Camouflage Treatment in Orthodontics

1. 1 Camouflage treatment in orthodontics Camouflage treatment in orthodontics Prepared by: Prepared by: Dr. Mohammed Alruby Dr. Mohammed Alruby كبر مكحل ربصاو ف ا ء اننيعاب كن Camouflage Camouflage T Treatment reatment in in O Orthodontics rthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Definition Indication Contraindication Classification Class II camouflage Class III camouflage Cases good and not good for camouflage treatment Treatment approach for camouflage treatment Camouflage treatment of open bite cases Surgical camouflage: -Chin surgery -Nasal surgery -Graft tissues Camouflage Camouflage T Treatment reatment in in O Orthodontics rthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 Definition: Term used to describe treatment procedure where the dental problem is corrected therefore the skeletal problem no longer apparent Camouflage: -- conceal --- cover-up ---- hid ---- mask Or: less intensive treatment plane option in patient with sever problem to obtain optimum results within physiologic limit The goal of camouflage is to disguise the unacceptable skeletal relationship by orthodontically repositioning the teeth in the jaws, there is an acceptable dental occlusion and an esthetic facial appearance Indication: 1-Mild to moderate skeletal class II or mild class III 2-Reasonable good alignment of teeth, so that the extraction spaces would be available to control anterior posterior displacement and not for relief crowding 3-Good vertical facial proportion Contraindications: 1-Severe class II, moderate or severe class III and vertical skeletal discrepancies in which orthognathic surgery is better 2-Patient with severe crowding or protrusion of incisors because the spaces is consumed for crowding only 3-Patient with good growth potential 4-Medically compromised patient 5-Mentally retarded patient 6-Periodontal compromised patient Classification of camouflage 1-Orthodontic camouflage: Class II Class III Open bite A symmetry 2-Surgical camouflage: Chin surgery Nasal surgery Single jaw surgery with double jaws problem Class II camouflage Dental camouflage of class II skeletal problems done by: with extraction or without extraction Class II camouflage can take three form: 1-Retraction of protruding maxillary incisors by extraction of maxillary 1st premolar and moving and anterior teeth posteriorly into the space, take care about anchorage to prevent maxillary posterior teeth to come forward Camouflage Camouflage T Treatment reatment in in O Orthodontics rthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 2-Moving upper teeth backward and lower teeth forward: by using fixed appliance and class II elastics, that leads to -Retraction of upper back and lower forward -Elongation of upper incisors and lower molars -Rotation of occlusal plane – down in front / up in back This procedure has big problems: a-Moving the lower arch forward lead to unstable position of incisors so need more time for retainer or tend to relapse b-The tooth movement tends to accentuate the chinless appearance of patient because the lower lip goes forward but soft tissue chin goes backward c-Extrusion of upper incisors increase tooth display and may lead to gummy smile 3-Repositioning of chin and / or nose: Genioplasty and Rhinoplasty can be viewed as a form of camouflage To improve the balance between lower incisors and chin, move the chin forward, augmenting the chin itself can solve the esthetic problem Reducing the size of nose, change the profile of patient to acceptable profile N: B: Long face: high plane angle: with vertical maxillary excess with or without mandibular deficiency are poor candidate for camouflage treatment because there will be extrusion of lower molars that will worsen the case Surgical / non-surgical decision in class II treatment: Soft tissue change must be done to evaluate the case and estimate the following: 1-Anterior posterior position of upper incisors 2-Angulation of upper and lower incisor in relation to palatal plane and mandibular plane 3-Vertical dimension to evaluate the overbite 4-Possibility of genioplasty 5-Risk of root resorption with camouflage treatment Camouflage of class III Class III camouflage more difficult than class II component due to: -Difficult tooth movement -Difficult to obtain acceptable esthetics -Most of cases have dental compensation that developed during growth Features of class III: 1-Upper incisors proclined relative to maxilla 2-Lower incisors upright and retrusive relative to chin Treatment procedure based on: -Retracting lower incisors -Advancing upper incisors -Surgical reducing prominent chin = malocclusion with mild mandibular prognathism and moderate overbite can be corrected by: -Dento-alveolar movement Camouflage Camouflage T Treatment reatment in in O Orthodontics rthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 -Class III elastics with or without extraction Or extraction of maxillary 2nd premolar and mandibular 1st premolar but all these procedures correct the dental occlusion but facial deformity corrected by: Graft to anterior maxilla Reduction genioplasty Factors affect camouflage treatment: 1-Growth: After finishing of growth stage and all treatment need pass the growth period, the cases require non- surgical treatment approach or extraction approach 2-Limitation of tooth movement: In cases of class III malocclusion: dental compensation occurs mask the severity of underlying skeletal discrepancies, so non-extraction treatment will enhance the dental compensation that can affect the general condition Excessive proclination of maxillary incisors and lingual tipping of mandibular incisors could result root to close to palatal and labial alveolus which could compromise periodontal health 3-Psychology, treatment coast and relapse: Camouflage treatment should consider patient willingness, motivation and expectation Patient should a ware about the economies of treatment and expectation of limitation of results Cases good for camouflage treatment: 1-Class III with mild to moderate severity 2-Absence of skeletal facial a symmetry 3-Hypodivergant class III pattern 4-Lack of posterior cross bite or mild posterior cross bite 5-Subjects who have passed the active growth period for orthopedic treatment of maxillary protraction and chin cup therapy 6-Presence of good alveolar bone support in mandibular anterior symphysis and maxilla to accommodate mandibular anterior retroclination / maxillary anterior proclination Cases who not good for camouflage treatment: 1-Acute naso-labial angle which indicate further proclination of maxillary anterior could worsen the profile 2-Limited possibilities of further retroclination of mandibular incisors 3-Large negative overjet 4-Class III genetic etiology because high tendency for relapse 5-Patient with skeletal facial a symmetry 6-Open gonial angle and open bite cases Treatment approach for camouflage treatment: 1-Non-extraction approach; Is used for cases that have minor crowding that can be resolved easily by arch expansion or incisors proclination -Expansion in both arches -Proclination of incisors -Distalization of lower arch Camouflage Camouflage T Treatment reatment in in O Orthodontics rthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

6. 6 -Using MEAW technique: this is Multiloop edge wise arch wires, that produced by Kin 1987 this arch wire has horizontal and vertical loops that allow more flexibility to the arch wire which permit horizontal positions 2-Extraction approach: Extraction is planned to allow relief of crowding and correction of negative overjet and overbite Choice of extraction: -Mandibular incisors: In case of minor crowding or Bolton discrepancy but need to mismatch the midline between upper and lower—lower bonded retainer is indicated -Upper 2nd premolars and lower 1st premolar: Classic form of extraction in class III case to allow relief of crowding and correct molar relationship -Only lower 1st premolars -Mandibular 2nd molars: That allow significant distal movement in lower arch by using intra-oral implant or by using headgear cervical Advantages: 1-Rapid eruption of 3rd molars 2-Prevent late incisors crowding 3-Reduce the quality and duration of therapy with fixed appliance 4-Facilitate distal movement of 1st molars and anterior dentition 5-Less residual space is left after end of treatment 6-Reduce probability of relapse 7-Maintain the facial esthetics 8-Avoid complication of surgical removal of third molars Camouflage of a symmetry When facial a symmetry exists, the nose is likely to tilt in the same direction as the chin, dental compensation usually brings the dental midlines closer together than skeletal midline With camouflaging treatment, it is not possible to correct all dental midline but only upper because it more obvious and important in esthetic than lower midline Wait for rhinoplasty until everything is completed and acceptable. Camouflage of skeletal open bite there are a number of recommended techniques for orthodontic treatment of patient with skeletal open bite 1-Prevent extrusion of upper posterior teeth 2-Prevent extrusion of lower molars 3-Maintain or create curve of spee 4-Avoid both class II and class III elastics as both lead to posterior extrusion 5-If extraction is indicated, the more posterior teeth is better 6-Avoid anterior vertical elastics because the incisors are already over erupted to compensate anterior open bite skeletal Camouflage Camouflage T Treatment reatment in in O Orthodontics rthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby

7. 7 7-Avoid include 2nd molars because they tend to extrude but if they should be included put the molar tube more occlusally at the crown to avoid extrusion N: B: 1mm extrusion on posterior segment lead to 3mm bite closing by mandibular counter clock wise rotation During correction of skeletal open bite, we deal with intrusion of posterior teeth and prevent any extrusive movement to prevent any clockwise rotation of the mandible. So we use implant as stationary anchorage in skeletal open bite cases to allow successful results = titanium miniplates implant in the buccal cortical bone in the apical region of 1st and 2nd molar have shown to produce 3 – 5 mm of molar intrusion and followed by counter clockwise rotation of the mandible Surgical camouflage Has the same goal as orthodontic camouflage to remove jaw deformity without correcting the underlying problems This type includes: 1-Chin surgery: The position of chin can be changed in two ways: a-By adding some extra-material as: bone, cartilage or alloplastic material b-Using inferior border osteotomy to free it so that it can be repositioned The chin can be repositioned in all three planes of space with an inferior border osteotomy Any a symmetry can be corrected by sliding the chin sideway or positional it vertically Moving chin forward or downward require inter-positional graft 2-Nasal surgery: Nasal surgery to correct nasal distortion is an adjunct to orthodontic camouflage or to orthognathic surgery Rhinoplasty is the primary treatment procedure The variation in normal nasal anatomy among racial and ethnic group must be kept in mind when nasal deformity is diagnosed 3-Augmentation of defective facial surface: mid face and paranasal deficiency: Deficiency in the midface and paranasal area is difficult to described but affect facial esthetics = If severe: it affects the appearance of eyes because the lower eyelid tends to drop downward when is not adequately supported = The lower third of eye iris should be covered by lower eyelid which is supported by high Lefort I osteotomy, but if Lefort osteotomy is not indicated, augmentation of mid face offers alternative treatment by using cartilage or alloplastic material Camouflage Camouflage T Treatment reatment in in O Orthodontics rthodontics Dr. Mohammed Alruby Dr. Mohammed Alruby