Surgical-orthodontic Approach Research Articles

Two-Dimensional Radiographic Diagnosis of Maxillary Canine Impactions.

Background: The primary aim of this study was to evaluate, using conventional radiographic imaging, the height, angulation, and mesiodistal position of impacted maxillary canines to determine if these variables are significantly associated with the palatal or buccal positioning of the tooth. Methods: A retrospective analysis was conducted on all patients diagnosed and treated for at least one impacted maxillary canine over a 4-year period in the Principality of Asturias. The final sample included 159 impacted canines. The variables analyzed were age, gender, associated pathology, location, angulation, height, mesiodistal position, buccopalatal position, and treatment method. Follow-up periods ranged from 12 to 50 months. Results: The mean age of the patients was 21 years (range 10-41 years), with most cases occurring in patients aged 14 to 30 years. Females accounted for 66.1% of the sample, with a female-to-male ratio of 1.95:1. The type of treatment (extraction/traction, surgical-orthodontic approach) was significantly associated with patient age. Additionally, the proximity of the impacted canine crown to the palatal or buccal cortices was significantly related to the treatment choice. However, no significant relationship was observed between the palatal/buccal position of the canine crown and its height or angulation. Conclusions: In the present work, the upper canines included by the palatal did not have a greater height or angulation than the canines included by the vestibule.

Skeletal Anchorage as a Therapeutic Alternative for Mandibular Second Molar Impaction: A Prospective Case-Control Study.

Background: The treatment of mandibular second molar (MM2) impaction presents a challenge for orthodontists and requires a surgical-orthodontic approach. This study aims to compare the effectiveness of two techniques for treating impacted MM2: a traditional technique using brass wire and a technique employing skeletal anchorage. Methods: Twelve MM2 with mesio-angular impaction, with an inclination angle between 25° and 40° and an impaction depth between 4 and 10 mm, were selected and randomly divided into two treatment groups. Patients in Group A were treated using the traditional brass wire technique, while those in Group B underwent treatment with a skeletal anchoring technique that utilized a miniscrew positioned in the retromolar region and an elastic sling chain. For both groups, treatment time and the influence of the disimpaction technique on oral health-related quality of life (OHRQoL) were evaluated using the short-form Oral Health Impact Profile (OHIP-14). Results: The results indicated an average treatment time of 168.67 ± 52.32 days for Group A and 76 ± 10.17 days for Group B, with a statistically significant difference (p-value = 0.0002). Regarding the impact on the patients' OHRQoL, Student's t-test did not reveal a statistically significant difference between the two groups at 3 and 7 days of follow-up. Conclusions: Both techniques are considered effective for the treatment of impacted MM2 (angulation 25-40°, depth 4-10 mm). The use of skeletal anchorage significantly reduces treatment times without negatively affecting OHRQoL. The results of this study should be confirmed by further studies with larger sample sizes.

Mandibular second molar impaction: introducing a novel and validated 3D classification system

BackgroundMandibular second molar (M2M) impaction is a clinically significant manifestation of eruption disturbance in dental development. The primary aim of this study was to investigate the impact of the three-dimensional (3D) characterization on clinical and therapeutic decisions for M2M impaction. The secondary aim was to introduce a validated 3D classification system incorporating both surgical and orthodontic parameters.MethodsBidimensional (2D) and 3D radiological records of 15 impacted M2M were collected and deidentified. Ten experienced clinicians (5 oral surgeons;5 orthodontists) categorized each case, first based on 2D records and then with 3D scans. The degree of orthodontic and surgical difficulty in treating impacted M2M was evaluated using a novel classification system based on anatomical and radiological features. The primary outcome variable was the assessment of differences in diagnosis and decision-making protocol using 2D or 3D records, where clinical relevance ranged from 0 to 4. The secondary outcome variable was the validation analysis of the proposed 3D classification system to determine the concordance among the clinicians. Descriptive statistics and multivariable inferential analysis based on Akaike information criterion (AIC) were performed (α = 0.05).Results3D examination allowed a better visualization of M2M impaction with higher clinical relevance for diagnosis of M2M root relationship to alveolar nerve and lingual plate, height to alveolar crest, depth, and inclination relative to the first molar and position relative to the third molar (range:2.69–3.43). The proposed 3D classification of M2M impaction changed clinical decisions regarding surgical-orthodontic approach, biomechanics, patient education, and treatment time estimate (range:2.59–3.33). In the validation analysis of the classification, no evidence of inter- or intra-group (surgeon/orthodontist) bias in score attribution occurred: the model with the minimum AIC was the null model (AIC = 718.04).Conclusion3D evaluation of impacted M2Ms could enhance diagnostic accuracy, and a classification system was proposed and validated by a group of experienced surgeons and orthodontists with high concordance.

Early intervention of unerupted maxillary central incisor: A case series

Early intervention of an impacted maxillary central incisor is crucial to avoid space loss with tipping of the adjacent teeth and allows normal root development. This case series demonstrates the clinical considerations of a surgical-orthodontic approach in managing this eruption anomaly and its challenges. All three cases involved young patients aged 7–9 years with an impacted upper left central incisor and a positive history of dental trauma. An upper sectional fixed appliance was bonded to facilitate the closed eruption of the impacted central incisor. The treatment duration increases when more space is required for the impacted tooth. There was a marginal gingival discrepancy of all the treated central incisors with vertical relapse seen upon review, indicating the need for a careful surgical approach with good hygiene maintenance and a bonded retainer as retention. Early referral for the management of an impacted maxillary central incisor through a surgical-orthodontic approach is often successful, but treatment risks, duration, and retention regimen should be discussed with the parents for informed consent.

Growth Evaluation After Costochondral Graft Combined With Functional Appliance in Children With Temporomandibular Joint Ankylosis.

The treatment of temporomandibular joint (TMJ) ankylosis in children is a great challenge for surgeons. Costochondral graft (CCG) is a common method of reconstructing the TMJ in children. However, the growth pattern of CCG is unpredictable. In this study, we introduced a surgical-orthodontic approach and evaluated the growth results of the mandible and maxilla in children with TMJ ankylosis through 3-dimensional computed tomography measurements. A prospective cohort study was conducted on child patients diagnosed as having TMJ ankylosis between September 1, 2018 and June 1, 2020. Computer-aided virtual mandibular position guided the CCG, and removable functional appliance was used after surgery. The maximal incisal opening (MIO), the maxilla height, and the length of mandibular ramus were determined. Paired t test was performed to analyze the differences among various stages. Six patients (3 females, 3 males; aged 6-9y) were included in this study. MIO was 12.4mm before surgery and improved to 36.8mm after 42.8 months' follow-up. Mandible length increased by 5.1mm in the affected side and by 5.3mm in the unaffected side, without significant difference. The affected maxilla height increased by 6.7mm, which was more than 5.0mm in the unaffected side. In conclusion, continued growth of mandible and maxilla can be achieved through CCG combined with functional appliance treatment for children TMJ ankylosis.

Inhibition of miR338 rescues cleidocranial dysplasia in Runx2 mutant mice partially via the Hif1a-Vegfa axis

Haploinsufficiency of Runt-related transcription factor-2 (RUNX2) is responsible for cleidocranial dysplasia (CCD), a rare hereditary disease with a range of defects, including delayed closure of the cranial sutures and short stature. Symptom-based treatments, such as a combined surgical-orthodontic approach, are commonly used to treat CCD patients. However, there have been few reports of treatments based on Runx2-specific regulation targeting dwarfism symptoms. Previously, we found that the miR338 cluster, a potential diagnostic and therapeutic target for postmenopausal osteoporosis, could directly target Runx2 during osteoblast differentiation in vitro. Here, we generated miR338−/−;Runx2+/− mice to investigate whether inhibition of miR338 could rescue CCD defects caused by Runx2 mutation in vivo. We found that the dwarfism phenotype caused by Runx2 haploinsufficiency was recovered in miR338−/−;Runx2+/− mice, with complete bone density restoration and quicker closure of fontanels. Single-cell RNA-seq analysis revealed that knockout of miR338 specifically rescued the osteoblast lineage priming ability of bone marrow stromal cells in Runx2+/− femurs, which was further confirmed by Osterix-specific conditional knockout of miR338 in Runx2+/− mice (OsxCre; miR338fl/fl;Runx2+/−). Mechanistically, ablation of the miR338 cluster in Runx2+/− femurs directly rescued the Hif1a-Vegfa pathway in Runx2+/− osteoblasts, as proven by gene expression profiles and ChIP and Re-ChIP assays. Collectively, our data revealed the genetic interaction between Runx2 and the miR338 cluster during osteoblast differentiation and implied that the miR338 cluster could be a potential therapeutic target for CCD.

Evaluation of Postoperative Pain and Discomfort in Patients Undergoing Surgical Exposure of Impacted Maxillary Canines.

ABSTRACTObjectivesThe purpose of the retrospective study was to evaluate pain and discomfort related to surgical exposure according to initial localization of impacted maxillary canines.Material and MethodsPre-treatment cone-beam computed tomography (CBCT) data and discomfort evaluation questionnaire of 25 patients (17 female, 8 male), treated with combined surgical-orthodontic approach was analysed. The questions included: level of discomfort during surgery (0 to 10), level of pain (0 to 10) in the evening, one, two days and a week after surgery. CBCT analysis consisted of evaluation of impacted maxillary canines mesiodistal inclination, horizontal, vertical dislocation from alveolar process edge, labiopalatal localization and length of eruption path. To carry out research objectives a Spearman and interclass correlation coefficients, Mann-Whitney U test, Cohen’s kappa coefficient were used. Level of significance was 0.05.ResultsAverage level of discomfort during the procedure was 2.8 (SD 2.3). Pain level the evening after the surgery was the highest - 3.3 (SD 2.1) and decreased over the week. Pain level differed significantly between different days (P < 0.001). Neither labial or palatal location nor the unilateral or bilateral impaction had effect on the level of pain (P > 0.05). The results showed that pain during different stages of measuring as well as level of discomfort during surgical exposure did not differ statistically significantly depending on severity of impaction (P > 0.05).ConclusionsThere was no significant relation between the discomfort and the location of the impacted canine. Patient’s gender or age did not have an impact on discomfort and pain.

Eruption Treatment of Impacted Teeth Following Surgical Obstruction Removal

Supernumerary teeth and odontomas are obstacles for spontaneous tooth eruption and may result in impaction. The aim of the study is to present a conservative treatment approach for impacted teeth following surgical obstruction removal by reviewing three treatment modalities: surgery only, which involves the surgical removal of the obstruction and the spontaneous eruption; surgery with immediate traction, which includes surgery combined with immediate active orthodontic brace cementation and traction; and surgery with delayed traction, which combines a surgical procedure of obstacle removal and orthodontic brace cementation with follow-up for the spontaneous eruption. The first two modalities require orthodontic traction either by an additional surgical procedure for orthodontic brace cementation, or combined with the surgical obstacle removal. With the third approach, clinical follow-up is performed via connected ligature wire elongation applied during the surgical procedure for the spontaneous emergence of the impacted tooth. Active orthodontic traction is only employed if the tooth fails to erupt. The visual follow-up via wire elongation serves as a reference during the emergence of the impacted teeth and reduces the need for radiographic examination. The surgical-orthodontic approach saves both further surgery and orthodontics (spontaneous eruption) or further surgery (in failure to erupt).

Post-Treatment Status of Impacted Maxillary Central Incisors following Surgical-Orthodontic Treatment: A Systematic Review.

Background and Objectives: The aim of this systematic review was to summarize currently available data of published articles that have investigated the post-treatment status of impacted maxillary central incisors (ICI) treated by the surgical-orthodontic approach. Materials and Methods: MEDLINE, Scopus, Cochrane Oral Health Group’s Trials Register, and ScienceDirect electronic databases were systematically searched with no publication date restrictions up to January 2021. Data assessing the status of ICI after combined surgical-orthodontic treatment and forced eruption duration were extracted, and the quality of the studies was evaluated. Results: In total, 7074 studies were identified, of which 42 articles were assessed for eligibility through full-text evaluation. Seven included studies (five retrospective studies, one randomized clinical trial, and one prospective clinical trial) met the inclusion criteria, representing 211 patients with unilaterally impacted maxillary incisors. The risk of bias ranged from moderate to high. The results show that the root length of immature ICIs increased significantly but remained shorter than that of homonym teeth at post-treatment. Periodontal parameters of treated ICIs were in a clinically acceptable range. Measurements of the alveolar bone showed a reduction of bone thickness and support. The average forced eruption duration ranged from 8.0 ± 4.5 to 14.41 ± 4.03 months. Conclusions: Based on existing evidence, it is reasonable to conclude that the surgical-orthodontic treatment affected the post-treatment status of ICI; however, the current literature is insufficient to draw concrete conclusions. Further well-conducted multi-center randomized studies with a large sample are needed to confirm this statement.

Skeletal open bite Class III compensatory treatment with biofunctional therapy

Introduction: Class III skeletal malocclusion in adult patients presents mainly two treatment options: the surgical-orthodontic approach or compensatory treatment. Case Report: In the present report, it was described the case of a 23-year-old male patient who presented skeletal Class III malocclusion associated with anterior open bite. The patient refused surgical-orthodontic treatment. Thus, the compensatory orthodontic treatment was performed with the biofunctional technique, consisting of preadjusted brackets with accentuated palatal torque on the maxillary incisors and accentuated buccal torque on mandibular incisors. This prescription aims to minimize the effects of Class III intermaxillary elastics, promoting more bodily movement than tipping of the anterior segments and improve bone remodeling. The anterior open bite was treated with lingual spurs, differentiated bonding of the accessories and early intermaxillary elastics. After 23 months of treatment, a functional occlusion was observed with bilateral Class I canine and molar relationships, overbite correction, and satisfactory smile esthetics. Conclusion: The great outcomes indicate that compensatory orthodontic treatment is possible in skeletal discrepancies, with the correct diagnosis and considering patient compliance. The biofunctional technique provided a favorable dental positioning for Class III correction.

Comprehensive management of severe skeletal Class III malocclusion through a combined surgical and orthodontic approach

Management of skeletal Class III malocclusion requires a comprehensive approach since several factors such as severity of reverse overjet and facial divergence govern the treatment plan. Management of the nongrowing skeletal Class III individual with moderate-to-severe skeletal discrepancy is either by surgical management or orthodontic camouflage. Although various reports emphasize that both the treatment options are equally successful, the degree of correction which can be achieved differs. This report describes the comprehensive management of a case of severe skeletal Class III malocclusion through a combined surgical-orthodontic approach.

Are age and radiographic features effective on orthodontic alignment of palatally impacted maxillary canines? a retrospective study.

The purpose of the study was to evaluate the effects of age and radiographic parameters on success of orthodontic alignment of impacted maxillary canines. The retrospective records of 50 patients (mean age 20.44 years) who had impacted maxillary canines in palatal position were included. The patients was requiring surgical exposure and mechanical orthodontic treatment were divided into two groups as adolescent (age≤18; n=24) and adult (age>18; n=26). In both groups, the treatment time and success were evaluated clinically and radiographically. Fifty patients between the ages of 13 to 42 (12 males and 38 females) with palatally impacted canines were treated with combined surgical-orthodontic approach. Forty-seven teeth (94%) had reacted to surgical exposure and orthodontic alignment within 16 to 36 months with a mean of 24.81 months. Three of the impacted canines (6%) were surgically removed because no movement was observed following 10 months of traction forces. The distance of the canine tip to the occlusal plane on the lateral cephalometric radiographs have found to be related with the total orthodontic treatment time. Neither the age of the patient nor other clinic and radiographic parameters had influence on the treatment results of alignment of maxillary canines following surgical exposure.

Surgical-orthodontic approach for facial rejuvenation based on a reverse facelift

BackgroundOrthodontic treatment combined with a maxillomandibular advancement (MMA) can be an effective option for patients who need not only corrected occlusion but also facial rejuvenation. In this case series, two patients underwent orthodontic treatment and bimaxillary orthognathic surgery involving MMA, one of them with a counterclockwise rotation of the occlusal plane (OP).FindingsIn both cases, the face was rejuvenated, a functional occlusion was established, and the posterior airway space (PAS) was widened.ConclusionsThe facial mask ages three dimensionally. MMA should be offered to patients who have insufficient skeletal projection and are considering improving their facial appearance beyond just correcting a malocclusion problem. The reverse facelift provides more soft-tissue support, resulting in mid- and lower-face rejuvenation.

Posterior Available Space for Uprighting Horizontally Impacted Mandibular Second Molars Using Orthodontic Microimplant Anchorage.

Treatment of horizontally and deeply impacted mandibular molars is challenging for both orthodontists and oral surgeons because of the limited access and anchorage control. We report on two patients who had horizontally and mesially impacted mandibular second molars (MM2s). Both patients were treated by a surgical orthodontic approach, and the crowns of the impacted teeth were brought into the arches by closed forced eruption. Mesially impacted MM2s were uprighted with orthodontic microimplants, inserted in the retromolar area, and then moved into their ideal position. The first patient was in an active growing stage, while the second patient was beyond the active growing stage. Therefore posterior available space (PAS) should be analyzed before treatment of impacted MM2s to prevent periodontal problems after uprighting of impacted teeth. If PAS is not enough for uprighting impacted MM2s, alternative treatment should be considered based on the stage of growth.

Conventional surgical-orthodontic approach with double-jaw surgery for a patient with a skeletal Class III malocclusion: Stability of results 10 years posttreatment

This case report presents the treatment of a young man with a skeletal Class III malocclusion. He was treated with a conventional surgical-orthodontic approach in which 2 jaw surgeries were performed. The esthetic facial profile, pleasant smile, appropriate occlusion, and overall good treatment outcome remained stable10years after active orthodontic treatment.

Clinical Outcome of an Impacted Maxillary Canine: From Exposition to Occlusion

The aim is to report a case of impacted maxillary right canine successfully positioned into the occlusion line. Although the treatment of choice for an impacted canine is a combined surgical-orthodontic approach, there are differences in technique. The preorthodontic uncovering and autonomous eruption technique is a safe and predictable option for the treatment of palatally impacted maxillary canines in adolescents and adults as is the orthodontic creation of a space before minimal surgical exposure, the bonding of a small attachment (an eyelet), full-flap closure, and immediate traction. Although the mechanical management of impacted teeth is a routine task for most orthodontists, certain types of impaction can be frustrating. An 18-year-old adult patient presented for clinical examination with a mobile maxillary right deciduous canine, the absence of a maxillary right permanent canine, Angle Class I malocclusion, an overjet of 2.0 mm, an overbite of 3.0 mm, and rotated canine and left maxillary central and lateral incisors. Cephalometric measurements revealed a skeletal Class I relationship as well as upright maxillary incisors (1. NA = 18°) and mandibular incisors (1. NB = 16°, IMPA = 80°). The facial profile was concave. Clinically, a constricted maxillary arch was observed, and the patient had a nail-biting habit. The canine was aligned, leveled and positioned in the occlusion line. The esthetic, functional and periodontal results remained stable in the retention phase. Various treatment strategies are available to treat impacted maxillary canines. The surgical, periodontal, and orthodontic considerations in the management of impacted canines must be clearly explained to the patient.

Aesthetic and functional outcomes using a multiloop edgewise archwire for camouflage orthodontic treatment of a severe Class III open bite malocclusion

Occasionally, orthodontists will be challenged to treat malocclusions and skeletal disharmonies, which by their complexity one might think that the only treatment alternative is the surgical-orthodontic approach. A male patient, aged 17 years old, was diagnosed with a skeletal Class III malocclusion, anterior open bite and negative overjet. An unpleasant profile was the patient's 'chief complaint' showing interest in facial aesthetics improvement. Nevertheless, the patient and his parents strongly preferred a non-surgical treatment approach. He was treated with a multiloop edgewise archwire to facilitate uprighting and distal en-masse movement of lower teeth, correct the Class III open bite malocclusion, change the inclination of the occlusal plane and obtain the consequent morphological-functional adaptation of the mandible. The Class III malocclusion was corrected and satisfactory changes in the patient's profile were obtained. Active treatment was completed in 2 years, and facial result remained stable at 2 years 6 months after debonding.

Surgical Orthodontic Treatment for a Skeletal Class III Young Patient with Tongue Thrust Habit

This article describes the treatment of a skeletal Class III patient with a severe anterior cross-bite, open-bite, crowding and a tongue thrust habit. Two treatment options were proposed: -conventional orthodontics to camouflage the skeletal anomaly and traditional orthodontics/orthognathic surgery approach. The surgical orthodontic approach was selected, but treatment was started 3 years 8 months from the treatment plan presentation appointment. Surgery was scheduled when pre-surgical orthodontics was finished; a Le Fort I osteotomy was performed for maxilla advancement and a bilateral sagital split osteotomy (BSSO) for mandibular setback. Post-surgical orthodontics was applied for finishing and detailing the occlusion. Total treatment time was 24 months. Good facial balance and occlusal relationships were achieved.

Surgical Orthodontic Treatment for a Skeletal Class III and Asymmetric Patient: Case Report

The aim of this article is to describe the treatment of a skeletal Class III and asymmetric patient. Two treatment alternatives were explained: -conventional orthodontics to camouflage the skeletal anomaly and -traditional orthodontics/orthognathic surgery approach; the surgical option was selected. Pre-surgical orthodontics was applied for leveling, aligning and relieving dental compensations. A Bilateral Sagital Split Osteotomy was performed for mandibular setback. Post-surgical orthodontics was applied for finishing and detailing occlusion. Total treatment time was 10 months. Facial balance was enhanced and a good dental occlusion was achieved. Careful treatment planning by the ortho-surgical team, proper application of biomechanics and good selection of dental orthodontic materials, allow the orthodontist to delay less time in the pre and post-surgical stages in the traditional surgical orthodontic approach.

Surgical-Orthodontic Management of Mandibular Hypoplasia with Severely Short-Rooted Dentition Secondary to Anti-Leukemic Treatment: A Case Report

Major advances in anti-leukemic treatment have increased a significant number of pediatric cancer survivors over the past few decades. Such treatment in children is also reported to cause abnormal dentofacial development including a significant mandibular hypoplasia, dental anomalies, and severely short-rooted dentition. These problems, despite a becoming both functional and psychosocial problems, are often neglected as many clinician’s lack experience in managing them. They are exacerbated by the fact that orthodontic treatments can potentially cause further root shortening. Therefore, a special consideration to minimize a risk of root resorption must be given when an orthodontic treatment plan is formulated for these patients. We report a unique treatment approach employed on a 14-year-old male patient with severe dentofacial abnormalities secondary to anti-leukemic treatment. Treatment goals were to correct dental malocclusion, optimize facial balance, and also prevent further root shortening. A treatment plan combining orthodontics, orthognathic surgery, and use of temporary anchorage devices, was developed so that light orthodontic forces could be used throughout the course of treatment. Consequently, the lighter force reduced the risk of potential root resorption. The final outcome demonstrates that the surgical-orthodontic approach optimizes facial and occlusal changes while minimizing further root resorption.