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38 Dental Tribune Middle East & Africa Edition | November-December 2014mCME < Page 37 mCME SELF INSTRUCTION PROGRAM CAPP together with Dental Tribune provides the opportunity with its mCME- Self Instruction Program a quick and simple way to meet your continuing education needs. mCME offers you the flexibility to work at your own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presents a regional outlook in terms of perspective and subject matter. Membership: Yearly membership subscription for mCME: 600 AED One Time article newspaper subscription: 200 AED per issue. After the payment, you will receive your membership number and Allowing you to start the program. 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The answers and critiques published herein have been checked carefully and represent authoritative opinions about the questions concerned. Articles are available on www.cappmea.com after the publication. For more information please contact events@cappmea.com or +971 4 3616174 FOR INTERACTION WITH THE WRITERS FIND THE CONTACT DETAILS AT THE END OF EACH ARTICLE. measurement that we need, it’s easy to place the maxilla cor- rectly to the mandible. There are certain surgical tech- niques that need to be applied to accomplish the surgical correc- tions. By following the proper surgical techniques, the post- surgical relapse can be kept to a minimum. The other thing that we can do is establish even centric stops, according to the axis position. That’s why in Figures 17a & b the models are painted red. We can do an occlusal analysis and equilibration and establish a sta- ble tooth fit before surgery; all of which is based on the true ter- minal hinge axis. We’re able to get a Class I and we’re able to gain enough over- bite. We will need to do some postsurgical orthodontics to fin- ish the occlusion, but the image shows the hinge axis closer on the articulator. If you were able to hold the mod- el, you would notice that there’s no rocking. Everything is stable. You don’t want the patient to come out of burger and find that the patient has trouble finding a stable maximal intercuspation with the joint seated. In order to gain even stops, we had to remove some tooth enamel around the upper and lower arches. That’s what we do in the operating room before we begin the operation. We do the equilibration when the patient is asleep and before the operation begins. As you can see in the post treat- ment intra-oral and extra-oral photos (Fig. 18), the facial changes include a shortening of the lower facial third. An ad- equate overbite has been estab- lished so a mutually protected occlusion can seen. The proper disclusion, where the back teeth separate by at least 2 to 3 mm, has been established. If we apply the second concept (“you can’t believe what you see in the mouth”), we need to go to post treatment hinge-axis mounted models. Figure 19 shows the cone-beam data, both pre- and post treatment. Note the double plates on the mandi- ble to establish a stable platform to position the maxilla. Surgery One of the most important take- away lessons from this article is that you need to know your sur- geon. Establishing a one-on-one relationship with your surgeon can be challenging. If the or- thodontist does not know what the surgeon goes through, then in the planning stage pre-treat- ment, the teeth may be placed in a position that the surgeon will have trouble establishing in the correct skeletal position. This is a relationship that simply takes time. Once you have knowledge of the surgeon, then you need to know what happens at the hospital because this becomes an im- portant part, especially during recovery. The people who are handling recovery need an exceptional level of compassion, and they need to be able to handle emer- gencies. Oftentimes the patient will get sick, and his or her teeth are held together with elastic and wires. The healing period normally lasts 10 weeks. It may be longer depending on how the segments are healing. The point is that we don’t get into post- surgical orthodontics before the segments have stabilized Additional considerations We know that you need to know the joint status. You’ll need to know how to do a soft-tissue analysis and how to establish a surgical treatment objective. You’ll need to know how to do pre-treatment setups and surgi- cal setups. You need to apply all of these techniques on all pa- tients (mixed dentition, adoles- cent or adult). If the teeth aren’t in the correct position in the jaw, then there’s no way the surgeon can place the parts correctly, resulting in surgical failure. Most surgical failures happen because of or- thodontics. One of the things you need to keep in mind in your pre-treat- ment surgical orthodontics is that you established the correct arch form. Without the correct arch form, it’s difficult to put the parts together. The other thing to keep in mind is the actual 3-D position of the teeth. If you have up-righted the upper anterior teeth, the sur- geon will have a difficult time fitting the mandible to this. If you have tipped the lower an- terior teeth back too far — such as in a Class III — then you can- not obtain a good maximum intercuspation because of the incorrect torque of the anteriors. The setup part of the procedure will give you this information. Age If it’s an adolescent patient, you can do the presurgical orthodon- tic and establish the correct axial position of the teeth in each jaw. However, do not try to fix the oc- clusion. That means the teeth will be in the proper positions when you approach the surgery. As a rule, I won’t get into a sur- gical case before a female is in her early 20s, and with males in their mid 20s. I’ve seen cases where they were done earlier and actually grew out of the cor- rection. Learning these techniques We all need to be taught to do these things, and it needs to be from someone who has done them for a number of years so you can be certain that the methods you are learning will work. They are taught in the Advanced Education in Ortho- dontics (AEO) course, and we do practice them. That includes surgical setup, orthodontic setup, soft-tissue cephalometric analysis and sur- gical treatment objective. They need to be practiced a number of times. It’s not something you can learn on your own. You need a mentor who will teach you all the characteristics you’ll need. In the lab phase of the AEO class, we do get into mounting cases on the true hinge axis. You will learn how to establish these on patients. They are not time consuming. Normally, establish- ing a hinge axis in the axio-path tracing and transfer takes no more than six or seven minutes, so the clinician is not using a lot of his or her time to establish a correct hinge-axis mounting. Theinstructorswilldemonstrate how it’s done, and then have you perform the procedures. Under the proper guidance, you can learn these techniques and ap- ply them in an office setting in an economical manner. Without the coaching, these pro- cedures can feel like too much of a chore. Moreover, without coaching, there’s no way to do a surgical workup for the benefit of the patient, which of course, is the main reason you need to know these procedures. It also helps if you work with the surgeon and the restorative dentist because it’s the restora- tive dentist who obtains the final outcome, and he or she needs to finish the case from where you left it. It takes some time and it takes some effort to learn these pro- tocols. But once you do learn them, and you have the tech- nique, your surgical cases will be more stable, and you’ll cut down the instances of surgical relapse that you see. Above all, remember this is all for the benefit of the patient. You need to spend time learning and youneedtospendtimeintheop- erating room to know the prob- lems the surgeon encounters. Then you need to spend time in the diagnoses and workup. However, the benefit is for the patient, who winds up with a functioning occlusion and im- proved face, and the gingival tissues are healthy and the jaw functions correctly. Fig. 18. Post-treatment intra-oral and extra-oral photos. Fig. 19. Cone-beam data, both pre- and post treatment. Dr Theodore D. Freeland, DDS, MS, is a board-certified ortho- dontist in Gaylord, Mich. After graduating from Albion College in 1967, he attended the Uni- versity of Detroit Mercy, earning a dental degree in 1971 and his master’s of science in orthodon- tics in 1978. Freeland has com- pleted Dr. Gene Williamson’s course in occlusion and TMJ and the Roth/Williams course in ad- vanced orthodontics. In addition, Freeland has served as an adjunct professor in or- thodontics at the University of Detroit Mercy, and held ap- pointments at the University of Detroit in fixed prosthetics and orthodontics; the Roth/Williams Center as a clinical instructor; and the Advanced Education in Orthodontics Group as director and instructor. Freeland is an accomplished au- thor who lectures nationally and internationally. About the Author