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CASE REPORT Skeletal Open-Bite Correction with Mini-Implant Anchorage and Minimally Invasive Surgery

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CASE REPORT Skeletal Open-Bite Correction with Mini-Implant Anchorage and Minimally Invasive Surgery ©2018 JCO, Inc. May not be distributed without permission. www.jco-online.com CASE REPORT Skeletal Open-Bite Correction with Mini-Implant Anchorage and Minimally Invasive Surgery FLAVIO URIBE, DDS, MDS NILOUFAR AZAMI, DDS DEREK STEINBACHER, DMD, MD NANDAKUMAR JANAKIRAMAN, BDS, MDS, MDentSc RAVINDRA NANDA, BDS, MS, PhD emporary anchorage devices protraction, distalization of posteri- (TADs) have expanded the or teeth, and anchorage for patients Tboundaries of tooth movement with missing teeth.3 In addition, nu- in three dimensions, increasing the merous reports have documented scope of potential orthodontic cor- the successful treatment of mild to rections.1,2 The primary uses for moderate surgical cases, obviating TADs include molar intrusion, molar the need for orthognathic surgery.4-6 Dr. Uribe Dr. Azami Dr. Steinbacher Dr. Janakiraman Dr. Nanda Dr. Uribe is an Associate Professor, Postgraduate Program Director, and Charles J. Burstone Endowed Professor, Division of Orthodontics, Department of Craniofacial Sciences; Dr. Azami is a resident, Department of Craniofacial Sciences; and Dr. Nanda is a Professor, Division of Orthodontics, De- partment of Craniofacial Sciences, University of Connecticut School of Dental Medicine, Farmington, CT. Dr. Steinbacher is an Associate Professor of Plastic Surgery, Assistant Professor of Pediatrics, and Director of Dental Services, Oral Maxillofacial and Craniofacial Surgery, Yale School of Medicine, New Haven, CT. Dr. Janakiraman was formerly with the Department of Orthodontics, University of Louisville, Louisville, KY, and is currently an Assistant Professor, Georgia School of Orthodontics, Atlanta, GA; email: [email protected]. Dr. Nanda is also an Associate Editor and Dr. Uribe is a Contributing Editor of the Journal of Clinical Orthodontics. VOLUME LII NUMBER 9 © 2018 JCO, Inc. 485 SKELETAL OPEN-BITE CORRECTION WITH MINI-IMPLANTS AND SURGERY Fig. 1 24-year-old female patient with anterior open bite and missing lower teeth before treatment. 486 JCO/SEPTEMBER 2018 URIBE, AZAMI, STEINBACHER, JANAKIRAMAN, NANDA Kuroda and colleagues demonstrated the cor- the chief complaint of anterior open bite (Fig. 1). rection of skeletal anterior open bites with posteri- She had an orthognathic facial profile with exces- or intrusion using mini-implants.5 Similar reports sive lower facial height. In smiling, she showed a have described management of the vertical dimen- reverse smile arc and a 5mm gingival display in sion by means of molar intrusion with TADs.7-9 In the premolar and molar regions. Wide buccal cor- a patient with a long face and retrognathic mandible, ridors resulted from excessive lingual inclination maxillary posterior intrusion not only reduces the of the upper posterior segments and constriction mandibular plane angle by mandibular autorotation, of the maxillary arch. The patient had two maxil- but also diminishes chin projection, thus improving lary occlusal planes, with a step in the canine re- facial esthetics and mimicking the results achieved gion and a canted occlusal plane that was lower on through orthognathic surgery.6 On the other hand, the right side. She exhibited a 6mm open bite from a patient with adequate or slightly excessive chin canine to canine, a Class II canine relationship, a projection and a long face may be unfavorably af- Class I molar relationship, and a 4mm overjet, as fected by this mandibular autorotation. well as a 2mm midline deviation in the lower arch The present article describes the manage- and moderate crowding in the upper arch. The pa- ment of a complex skeletal open bite by a combi- tient was missing the lower right second premolar nation of miniscrew-anchored maxillary posterior and left first molar and had porcelain-fused-to- intrusion and minimally invasive surgery. metal crowns on the lower incisors. Cephalometric analysis confirmed a skeletal Diagnosis and Treatment Planning Class I relationship (Table 1). Vertically, the man- dibular plane and gonial angles were excessive. A 24-year-old female patient presented with The maxilla was rotated counterclockwise, and the TABLE 1 CEPHALOMETRIC ANALYSIS Measurement Mean ± S.D. Pretreatment Post-Treatment Difference SNA 82.0° ± 3.5° 80.0° 79.4° −0.6° SNB 80.0° ± 3.4° 79.5° 79.9° 0.4° ANB 1.6° ± 1.5° 0.4° −0.5° −0.9° Wits appraisal −1.0mm ± 1.0mm −3.1mm −4.9mm −1.8mm SN-GoGN 32.0° ± 5.2° 38.1° 35.0° −3.1° U1-SN 102.0° ± 5.5° 107.3° 103.3° −4.0° IMPA 95.0° ± 7.0° 78.7° 78.2° 0.5° U6-NF 23.0mm ± 1.3mm 25.8mm 23.2mm −2.6mm U1-NF 27.5mm ± 1.7mm 28.2mm 29.7mm 1.5mm L6-MP 32.1mm ± 1.9mm 21.6mm 21.0mm −0.6mm L1-MP 40.0mm ± 1.8mm 31.2mm 30.8mm −0.4mm Upper lip-SNPg 3.0mm ± 1.0mm 2.6mm 2.3mm −0.3mm Lower lip-SNPg 2.0mm ± 1.0mm 1.3mm 1.6mm 0.3mm VOLUME LII NUMBER 9 487 SKELETAL OPEN-BITE CORRECTION WITH MINI-IMPLANTS AND SURGERY Fig. 2 Two mini-implants* placed in infrazygomatic crest and two** in palatal shelves near premolars for posterior intrusion, with fiber-reinforced composite splinting of upper posterior teeth. Two lower mini-implants* placed mesial to edentulous sites for molar protraction with nickel titanium coil springs and lingual arch. distance of the upper molar apex to the palatal edentulous spaces. The patient selected the second plane indicated posterior vertical maxillary hyper- treatment option, because it avoided orthognathic plasia. Maxillary incisor inclination was normal, surgery, and opted for closure of the lower edentu- but the lower incisors were mildly retroclined. lous spaces with TADs. Treatment objectives were to resolve the an- terior open bite, correct the midline deviation and Treatment Progress close the edentulous spaces in the lower arch, and reduce the lower facial height while maintaining Two 2mm × 9mm mini-implants* were the orthognathic facial profile. placed in the infrazygomatic crest, and another two The first treatment option involved orthodon- 1.8mm × 8mm mini-implants** were inserted in tics combined with orthognathic surgery—a Le the palatal shelves near the second premolars (Fig. Fort I osteotomy for posterior impaction of the 2). The upper posterior teeth were splinted by maxilla and a bilateral sagittal split osteotomy in bonding fiber-reinforced composite to the buccal the mandible. The second option was to use TADs and palatal surfaces of the upper premolars and for intrusion of the upper posterior teeth to level first molars. Elastic chain between the mini- the maxillary occlusion, maintain the incisor dis- implants delivered 150g of intrusive force to the play, correct the maxillary cant, and reduce the posterior dentition both buccally and palatally. In lower facial height. Both choices would have re- the lower arch, two 2mm × 9mm mini-implants* quired either endosseous dental implants or TAD- were placed mesial to the edentulous sites. Power based protraction of the lower molars to close the arms were extended from the right first molar and the left second molar, and a protraction force of 150-200g was applied from the mini-implants by *Mondeal Medical Systems GmbH, Tuttlingen, Germany; www. nickel titanium coil springs. A lower lingual arch mondeal.de. **Imtec, 3M Unitek, Monrovia, CA; www.3Munitek.com. was cemented to lie 3-4mm away from the lingual ***Trademark of 3M Unitek, Monrovia, CA; www.3Munitek.com. surfaces of the incisors. 488 JCO/SEPTEMBER 2018 URIBE, AZAMI, STEINBACHER, JANAKIRAMAN, NANDA A B Fig. 3 A. Anterior open bite corrected after 36 months of treatment, with slight lateral open bite remaining on left side. B. After 42 months of treatment, showing increased chin prominence due to mandibular autorotation sec- ondary to maxillary molar intrusion. After eight months of leveling of the maxil- (Fig. 3). Increased chin prominence due to auto- lary occlusal plane by intrusion of the posterior rotation of the mandible, secondary to the maxil- teeth, preadjusted .022" MBT*** brackets were lary posterior intrusion, was observed after 42 bonded in both arches and the lower lingual arch months of treatment. was removed. Closure of the edentulous spaces was Seven months later, during the finishing stage continued in conjunction with intrusion of the up- of treatment, the patient was referred to an oral and per molars. The anterior open bite was corrected maxillofacial surgeon for a reduction genioplasty, in 36 months without the use of anterior elastics in which the chin was repositioned 5mm up and VOLUME LII NUMBER 9 489 SKELETAL OPEN-BITE CORRECTION WITH MINI-IMPLANTS AND SURGERY A A B Fig. 4 A. Patient after 53 months of active treatment, including genioplasty and microfat grafting. B. Superimpo- sition of pre- and post-treatment cephalometric tracings. 490 JCO/SEPTEMBER 2018 URIBE, AZAMI, STEINBACHER, JANAKIRAMAN, NANDA 2mm back. The mentalis muscle and the median Discussion raphe were gently thinned to reduce soft-tissue chin thickness. To enhance facial esthetics, submental The introduction of TADs has led to a para- liposuction was performed by harvesting about digm shift in the management of skeletal open bites.1 Umemori and collegues documented the use 10cc of fat from the abdomen and injecting it into 9 the labiomental crease of the upper lip and the la- of miniplates for the intrusion of lower molars. biomental and nasolabial folds. Finishing was car- Other studies demonstrated the intrusion of upper posterior teeth with miniplates placed in the zygo- ried out on .016" × .022" beta titanium archwires. 7,8 After 53 months of active treatment, Essix† matic buttress. Deguchi and collegues inserted retainers were delivered for retention in both mini-implants between the first molars and second arches. Rigid stainless steel wires were bonded premolars or second molars for the correction of buccally over the lower premolars and molars to skeletal anterior open bite, achieving favorable skel- prevent space reopening.
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