used in the correction of
Class II malocclusions, there is still a belief that their side effects
override the intended objectives. The aim of this systematic review
was to evaluate the true effects of Class II elastics in Class II
malocclusion treatment.
Based on the current literature, we can state that Class II
elastics are effective in correcting Class II malocclusions, and
their effects are primarily dentoalveolar. Therefore, they are
similar to the effects of fixed functional appliances in the long term,
placing these 2 methods close to each other when evaluating
treatment effectiveness. Little attention has been given to the effects
of Class II elastics on the soft tissues in Class II malocclusion
treatment.
Janson et al. Am J Orthod Dentofacial Orthop. 2013
Mar;143(3):383-92.
Jumping the bite
Dentális:
Fölső fogak disztalizálása
Alsó fogak mezializálása
Szkeletális:
Kondiláris növekedés
Mandibula hossznövekedés
Mandibula autorotáció?
Intermaxilláris gumihúzás
Fölső front
Disztalizácó
Extrúzió
Alsó moláris:
Mezializáció
Extrúzió
Mandibula disztorotáció
Herbst zsanér
Alsó front:
Proklináció
Fölső moláris:
Disztalizáció
Intrúzió
Mandibula autorotáció
Skeletal and dental changes in Class II division 1
malocclusions treated with splint-type Herbst
appliances. A systematic review
• Flores et al.Angle Orthod. 2007 Mar;77(2):376-81.
• Three articles were finally selected and analyzed. An individual
analysis of these articles was made and some methodological flaws
were identified. The selected studies all showed statistically
significant changes in the anteroposterior length of the
mandible, vertical height of the ramus, lower facial height,
mandibular incisor proclination, mesial movement of the lower
molars, and distal movement of the upper molars.
Posttreatment relapse in overjet and molar relationship was
also observed.
• CONCLUSIONS:
• Dental changes are as important as skeletal changes to attaining the
final occlusal results. Long-term, prospective, double-blinded,
randomized clinical trials are needed to support these conclusions.
Herbst zsanér
Alsó front:
Proklináció
Fölső moláris:
Disztalizáció
Intrúzió
Mandibula autorotáció
In all subjects (n=98), Herbst
treatment resulted in varying
degrees of lower-incisor
proclination (mean = 8.9
degrees, range = 0.5 degrees to
19.5 degrees).
Ruf et al.AJODO 1998
Jul;114(1):100-6.
The Miniscrew-Anchored Herbst
Luzi et al. JCO, 2012
Miniscrew anchored Herbst
The mean increase in lower incisor inclination at the end of treatment was 1°
(range 0° to 2°) for the EG and 7° (range 4° to 10°) for the CG. n=10
Luzi et al 2103.
The Miniscrew anchored Herbst
This study showed that the Herbst appliance associated to miniscrews
allowed a better control of the incisor flaring with a greater
mandibular skeletal effect. n=28
Manni et al. 2014.
Miniplate anchored Forsus
Although both appliances were successful in correcting the skeletal Class II
malocclusion, the skeletally anchored Forsus FRD EZ appliance did so
without protruding the mandibular incisors. n=32
Celikoglu et al. Angle Orthodontist, Vol 86, No 2, 2016
I. Osztály nyitott
harapás
Le Fort I Impakció
Steinhäuser et al. 2008. J Orofac Orthoped
Graber, Contemporary Orthodontics 2012. Ch 14. Optimizing Orthodontic and
Dentofacial Orthopedic Treatment Timing
Gurton et al. 2004
Rapid Molar Intruder Appliance
Cinsar et al. 2007.
Sherwood et al. 2002. AJODO
Kuroda et al. 2004.
Edgewise vs Molar intrusion
From the cephalometric values in the nonIA group, open-bite patients were generally
treated by extrusion of the maxillary and
mandibular incisors that resulted in
clockwise rotation of the mandibular plane
angle. In the IA group, intrusion of the
maxillary and mandibular molars that
resulted in counterclockwise rotation was
noted (n=30 with 2 years followup)
Deguchi et al. 2011. AJODO
Xun et al. 2007 Angle Orthodontist
Foot et al. 2014. Progress in Orthodontics
Stabil?
Deguchi et al. 2011. AJODO: 2 éves utánkövetéssel (n=15)
Scheffler et al. 2014. AJODO: 2 éves utánkövetéssel (n=33)
Dalci et al. 2015. EOS Venice, OP44: 3.6 év utánkövetéssel (n=30)
Intrusion of the maxillary posterior teeth can give satisfactory correction of moderately severe anterior
open bites, but 0.5 to 1.5 mm of reeruption of these teeth is likely to occur. Controlling the vertical
position of the mandibular molars so that they do not erupt as the maxillary teeth are intruded is important in
obtaining a decrease in face height. Scheffler et al. 2014, AJODO
Transverzális
eltérések
SARME – palat. szutura
elcsontosodása után
• Altatásos műtét
• Mellékhatások (műtéti, dentális
Hyrax-nál)
• Bölcsességfogak eltávolítása 6
hónappal a műtét előtt
• Időigényes (szájsebészekkel való
egyeztetés, 2-4 nap bentfekvés)
• Disztraktor esetén 2 műtét
• Költségek
Fog elhorgonyzású RME
időzítése
Graber, Contemporary Orthodontics 2012. Ch 14. Optimizing Orthodontic and
Dentofacial Orthopedic Treatment Timing
Hybrid-Hyrax mit várunk tőle?
- Kombinált csont- és fogelhorgonyzás
- Fogváltás közben is alkalmazható
- Az erők közvetlenül hatnak a palatinális
csontra
- Nagyobb szkeletális hatás, mert az
erőhatás közelebb esik a maxilla
rezisztenciaközpontjához
- Kevesebb olyan mellékhatás, mint a
fenesztráció és a bukkális dőlés
- Irodalom: hatékony expanziós módszer
Hyrax vs Hybrid hyrax
20 growing girls (ages, 12 6 0.6 years)
There were significant increases in facial and maxillary widths for the BBME
group and in nasal width for the TBME group. Both expanders produced basal
bone expansion at the level of the hard palate. The TBMEs produced more
dental expansion, buccal rolling, and a greater increase in nasal width than did
the BBMEs.
Hyrax vs Hybrid hyrax
14.3 ±2.3 years
13.8 ± 2.2 years
1. Both tooth-borne and tooth-bone-borne RME are effective methods for the treatment of maxillary constriction.
2. The hyrax and the hybrid hyrax expanders resulted in similar skeletal effects.
3. The hyrax appliance resulted in greater expansion in the premolar region than did the hybrid hyrax.
4. Both appliances reduced the buccal bone thickness and increased the palatal bone thickness in the molar area.
5. Buccal bone thickness decreased in the premolar area in the purely tooth-borne group, whereas the buccal bone
thickness in the hybrid hyrax group was maintained.
Toklu et al. 2015. AJODO
MICRO 4, MICRO 6
Winsauer et al. 2013. JCO (n=31)