Fixed applicance management of class II correction

Fixed Appliance Management of Class II

MalocclusionSUS2 Corrector

©Dr Sylvain Chamberland©sylvainchamberland.com

Literature review

©sylvainchamberland.com

Xbow appliance•Sample of 69 consecutive cl II patients compared to

30 historical cl II controls. Retrospective study.

•Xbow 4,5 months; T2 ceph : 6,5 months post Xbow removal

• Therefore, T2 measurement include relapse of most side effect

✦ Skeletal change:

✓ Diminution of Mx protrusion, without md advancement

✓ Increase vertical dimension compare to untreated controlFlores-Mir C, Barnett G, Higgins DW, Heo G, and Major PW. Short-term skeletal and dental effects of the Xbow appliance as measured on lateral cephalograms. AJODO; 2009;136(6):822-832.

Flores-Mir, AJODO 2009

Xbow appliance✦ Dental change

✓ Overjet

‣ Correction by increase incisor proclination (IMPA ➚ 4,7° ± 4,1°)

‣ No mx incisor movement

✓Molar relationship

‣ U6 distalize 0,9 ± 1,2 mm

‣ L6 mesialize 1,1 ± 1,3 mmFlores-Mir C, Barnett G, Higgins DW, Heo G, and Major PW. Short-term skeletal and dental effects of the Xbow appliance as measured on lateral cephalograms. AJODO; 2009;136(6):822-832.

Flores-Mir, AJODO 2009

Xbow vs Forsus•Sample of 38 consecutive xbow appliance tx compared to

36 Forsus appliance tx. Retrospective study.

• T1 ceph at baseline. T2 ceph at the end of tx

•Both appliance generate the same amount of incisors inclination

• The older the patient, the more OJ and upper incisors inclination remain

• The longer the tx time, the more the lower incisors procline

• Total tx time for both appliance is about the same

Flores-Mir et al AO 2013

Miller, Robert A, Long Tieu, and Carlos Flores-Mir. "Incisor Inclination Changes Produced by Two Compliance-free Class II Correction Protocols for the Treatment of Mild to Moderate Class II Malocclusions." Angle orthodontist 83, no. 3 (2013): doi:10.2319/062712-528.1.

Xbow appliance

•Sample of 25 consecutive cl II patients. Mean age 11,1 ± 1,1 y.

• Prospective study

•CBCT at T0 and after debonding Xbow (T1). Tx time 6,0 m (5,0-8,0)

•Skeletal effect

✦ Mild SNA decrease (0,67± 1,35°)

Erbas, Banu, and Ilken Kocadereli. "Upper Airway Changes After Xbow Appliance Therapy Evaluated with Cone Beam Computed Tomography." Angle Orthod 2014; 84, no. 4: doi:10.2319/072213-533.1

Erbas, A0 2014

Xbow appliance

•Dental effect

✦ U1: Palatal tipping (-3,58± 3,56°)+ extrusion (1,72 ± 1,87 mm)

✦ U6: No significant distal tipping or intrusion. Mesial mvt inhibited

✦ L1: Labial tipping (10,87± 4,91°)

✦ L6: Mesial mvt (2,07 ± 1,24 mm) + extrusion (1,52± 1,08 mm)

Erbas, Banu, and Ilken Kocadereli. "Upper Airway Changes After Xbow Appliance Therapy Evaluated with Cone Beam Computed Tomography." Angle Orthod 2014; 84, no. 4:: doi:10.2319/072213-533.1

p< .001

Erbas, A0 2014

•♀, 12 a. 5 m.

•End of Xbow

•Lower incisor proclination is obvious (+21°)

La.Sha 0807

La.Sha 0308

•Xbow undesirable side effect relapsed

• Incisor proclination return to normal

✦ Sometimes, we pray for relapse

La.Sha 0308. 5 month of Xbow

•Tx time 23 months

•Outcome

✦ 82 weeks into retention

La.Sha 22-03-11

Forsus vs Cl II elastic•Sample of 30 consecutive patients, 23 treated with Forsus (13,4 y), 7 with cl II

elastics (14,3 y). Prospective.

•Ceph T0 after alignment, ceph T1 at removal of Forsus. Tx time 6 m.

•No difference in skeletal effect Mx or Md

•Dental effect

✦ Forsus:

✓ 1/FH retroclined. /1-MP proclined

✓ Significant increase of occlusal plane to FHDubois A, Rompré P, Rodrigue C, Remise C, Comparaison des effets sur la croissance des maxillaires de l’utilisation du Forsus versus celle des élastiques de classe II, Thèse de maîtrise

Dubois, Master thesis U. MTL.

Forsus effectiveness•Retrospective study, 32 consecutive patients (12,7± 1,2 y) matched to 27 historical

untreated controls (12,8 ± 1,3 y)

•Ceph T0 prior tx and Ceph T1 at completion of ortho therapy. Tx time 2,4 ± 0,4 y

✦ Mean duration of FRD active phase: 5,2 ± 1,3 m

✦ Successful cl II correction in 87,5% of the patients

✦ Greater skeletal effect on maxillary structures by restraining sagittal advancement of the mx (SNA ➘ 1,6 ±1,4°)

✦ Effect on the mandible is mainly dentoalveolar: large amount of mesial mvt of L1 (6,1° ± 6,3°) and L6 (2,4 ± 1,6 mm), extrusion of L6 (3,6 ± 1,5 mm)

Franchi L, Lisa Alvetro, Veronica Giuntini, Caterina Masucci, Efisio Defraia, and Tiziano Baccetti. "Effectiveness of Comprehensive Fixed Appliance Treatment Used with the Forsus Fatigue Resistant Device in Class II Patients." Angle orthodontist 2011; 81, no. 4: doi:10.2319/102710-629.1

Franchi, A0 2011

Forsus effectiveness•Follow-up at 2,3 ± 1,1 y post comprehensive tx. 36 consecutive patients/

20 historical untreated controls. Retrospective study.

✦ Mean FRD duration 4,8 ± 2,4 m

✦ Outcome (retrospective study)

✓ T1-T2: Baseline to end of ortho

✓ T2-T3: End of ortho to end of retention

✓ T1-T3: Baseline to end of retentionCacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist (2014):doi:10.2319/112613-867.1

Cacciatore, A0 2014

Forsus effectiveness•Follow-up

✦ T1-T2 FRD vs untreated controls

✓ Significant skeletal effect on Mx (SNA ➘ 1,7 °)

✓ No significant effect on Md

✓ Significant improve of dental relationship

‣ OJ -5,1mm; OB -3,1 mm; molar relationship +3,5 mm

‣ U1 retruded 1,6 mm, L1 proclined 5,6°/ 1,5 mm. L6 extruded 1.3 mm. U6: no vertical change

Cacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist 2014 doi:10.2319/112613-867.1

Cacciatore, A0 2014

✓ Significant greater increase in sagittal position of Mx (SNA ➚ 1,4°)

✓ Significantly increase of both OJ (1,3 mm) and OB (1,5 mm)

✓ Significant intrusion of U1 (-1,2 mm)

Cacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist 2014 doi:10.2319/112613-867.1

Cacciatore, A0 2014

✓ No significant sagittal or vertical skeletal change

✓ Significant reduction of OJ (-3,8 mm), OB (-1,5 mm)

✓ Significant improvement of molar relationship (+ 3,7 mm)

✓ Significant retrusion of U1 (-1,1 mm)

✓ Significant intrusion of L1 (-1,2 mm)

✓ Success rate of overall correction: 83,3%Cacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Effects Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist 2014 doi:10.2319/112613-867.1

Cacciatore, A0 2014

Fatigue Resistant Device•29 subjects, prospective study, 15 prior growth peak; 14 post growth peak.

• Tx time 9 months. Ceph + MRI study

✦ Palatal tipping + extrusion of mx incisors

✦ Protrusion + intrusion + labial tipping (5,5° - 6°) of md incisors

✦ Distal tipping of Mx molars

✦ Mesial movement + mesial tipping of Md molars

✦ No change in disk positionAras, Ada, Saracoglu, Gezer, and Aras. "Comparison of Treatments with the Forsus Fatigue Resistant Device in Relation to skeletal maturity: A cephalometric and magnetic resonance imaging study. AJODO 2011; 140: 616-25: doi:10.1016/j.ajodo.2010.12.018.

Aras, AJODO 2011

•Class II div 1

•Constricted maxilla

• Tx time: 99 weeks

Gu.Ma. 0707

Gu.Ma. 0708

Gu.Ma.250811; 2 years out of ortho

•Side effects relapsed

Twin Force Bite Corrector•Sample of 23 patients before Pubertal Growth Spurt compared to 18

patients post PGS. Retrospective study.

•Skeletal change

✦ Mx restriction SNA ➘ 1,22°

•Dental change

✦ IMPA increased 4,4° to 5,5° Chhibber, Aditya, Madhur Upadhyay, Flavio Uribe, and Ravindra Nanda. "Mechanism of Class II Correction in Prepubertal and Postpubertal Patients with Twin Force Bite Corrector." Angle Orthod. 2013; 83, n718-727: doi:10.2319/090412-709.1

Chhibber, A0 2013

Twin Force Bite Corrector

•At end of ortho

✦ No difference between skeletal and dental parameters of both groups

✦ Significant longer tx time for the youngest group (3,67 y vs 2,75 y)

✦ Tx efficiency is greater for the post pubertal group

Chhibber, Aditya, Madhur Upadhyay, Flavio Uribe, and Ravindra Nanda. "Mechanism of Class II Correction in Prepubertal and Postpubertal Patients with Twin Force Bite Corrector." Angle Orthod. 2013; 83, n718-727: doi:10.2319/090412-709.1

Chhibber, A0 2013

SaAl180111

SaAl271009. male; 13y 10 m

SaAl151112, 16y 11 m

•Tx plan: exo 4s/5s

•Cl II correction device helped to maintain anchorage while retracting U1 and protracting L6

SUS2 vs Forsus FRD•Sample: 20 SUS2, 20 Forsus, 19 controls. All post pubertal (~15 y±1 y)

•Both appliances. Tx time 5 m ± 1 m. Prospective study.

✦ Dentoalveolar effect

✓ 1/: retrusion + extrusion

✓ /1: protrusion + intrusion

✦ No significant skeletal effect on Mx and Md. No vertical change

✦ Soft tissue profile improvement is limitedOztoprak MO, Nalbantgil D, Uyanlar A, and Arun T. A cephalometric comparative study of class II correction with Sabbagh Universal Spring. European journal of dentistry. 2012 Turkey;6(3):302-10

Oztoprak, Eur. J. Dent. 2012

SUS2 vs Forsus FRD•However:

✦ Lower incisors proclination more prominent with Forsus FRD

✓ SUS2 : ∆IMPA= 5,78° ± 3,91°

✓ Forsus: ∆IMPA = 10,8° ± 3,07°

✦ N-A-Pg: better reduction in facial convexity with SUS2

✓ SUS2 : -2,13°± 2,85°

✓ Forsus: + 0,65° ± 3.04°

p < .001

p < .05

Oztoprak MO, Nalbantgil D, Uyanlar A, and Arun T. A cephalometric comparative study of class II correction with Sabbagh Universal Spring. European journal of dentistry. 2012 Turkey;6(3):302-10

Oztoprak, Eur. J. Dent. 2012

Study DesignExperimental groups Observation Time Point

Sample size (>25) Untreated Controls T0 Baseline T1 Prior Cl II device T2 Post Cl II device T3 End of Ortho T4 Follow-up

Flores-Mir AJODO 2009 R ✔ 69 ✔ 30 ✔ 6 m. post Xbow

Miller AO 2013 R ✔ 38/36 ✔ ✔

Erbas AO 2014 P ✔ 25 ✔ ✔

Dubois et al P ✔ 23 / 7 ✔ ✔

Franchi AO 2011 R ✔ 32 ✔ 27 ✔ ✔

Cacciatore AO In press R ✔ 36 ✔ 20 ✔ ✔ ✔

Aras AJODO 2011 P ✔ 15 / 14 ✔ ✔

Chhibber AO 2013 R ✔ 23 / 18 ✔ ✔

Oztoprak EJD 2012 R ✔ 20 / 20 ✔ 19 ✔ ✔

Poor Study Design

•Study about Cl II correction device are not at the level of RCT.

•Evidences are below that level of confidence

•Even meta-analysis should be interprete with caution

Giuseppe Perinetti, Jasmina Primožič, Giovanna Furlani, Lorenzo Franchi, and Luca Contardo (2014) Treatment effects of fixed functional appliances alone or in combination with multibracket appliances: A systematic review and meta-analysis. The Angle Orthodontist In-Press.

SUS2 Corrector

SUS2 Telescope Element

Telescope rod with ring

Position for turbo spring or spacer

Arch adaptor

Fixing screw

Middle telescope tube

Inner spring 2,4 N

Guide Tube

Hexagon socket screw

Inner Spring•At maximum activation

✦ Spring path of 6 mm

✦ 2,4 N at full compression

•Deactivation with hexagon screw

✦ Spring path 2,1 mm

✦ 1,0 N at full compression

Spring span

Front stop

Back stop

Spring span

Turbo Spring

•Place on the telescope element

✦ Force of 3,0 N

•Spacer of 1 or 2 mm

✦ If required for reactivation, although seldom necessary

SPEED™ Convertible Tube

• For class II correction devices!

•Repeatably convertible

• Facilitate insertion and removal of cinched back SS wire

SPEED™ Convertible Tube

•Tips for bonding

✦ Adapt meshpad on the model

✦ Microetch enamel

✦ Use light bond adhesive or 2 paste system

✓ Extra care should be taken to ensure sufficient curing time

Tips for bonding•Etch enamel 15s

•Wash, rince & dry

•Apply Assure sealant on the tooth & light cure

•Apply Assure sealant on the bracket base & light cure

•Wipe the bracket base into Assure paste

•Place on the tooth & light cure

•Large mesh pad needs slight adjustment to obtain best fit on the buccal surface

•Good adaptation of the mesh pad is warrant of good bond strength

✦ Left side is not as nicely bonded than the right side

SPEED™Convertible Tube

•Cinching a 20 x 25 SS wire in the gum and without debonding the tube is challenging

•Convertible tube permits easy cinching outside the mouth

• Insertion and removal of the SS wire takes seconds and done without fear of debonding

•Buccal offset of the L pin at 3-4 mm distal to the tube

✦ Longer extension may impinge over the bracket of the 7s

✦ The L ball-pin is bent gingivally or occlusally at the mesial

✓ After some trial and errors, I prefer occlusal bend of the L pin

L Pin•Inserted distally on the eye of the telescope

• Inserted distally into the head gear tube

•Buccal offset 3-4 mm long

• The pin is bent gingivally or occlusally at the mesial of the tube

✦ With bonded convertible head gear tube, I prefer to bend occlusally

•Distal buccal offset and mesial occlusal bend are at 90° each other

•SUS2 telescope is used without the outer turbo spring for the first 6 weeks

AlLa110814

•SUS2 telescope is used without the outer turbo spring for the first 6 weeks

• Turbo spring is added to maintain forward activation

AlLa110814

LaShMa080813

This is not the same case as above

•L pin bent occlusally

•SPEED™ convertible tube on lower molars for easier insertion

•Arch adaptor tightly screwed onto the arch wire distal to the offset

•Buccal offset of the archwire distal to the lower canines

Case Presentation

•Class II div 1

•Deep overbite

LaShMa160712

•Class II skeletal relationship

✦ ANB 7°, ABOP = 4 mm

•Bimax protrusion

12y 0m

Tx plan

•Comprehensive tx + SUS2 cl II corrector device

•Alternative tx plan

✦ Comprehensive + Extractions 4s/5s

At 44 weeks•SUS2 corrector engaged in june 2013 at 36 weeks

✦ .020 X .025 SS wire U & L

• Turbo spring added in august at 44 weeks

LaShMa080813

At 52 weeks•E links from the molars to the canines

LaShMa021013

At 62 weeks•SUS2 for 26 weeks

LaShMa121213

•Tx time = 105 weeks

•Class I relationship achieved

•White spot lesion: !!! poor oral hygiene despite several warning

MaLaSh270814

• /1 AP relationship nicely controlled

• /1 intrusion obtained

• /6 eruption occurred

•Class II div 1

•Deep curve of Spee. deep overbite

EmEho121212

•Severe class II skeletal relationship

✦ ANB 6,4°; ABOP = 7.5 mm

•Hypodivergent

13y 6m

Tx plan

•Comprenhensive tx, RPE + Fixed cl II correctors

✦ Increase vertical dimension

•Alternate tx plan

✦ Comprehensive tx+ Orthognathic surgery (BSSO)

At 32 weeks•SUS2 were engaged at 26 weeks

• 32 weeks

✦ E links 6-3 to distallize the canines

EmEho190913

At 43 weeks•SUS2 removal (breakage occurred)

• 17 weeks of SUS2 cl II correctors

• 17x25 TMA mushroom loop

EmEho021213

•At 71 weeks

✦ Rebond 16, 26. Mx: 20x20 niti. Cl II elastic nightime

•At 81 weeks

✦ Mx: 21x25TMA, CE

EmEho180614

EmEho170714 EmEho260814

•Vertical dimension improved

• /1 proclined 19°

✦ Not only because of SUS2 but also to arch leveling

• 1/ retroclined 11°

15y 1mANB = 5,6° ABOP = 4,3 mm

•Some condylar growth and molar eruption + mesialisation helped to achieve cl II correction

• Improved facial profile

13y 6m 15y 1m

•Class II div 1

•Severe ALD, impacted 37

•Heavily restored 16, 46

•Md dental asymmetry

KiLe250311

•Hyperdivergent

•Convexe profile

•Mild skeletal cl II (ANB = 6°; ABOP = 4 mm)

11y 8m

Tx plan

•Extraction of 16, 24, 46, 38

•SUS2 corrector

•Alternate tx plan

✦ Likely 14, 24, 35, 44

•SUS2 engaged at 30 weeks (march 2012)

• E links to distalize the canines + protract 47

KiLe040612 43 w

KiLe230412 37 w

•20 weeks of SUS2 corrector

• #47 protracted

•Arch symmetry achieved

KiLe160712 50 w

KiLe160712 50 w Bond #37

•Dentoalveolar protrusion

• Lower lip procumbency

•Unpleasant smile

12y 10m

•Class I canine relationship achieved

KiLe160913 110 w

post SUS20712

•Lip incompetency

•Strain of the mentalis muscle

14y 0m

End of Ortho

KiLe091213 122W

•Functional genioplasty to

✦ Obtain lip competency

✦ Improve profile + smile display

14y 2m

11y 8m 12y 10m 14y 2m

Initial Post SUS2 Pre genio Final14y 0m

Chamberland S, Proffit WR, Chamberland P-E, Genioplasty in growing patients, Angle Orthod, in press

•Cl II div 1

•Accentuated curve of Spee Mx + Md

ElLa210812

•Vertical maxillary excess

•Gummy smile

• Lip incompetency at repose

14y 5 m

Mini screw•Mx:

✦ Palatal side (one on the left failed)

✓ Replace by one paramedian

•Md: Buccal

✦ The one on the left is too low and became submerged

ElLa221112

• Intrusion of mx posterior teeth help achieve some cl II correction

• Posterior open bite

•Deep overbite

ElLa070313

•Posterior intrusion helped to improved AP relationship

14y 11 m

•Md forward rotation

•Upper molar intrusion

• Limited eruption of lower molars

•SUS2 corrector

•E links were maintained for a few weeks

ElLa100613

•Classe I relationship achieved

ElLa190814

•Facial profile improve

• Lip strain persist

✦ A functional genioplasty is indicated

16y 5 m

•Limited mx dentoalvolar growth

• Favourable md growth

• L6 extrusion

• L1 proclination + intrusion

•Lip competency

•Smile display

16y 5 m14y 5 m

•Anchorage for molar protraction

✦ Congenitally missing 35, 45

BiAu 190814

BiAu060513

Molar protraction + Cl II correction device

•Classe II div 2

• Internal root resorption of #46

• Tx plan

✦ RPE, Cl II correction device. Exo 46. Protraction 47.

MaHe220611

Molar protraction + Cl II correction device

•Class I relationship + molar protraction achieved in 96 weeks

MaHe220611 MaHe031012

MaHe040613

•Class II div 2, deep overbite

•Hopeless 14, 36, 46

• Impacted 13

FrRo211111 16 y 2 m

•Tx plan

✦ Would usually not need extraction in the md arch

✦ How about exo 4s/6s + SUS2

•SUS2 were engaged ~ 1 years after tx was initiated because the above mentioned reasons

•SUS2 was used 36 weeks

FrRo041113

FrRo270114

The patient delayed extraction of U4 some 3 months and L6 some 9 months

• Reassessment of bracket position

• Lower 7s protracted (3 mm to go for 47)

FrRo260814

Patient didn’t show for 4 months (april to august)

• /1- maintained AP

• 1/ torque improved

• Lip support maintained

•L7s protracted

• /1s maintained AP

Discussion - Conclusion

Does the approach really matter?•Most studies showed

✦ Some restriction of Mx forward growth

✦ No significant increase of Md growth

✦ Significant dentoalveolar change at end of ortho

✦ Class II correction is maintained at 2 y follow-up (83%)

✦ No significant skeletal change at 2 y follow up.

Side effect• Incisor proclination occurred in spite of arch wire cinchback and -6° torque

embed in the brackets (19x25 into .22 slot)

•Wire-slot interplay should be reduce

✦ 20x25 or 21x25 SS wire + cinchback

• TADs + Cl II correction device reduce lower incisors proclination

✦ /1 change 3,61° ± 5,07° vs 9,29° ± 3,81°

•Extraction + cl II correction device: good marriage when space is necessary along cl II correction

Cacciatore G, et al AO in press

Aslan B, et al AO 2014;84;76-87

Cost•SUS2 : 135$ buy 3 get 1 (101$). One size fits all

• Forsus: 260$, need large inventory for all different sizes.

✦ Must buy > 15000$ annually to get 50% discount…

•TFBC: 239$ buy 4 get 1 (210$) ( 2 lenght sizes + double lock or anchor wire)

• XBow: 220$ + 260$ =480$

•Esprit corrector : ~ 169$

101/260 = 39%

• If most appliances do about the same

•Why should we pay >twice (257%) the price to get a Cl II corrector device?

Key points•SUS2

✦ Easy to install and remove.

✦ Less expensive.

✦ Minimal breakage if any

•U6 SPEED™ convertible tube’s headgear tube

• L6 & L7 SPEED™ convertible tube Repeatably convertible Much easier to cinchback

Thank you

Fixed applicance management of class II correction

Healthcare

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