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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)