rst approach Junji Sugawara - Digital Aligner Orthodontics · 2019. 2. 18. · skeletal anchorage s \stem (SAS) was reported E\ our team1. ... treatment of a skeletal Class III patient

$Page 1: rst approach Junji Sugawara - Digital Aligner Orthodontics · 2019. 2. 18. · skeletal anchorage s \stem (SAS) was reported E\ our team1. ... treatment of a skeletal Class III patient$
283Journal of Aligner Orthodontics 2018;2(4):283–294

CASE REPORT

Junji Sugawara, Kenji Ojima, Chisato Dan, Hiroshi Nagasaka

Application of aligners for detailing and nishing iomechanics in surger rst

approach Junji Sugawara

Junji Sugawara, DDS, DDSc Director, Department of D , Sendai Ao a Clinic, Sendai, Japan; and Visiting Clinical Professor, Division of Orthodontics, Department of Craniofacial Science, School of Dental edicine, niversit of Connecticut, Farmington, CT, USA

Kenji Ojima, DDS Director, Hongo Sakura Orthodontic Clinic, Tok o, Japan

Chisato Dan, DDS Associate Director, Hongo Sakura Orthodontic Clinic, Tok o, Japan

Hiroshi Nagasaka, DDS, DDSc Director, Department of Oral a illofacial Surger , Sendai Ao a Clinic, Sendai, Japan

Correspondence to: Dr Junji Sugawara, 1 31 F Hasekura machi, Ao a ku, Sendai 980-0824, Japan

- ail: j sugawara sendai-ao a com

Key words

Introduction

Surger rst (SF) is an innovative surgical orthodontic ap-proach for the correction of skeletal deformities. In this approach, no presurgical orthodontic treatment is carried out at all, and orthognathic surger (O S) is the rst step in the correction of skeletal disharmonies. Thanks to O S, the ma illomandi ular relationship is corrected into skeletal Class I with a s mmetrical face in the earl stage of the treatment period. Once the O S is completed, post-surgical orthodontics is required to correct the transitional skeletal Class I malocclusions with the comple dental pro lems these patients t picall displa .

In 2009, the rst ever SF case in com ination with the skeletal anchorage s stem (SAS) was reported our team1. In the 9 ears that have followed, there have een man other reports focused on a SF approach2-8. Some of these have een papers pu lished the present authors, some have een a out our method, and others have een on a di erent method with a similar-sounding name.

The following are the major advantages of SF compared to a conventional approach:• the facial pro le is improved in the earl da s after O S;• the total treatment time is signi cantl shorter;• orthodontic decompensation is e cient and e ective

ecause of the iological e ects derived from the natu-ral force provided lips and tongue;

Journal of Aligner Orthodontics 2018;2(4):283–294284

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• tooth movement appears to e accelerated the re-gional accelerator phenomena ( AP).

ecentl , we egan to provide a new option in SF to support those patients who voice their preference for aligners over

ed appliances in the post-surgical orthodontic treatment stage. At the present time, our advice to these patients has

een to reduce the ed appliance treatment and then switch to aligners for detailing and nishing.

This article illustrates a new treatment option in the treatment of a skeletal Class III patient who rst underwent O S, and then spent a short period of time undergoing postoperative ed appliance treatment with SAS efore switching to aligner treatment in com ination with micro- vi ration.

Diagnosis and treatment plan

A 24- ear-old male patient presented with the chief com-plaint of dissatisfaction with his facial appearance, and de-sired no presurgical orthodontics, short treatment time and treatment with invisi le orthodontic appliances. Initial e amination revealed mandi ular e cess, short lower facial height, Class III denture, proclination of ma illar incisors, retroclination of mandi ular incisors, deviation of mandi -ular midline and di cult in incising (Figs 1 and 2).

According to these orthodontic pro lems, and particu-larl the mandi ular e cess, mandi ular set ack osteotom was clearl indicated. Since the patient s ma illar incisor displa and interla ial gap were in the normal range, two-jaw surger was not indicated.

Two-dimensional (2D) paper surger and three-dimen-sional (3D) image predictions were used to esta lish the treatment goals (Fig 3). The 2D and 3D predictions indicated the need for a out 10 mm of mandi ular set ack. Su se-quent to mandi ular set ack ilateral sagittal split ramus osteotom ( SSO), his occlusion was predicted to change from Cass III to Class II with severe open ite (Fig 3a and ). Since no presurgical orthodontic treatment is carried out at all in the SF approach adopted in our clinic, a large overjet immediatel after O S reveals the true e tent of incisor decompensation. In the post-surgical orthodontic treat-ment stage, it was planned to retrocline the ma illar inci-

sors a out mm after the distalisation of the ma illar posterior teeth using SAS without premolar extraction. At the same time, the decompensation of the mandi ular in-cisors was planned the mesialisation of the entire man-di ular dentition using orthodontic miniplates, which were to e installed etween the second premolars and rst mo-lars at the mandi ular od .

Although the patient expressed his wish to undergo post-surgical orthodontic treatment with aligners through-out the whole treatment period, short-term treatment with

xed appliances in com ination with SAS was recommended to manage rapid occlusal changes and unsta le occlusion.

Treatment progress

Orthognathic surgeryA out months prior to O S, all of the third molars (teeth 18, 28 and 48) were extracted. Cast surger was set up ac-cording to the treatment goals, and a speci c surgical splint with a lingual ar and four all end clasps for the mandi -ular rst molars was fa ricated (Fig 4a). Since presurgical orthodontic treatment was eliminated in SF, the occlusion immediatel after O S is unsta le. Therefore, a surgical splint is essential to sta ilise the one segments and the temporomandi ular joint (T J). A surgical splint for SF is designed to cover onl the occlusal surface of the imaxil-lar lateral teeth to avoid pro lems with reathing and drinking. Shortl efore O S, eight hooks were onded at all canines and the rst premolars for the placement of the training elastics postoperativel . No racket was onded

efore O S (Fig 4 ). The modi ed SSO9 was then carried out to achieve the

required mandi ular set ack. T-shaped titanium one plates were used for rigid internal xation, and four ortho-dontic miniplates were put in place at the gomatic ut-tress and the mandi ular od ilaterall at the same time (Fig 4 ). In addition, four miniscrews were installed at the

imaxillar anterior alveolar regions to avoid unwanted ex-trusion of incisors. A surgical splint was placed for sta ilisa-tion of one segments and the T J. One da following O S, up and down training elastics were placed at the canines and rst premolars ilaterall (Fig 4 ).

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ig a to i Initial facial and oral photo-graphs, and a panoramic radiograph. A 24- ear-old male patient with mandi ular excess, whose main pro lems were Class III jaw relationship, edge-to-edge ite, and mandi ular dental midline shift efore treatment.

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ig 2a to c a and ) Initial cephalometric radiographs. c) Cephalometric template anal sis comparing craniofacial morpholog of patient with norms for Japanese male adults. The line drawings in lack indicate the patient, and the lines in green indicate the Japanese norm. The patient s skeletal facial t pe was Class III-short face, ut his interla i-al gap and maxillar incisor displa were in the normal range.

ig 3a and b a) Cephalometric prediction of treatment results immediatel after orthognathic surger and after orthodontic treatment with target dentofacial positions shown in red. ) 3D image prediction compared with efore and immediatel after orthognathic surger . Su sequent to 10-mm set ack of the mandi le ilateral sagittal split ramus osteotom ( SSO), his occlusion changed from Class III to Class II - open ite.

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ig 4a to i a to c) Cast surger and surgical splint for mandi ular dentition showing 10-mm mandi ular set ack. d to i) Patient at da s after surger , showing Class II denture with open ite and proper mandi ular position maintained with surgical splint. Four orthodontic miniplates were placed during the operation. A multi racket s stem was not applied during surger , ut eight hooks for training elastics were onded at canines and rst premolars, and four miniscrews were installed at anterior alveolar regions in case hooks dropped o .

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ig 5a to Treatment progress of skeletal anchorage s stem. a to c) da s after orthognathic surger (O S). rackets were onded in the maxillar dentition. evelling and distalisation of the maxillar posterior teeth started with SAS. d to f) 1. months after O S. Distalisation of the maxillar posterior teeth continued. g to i) 2. months after O S. rackets were onded in the mandi ular dentition. The occlusal splint had alread een discontinued. Distalisation of the maxillar molars continued and cross elastics were put in place at the canines and rst premolars. j to l) 3.3 months after O S. Distalisation of the maxillar right molars and the application of cross elastics continued.

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Post-surgical orthodontics with SASFive da s after O S, rackets were onded in the maxillar dentition, and levelling was started using 0.01 0.022 CuNiTi wire in com ination with the occlusal splint and training elastics (Fig 5a to c). At the same time, the distali-sation of the maxillar molars was started along the occlu-sal plane. The occlusal splint was arranged attening the occlusal surface of the surgical splint in order to facilitate

the movement of the maxillar posterior teeth. The distali-sation of the maxillar molars utili ing SAS continued until the rackets were de onded (Fig 5a to l). The splint was discontinued 2.5 months after O S and rackets were placed in the mandi ular dentition, and then transverse decompensation (dental arch coordination) was started with the application of cross elastics at the canine and rst premolar regions (Fig 5g to l). Since his Class II denture with



open ite was corrected into almost Class I denture in just 3.3 months after O S (Fig 5j to l), it was decided that, al-though earlier than expected, it would soon e time to change to aligner treatment.

Post-surgical orthodontics with alignersAt 4. months after O S, all of the rackets were de onded and vacuum-formed retainers were temporaril put into place in the imaxillar dentition (Fig ). At the same time, his dentition was scanned with a digital oral scanner (iTero; Align Technolog , San Jose, CA, USA). Figure shows the

ig 6a to i Facial and oral photographs, and a panoramic radiograph at de ond-ing and efore aligner treatment (4. months after orthognathic surger ) showing straight pro le and Class I occlusion.

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ig 8a to f First aligner treatment started at 5.4 months after surger . icro-vi ration (AcceleDent) was applied and instructed to use for 20 hours per da .

initial and nal ClinCheck simulation (Align Technolog ) for aligner treatment. ith the application of aligners (Invis-align; Align Technolog ), it was aimed to carr out the de-tailing and nishing stage of post-surgical orthodontic treat-ment in SF more precisel and invisi l than is possi le when using xed appliances. Aligner treatment with mi-cro-vi ration (AcceleDent; OrthoAccel Technologies, el-laire, T , USA) was started at 5.4 months after O S (Fig 8).

In this case, a series of 2 aligners was used oth in the maxillar and the mandi ular dentition. According to the conventional protocol (2-week change regimen and wearing at least 20 hours per da ), it was expected that treatment would take 13 months, ut thanks to micro-vi ration, the actual treatment time was signi cantl reduced to a out 4 months changing aligners ever 4 da s.

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ig 7a to f ClinCheck simulation: a to c) initial, d to f) nal.

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Treatment results

At 9.4 months after O S, aligner treatment was completed and retention was started with retention aligners (Fig 9). The treatment time of aligners with micro-vi ration was just 4. months. Thanks to SF and following xed appliance io-

ig 9a to i Facial and oral photos, and a panoramic radiograph after aligner treatment (9.4 months after surger ). All

one plates and orthodontic miniplates remained at this time, ut were removed approximatel 1 ear after orthognathic surger .

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mechanics with SAS and aligner treatment, the patient s skel-etal and dental pro lems were satisfactoril corrected in a short period of time. The one plates and orthodontic anchor plates were removed approximatel 1 ear after O S.

The cephalometric radiographs taken immediatel after aligner treatment are shown in Fig 10. According to the lat-


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ig 10a to c a and ) Cephalometric radiographs after Invisalign treatment. c) ateral cephalometric superimposition efore and after treatment. The mandi le was properl displaced ackward as planned and the maxillar incisor decompensation was carried out following distalisation of the maxillar posterior teeth.

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eral cephalometric superimposition efore and after treat-ment, the mandi ular set ack was carried out as planned with SSO and the maxillar incisor decompensation was completed following distalisation of the maxillar posterior teeth with SAS. this stage, his facial appearance and occlusion had drasticall improved.

Figure 11 shows facial and oral photographs and a pan-oramic radiograph at the 2- ear follow-up. The patient maintained a good pro le and occlusion during the short-term post-treatment period.

Discussion

an jaw deformit patients desire quick improvement of their facial appearance, short treatment time and orthodon-tic treatment without non-aesthetic xed appliances. Fol-lowing the development of SF, it has ecome possi le to improve facial appearance at the rst step of the treatment period, and signi cantl reduce the total treatment time involved in surgical orthodontics in comparison with that required the conventional approach. There have een some reports on the application of aligners to presurgical and post-surgical orthodontics in conventional surgical or-thodontics10-13, ut no paper could e accessed that re-ported on the application of aligners to the SF approach.

This paper details the case of a Class III patient who underwent SF in com ination with short-term xed applian-ces and aligners for detailing and nishing. This patient was

clear in his request to have as much of his post-surgical orthodontics as possi le done with aligners, ut instead short-term therap with xed appliances in com ination with SAS was recommended to manage rapid dental and occlusal changes immediatel after O S.

The current SF approaches can e classi ed into two rather di erent st les. One is the orthodontics-driven st le, in which skeletal pro lems are solved O S, and dental pro lems are xed orthodonticall . The other is the sur-ger -driven st le, in which oth skeletal and dental pro -lems are corrected as much as possi le O S. Since our SF elongs to the former st le, in terms of Class III, a tran-sitional occlusion usuall exhi its an unsta le Class II – open

ite immediatel after O S. In addition, owing to AP e ects at that time, tooth movement is signi cantl accelerated and occlusion changes ver quickl . Therefore, in the pres-ent authors opinion, the application of xed appliances with SAS at the eginning of post-surgical orthodontic treatment is advisa le. As shown the present case stud , SAS using titanium miniplates was remarka l e ective in solving the complex orthodontic challenges presented in the transi-tional occlusion the distalisation of the maxillar mo-lars14-20 and the mesialisation of the mandi ular molars. Di cult orthodontic pro lems can e solved with SAS and

xed appliances in a short period of time, and then the switch can e made to aligner treatment.

hile aligners have een more commonl associated with the treatment of mild orthodontic pro lems such as minor anterior crowding and spaced arch, the current



ig 11a to i Facial and oral photographs, and a panoramic radiograph at 2- ear follow-up. The patient maintained good occlusion and pro les.

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aligner s stem is eing applied to cases with more complex orthodontic pro lems such as extraction cases, open ite, interdisciplinar cases and surger cases. In addition, micro- vi ration21,22 and photo iomodulation23 are eing applied to accelerate tooth movement in com ination with aligners. In the present case report, with the added ene t of mi-

cro-vi ration, the treatment time in post-surgical orthodon-tics was shortened to 4. months following a 4-da change regimen. Note that it was supposed to take 13 months ac-cording to a 2-week change regimen. Katchooi et al22 con-ducted a randomised trial stud on examining the e ect of micro-vi ration on aligner treatment and concluded that no


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signi cant e ect was found on the reduction of orthodontic pain or oral health-related qualit of life, ut made no ref-erence to the reduction in treatment time.

The present paper demonstrated a new option for jaw deformit patients to appl SF instead of conventional sur-gical orthodontics, and aligners for detailing and nishing instead of traditional xed appliances. The patient was ex-tremel pleased with the short treatment time and the cos-metic and functional outcomes, and showed a signi cant improvement in his qualit of life.

eferences1. Nagasaka H, Sugawara J, Kawamura H, Nanda . Surger First skele-

tal Class III correction using the skeletal anchorage s stem. J Clin Orth-od 2009;43:97–105.

2. aek S, Ahn H , Kwon H, Choi J . Surger rst approach in skeletal class III malocclusion treated with 2-jaw surger : evaluation of surgical movement and postoperative orthodontic treatment. J Craniofac Surg 2010;21:332–338.

3. Sugawara J, A mach , Nagasaka H, et al. Surger rst orthognathics to correct a skeletal class II malocclusion with an impinging ite. J Clin Orthod 2010;44:429–438.

4. Villegas C, Uri e F, Sugawara J, Nanda . xpedited correction of signif-icant dentofacial as mmetr using a surger rst approach. J Clin Orthod 2010;44:97–103.

5. iou J, Chen PH, ang C, et al. Surger - rst accelerated orthognath-ic surger : orthodontic guidelines and setup for model surger . J Oral

axillofac Surg 2011; 9:771–780.

. Hernande -Alfaro F, uijarro- artine , olina-Coral A, adia- s-criche C. Surger rst in imaxillar orthognathic surger . J Oral

axillofac Surg 2011; 9:e201–e207.

7. A mach , Sugawara J, Nagasaka H, Kawamura H, Nanda . Non-ex-traction Surger -First treatment of skeletal Class III patient with se-vere maxillar crowding. J Clin Orthod 2013;47:297–304.

8. Hernande -Alfaro F, uijarro- artine , Peiro- uijarro A. Surger rst in orthognathic surger : what have we learned A comprehensive

work ow ased on 45 consecutive cases. J Oral axillofac Surg 2014;72:37 -390.

9. A mach , Nei H, Kawamura H, ell . iomechanical evaluation of a T-shaped miniplate xation of a modi ed sagittal split ramus osteoto-m with uccal step, a new technique for mandi ular orthognathic surger . Oral Surg Oral ed Oral Pathol Oral adol ndod 2011;111:58– 3.

10. o d . Surgical-orthodontic treatment of two skeletal Class III pa-tients with Invsalign and xed appliances, J Clin Orthod 2005;39:245–258.

11. omach , Da . Surgical-orthodontic treatment using the Invisalign s stem. J Clin Orthod 2008;42:237–245.

12. arcu i , alassini , Procopio O, et al. Surgical-Invisalign treatment of a patient with Class III malocclusion and multiple missing teeth. J Clin Orthod 2010;44:377–384.

13. Pagani , Signorino F, Poli PP, et al. The use of Invisalign s stem in the management of the orthodontic treatment efore and after Class III surgical approach. Case ep Dent 201 ;201 :9231219.

14. Umemori , Sugawara J, itani H, et al. Skeletal anchorage s stem for open- ite correction. Am J Orthod 1999;115:1 –174.

15. Sugawara J. JCO interview, Dr Junji Sugawara on the skeletal anchorage s stem. J Clin Orthod 2000:33: 89– 9 .

1 . Sugawara J, aik U , Umemori , et al. Treatment and posttreatment dentoalveolar changes following intrusion of mandi ular molars with application of a skeletal anchorage s stem (SAS) for open ite correc-tion. Int J Adult Orthod Orthog Surg 2002;17:243–253.

17. Sugawara J. A ioe cient skeletal anchorage s stem. In: Nanda (ed). iomechanics and esthetic strategies in clinical orthodontics. St. ouis:

Elsevier Saunders, 2005:295–309.

18. Sugawara J, Daimaru a T, Umemori , et al. Distal movement of man-di ular molars in adult patients with the skeletal anchorage s stem. Am J Orthod 200 ;125:130–138.

19. Sugawara J, Kan aki , Takahashi I, et al. Distal movement of the max-illar molars in nongrowing patients with the skeletal anchorage s s-tem. Am J Orthod 2004;129:723–733.

20. Sugawara J, Nagasaka H, amada S, et al. The application of orthodon-tic miniplates to Sendai surger rst. Semin Orthod 2018;24;17–3 .

21. Ojima K, Dan C, Nishi ama , et al. Accelerated extraction treatment with Invisalign. J Clin Orthod 2014;48:487–499.

22. Katchooi , Cohanim , Tai S, et al. E ect of supplemental vi ration on orthodontic treatment with aligners: a randomi ed trial. Am J Orthod Dentofacial Orthop 2018;153:33 –34 .

23. Ojima K, Dan C, Kumagai , Schupp . Invisalign treatment accelerated photo iomodulation. J Clin Orthod 201 ;50:309–317.

rst approach Junji Sugawara - Digital Aligner Orthodontics · 2019. 2. 18. · skeletal anchorage s \stem (SAS) was reported E\ our team1. ... treatment of a skeletal Class III patient

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