Surgically Facilitated Orthodontic Therapy: An Interdisciplinary Approach

Description

This book covers all aspects of Surgically Facilitated Orthodontic Therapy and is intended to guide practitioners involved in dental interdisciplinary therapy to managing complex cases. It demonstrates the next level of collaboration through managing core problems of the patients and planning cases using digital dentistry for enhanced disclosed and more ideal outcomes. Methods for regaining space appropriation and dentoalveolar bone engineering are illustrated. Emphasis is placed on corticotomy assisted orthodontic therapy and 3D planning in order to help practitioner to achieve outcomes that were previously unrecognized. The book is written by leading experts in the field and is a rich source for periodontists, oral and maxillofacial surgeons, orthodontists and restorative clinicians interested in the subject. Foreword Preface Acknowledgments Contents Editors and Contributors About the Editors Contributors Part I: Embryologic Basis of Bone Formation in the Human Craniofacial Skeleton and Its Relation to Malocclusion in Interdisciplinary Dentofacial Therapy Embryologic Development of the Jaws The Embryologic Basis for Bone Formation in the Human Craniofacial Skeleton Introduction Embryology of the Craniofacial Bones [1] Development of the Maxilla and Mandible Development of the Periodontium Common Goals of Embryogenesis, Constructive and Reconstructive Therapy Epigenetic Factors Influencing Development of the Maxilla and Mandible Implications of Normal Anatomy and Tooth Loss Frequency, Causes, and Consequences of Tooth Loss in the Adult Human Evaluating and Intercepting Resorptive Patterns The importance of socket grafting in maintaining physiologic proportional ridge volume The Functional Matrix Concept: Signaling Among Tissues by a Unifying Conduction System Classification of Residual Ridge Resorption Basic Summary Questions Regarding CBCT Ridge Assessment References Dental Space Deficiency Syndrome: An Anthropological Perspective Introduction Concepts Associated with Malocclusion and Tooth Crowding Dental Space Deficiency Syndrome, (DSDS): Classifying a New Syndrome for an Evolving Problem Gingival Recession—The Clinical Clue of Alveolar Bone Deficiency Radiographic Supporting Bone Index (RSBI) Classification Pathogenesis of Gingival Recession Tools for Analyzing Available Space for Orthodontic Tooth Movement, in a 3D Context Utilizing CBCT Imaging Opportunities to Overcome Mother Nature: Phenotype Modification Therapy and SFOT/PAOO (Image 14) Summary and Conclusion References Bone. The Foundation of a Smile Periodontal, Dentoalveolar Bone, and Dental Implant Surgery. A New Vision The Functional Matrix Hypothesis: Clinical Implications of Interactions Among Nerve, Muscle, and Osseous Tissues Important Characteristics for Osseointegration and Stability The Pivotal Importance of Biologic Cross-Talk in Terms of Successful Bone Grafting Tissue Engineering and Biologic Coupling Bone Graft Options When Constructive Surgery Is Needed Mechanotransduction and Tensegrity Mechanotransduction: A bottom-Up Departure from a Typical Top-Down Clinical Approach Tensegrity: Biology-Based Engineering and Vice Versa Pivotal Importance of Alveolar Remodeling and Facial Bone Thickness Assessments of Cranial Base Growth Centers, Condylar and TMJ Parameters, and Craniofacial Developmental and Autoimmune Disorders Sinus Bone Grafting (Sinus Floor Elevation or Sinus Lift) Virtual Treatment Planning Material Choices for Alveolar Augmentation Biomolecules: Morphogens and Mitogens Tissue Engineering: The Treatment of Choice The Use of BMP-2 in Conjunction with Implants References Part II: Patient Assessment, Co-discovery, Diagnosis and Planning the Vision Co-Discovery: A Pathway to Meaningful and Essential Treatment The Co-Discovery Process References Patient Assessment Determining the Position of the Central Incisors for Esthetics, Function, and Airway Facially Generated Treatment Planning Esthetics Facial and Dental Esthetics Tooth Position Arrangement Contour Color CORE Esthetic Values Facial Height Lip Length Lip Mobility Gingival Levels Tooth Length CEJ Dentofacial Analysis Digital Smile Design (DSD) Joint Based Malocclusion Airway Considerations Template 1 Treatment Planning Session Treatment Planning Session Diagnosis/Problem List Esthetic Occlusal/Functional Dental/Structural Integrity Biological/Periodontal – Endontic Patient Considerations Alternative Treatment Options References The IDT Action Plan: Developing and Planning the Vision Diagnostics in Contemporary Interdisciplinary Dentofacial Therapy (IDT) References Sleep Disordered Breathing Considerations and Screening in Patient Assessment and Treatment Planning Introduction The Importance of Screening The Role of Dental Professionals Methods of Screening for Sleep-Disordered Breathing in the Dental Practice High Resolution Pulse Oximetry High Resolution Pulse Oximetry and Oral Appliance Therapy Future Direction for Dentistry References Role of Oral and Maxillofacial Radiologist in Contemporary Interdisciplinary Dentofacial Therapy Utilizing CBCT Technology Introduction Pretreatment Evaluation with CBCT Volumetric Analysis Phase Neighboring Anatomy Skull Base Carotid Artery Calcification Paranasal Sinuses and Nasal Cavities Maxillary Sinuses Odontogenic Sinusitis Non-odontogenic Sinusitis Acute and Chronic Sinusitis Antroliths Mucous Retention Pseudocysts Mucocele Maxillary Sinus Polyps Pterygopalatine Fossa Airway Evaluation Tonsilloliths TMJ Evaluation Analysis Phase Cephalometric Analysis to Evaluate the Craniofacial Relationships Treatment Planning Phase Documenting Existing Periodontal Phenotype Using CBCT Dentoalveolar Bone Analysis Quantification of “Lack of Sufficient Bone” Via CBCT Analysis and General Plan to Graft Bone Imbrication of Teeth and Radiographic Assessment of Alveolar Bone Thickness Artifacts Post-treatment Evaluation Conclusion References Assessing the Temporomandibular Joint Condition in Surgically Facilitated Orthodontic Treatment planning Introduction Normal TM Joints Structurally Altered TM Joints The Impact of Disk Displacements in the Growing Patient TM Joint Evaluation Key Aspects to the TM Joint Screening Exam of a Patient History Intake from the Patient Occlusal and Facial Exam of the Patient Load Testing of the TM Joint Complex TM Joint Auscultation Range of Mandibular Motion Muscle Palpation Treatment Planning References Part III: The Orthodontic Perspective The Transverse Dimension: CBCT Treatment Planning in Growing Children Why Are We Narrow? The Importance of the Transverse Dimension Why Use CBCT to Evaluate the Transverse Dimension Orthodontic Diagnosis and Treatment Planning of the Transverse Dimension Using CBCT Surface Map Modeling Implications for Adult Orthodontic Patients Summary References Goal-Oriented Treatment Planning with Corticotomy-Facilitated Orthodontics Introduction Treatment Planning with the Ideal Tooth Position Relative to the Face and Skeletal Base Ideal teeth Positions—Three-Dimensional Goals Corticotomy-Facilitated Orthodontics as a Treatment Alternative A Segmental Approach Clinical Applications Case Example Initial Presentation Problem List Goals of Treatment Treatment Plan and Therapy Results Conclusions References Pre-surgical Orthodontic Therapy Orthodontic Diagnosis: The Foundation of Stable Treatment Foundational Diagnosis Temporomandibular Joint (TMJ) Foundation Diagnosis Airway Foundation Diagnosis Oral Muscle Foundational Diagnosis Alveolar Bone Foundational Diagnosis Maxillary Anterior Region Maxillary Anterior Thick/Thick Phenotype Maxillary Anterior Thick/Thin Phenotypes Maxillary Anterior Thin/Thick Phenotypes Maxillary Anterior Thin/Thin Phenotypes Mandibular Anterior region Mandibular Anterior Thick/Thick Phenotype Mandibular Anterior Thick/Thin Phenotypes Mandibular Anterior Thin/Thick Phenotypes Mandibular Anterior Thin/Thin Phenotypes The Maxillary Posterior Region Maxillary Posterior Thick/Thick Phenotype Maxillary Posterior Thick/Thin Phenotypes Maxillary Posterior Thin/Thick Phenotypes Maxillary Posterior Thin/Thin Phenotypes The Mandibular Posterior Region Mandibular Posterior Thick/Thick Phenotype Mandibular Posterior Thick/Thin Phenotypes Maxillary Posterior Thin/Thick Phenotypes Mandibular Posterior Thin/Thin Phenotypes Orthodontic Diagnosis: Facial and Smile Esthetics Ideal Position of Maxillary Anterior Teeth Orthodontic Diagnosis: Functional Occlusion Ideal Position of Upper Incisors Dictates Lower Incisors Management of Anterior-Posterior (A-P) Problems in the Skeletally Mature Patient Using SFOT Transverse Analysis Transverse Analysis of Maxilla Transverse Analysis of Mandible Management of Transverse Problems in the Skeletally Mature Patient Using SFOT SFOT and the Impact on Expanding Oral Cavity Volume and Airway Dimensions: The Intersection of Dentistry and Health Pre-surgical Orthodontic Preparation Factors for Determining the Location of Surgical Intervention(s) Factors for Determining Timing of Surgical Intervention Mechanics of Tooth Movement Clear Aligner System Implications Communication to Specialists Flow for SFOT Patients Case #1: Case Set Up and Communication for SFOT to Relieve Excessive Anterior Crowding and Improve Oral Cavity Volume in a Skeletally Mature Adult Case #2: Class III Patient with Orthognathic Surgical Plan Case #3: Class II Patient with MSE and Bimaxillary Advancement Planned Managing Risk: What Happens When We Don’t Look Closing Remarks: The Role of the Orthodontist as the Dentoalveolar/Alveoloskeletal Bone Engineer References Management of Skeletal Class II Malocclusion: Historical Challenges and New Opportunities Orthodontic Boundary Limits Diagnosis of Craniofacial and Dentoalveolar Complex 2D vs 3D Imaging Efficacy of CBCT Orthodontics and Gingival Recession Dimensional Changes of Dentoalveolar Gingival Complex Prevalence of Gingival Recession: No Orthodontic Treatment Post-Orthodontic Treatment and Gingival Recession Inclination of Mandibular Incisors and its Limitation Symphysis and Gingival Recession Does Compensatory Bone Formation Occur After Labial Tooth Movement? Compensatory Bone Formation Dentoalveolar Bone Deficiency Orthodontic Boundary Limits of Mandibular Incisor Advancement What Is the Limitation of Tooth Movement? Conclusion References Distraction Osteogenesis Maxillary Expansion (DOME) and SFOT for Naso-Maxillary Expansion in Obstructive Sleep Apnea (OSA) Introduction Rapid Palatal Expansion (RPE) Miniscrew-Assisted Rapid Palatal Expansion (MARPE) Distraction Osteogenesis Maxillary Expansion (DOME) (Figs. 1 and 2) Conventional DOME Minimally Invasive Nasal Endoscopic (MINE) DOME Difference Between SFOT and DOME Combination of SFOT and DOME References 3D Orthodontic Diagnosis, Planning, and Treatment Introduction Utilizing the SureSmile® System for 3D Modeling and Analysis to Develop the Interdisciplinary Treatment Plan SureSmile® Models Components of Diagnostic Simulations Patient Example of Team Sequencing: Problems with Traditional 2-Dimensional Diagnosis and Treatment Case Study: Transfer Patient. Treatment Out of Control. Significant Ortho-perio Issues. Treated with TADs, Augmentation, and Piezocision Radiographic Evaluation Treatment Considerations Simulated Treatment Plan Summary of Treatment Plan Final Result Initial Premium Diagnostic Model (Fig. 67) Post Treatment Premium diagnostic Model Conclusion References Digitally Guided Orthodontic Planning and Simulation Including Implant Placement SFOT in Combination with Pre-orthodontic Implant Placement SFOT and Esthetic Crown Lengthening with Digital Planning Surgical Facilitated Orthodontics Treatment in Combination with Prosthetically Guided Orthodontics Diagnostic Phase: Periodontics, Orthodontic, and Restorative Periodontics Orthodontics Restorative Teeth Size and Orthodontic Setup Bracket Ideal Position Orthodontic Movement and SFOT Final Restorations References Digital Smile Design (DSD) and Surgically Facilitated Orthodontic Therapy (SFOT) Introduction Concepts of Full Digital Workflow (FDWF) Reference Case I: Zhao—Case Details Case II: Ortho-Orthognathic References Part IV: The Periodontal Perspective Dentoalveolar Bone in Orthodontic Patients: The Periodontal Perspective Evolution, Development, and Physiology of the Dentoalveolar Bone Evolution of the Human Jawbone and Dentoalveolar Bone Anatomy and Physiology of Dentoalveolar Bone How Tooth eruption and Development of the Periodontium Impact Alveolar Bone Natural Course of Aging on Dentoalveolar Bone The Effect of Aging on the Volume and Plasticity of Dentoalveolar Bone Resorptive Field and Muscle Attachment—Functional Theory The Impact of Osteoporosis-Related Drugs and Systemic Factors on Dentoalveolar Bone Dentoalveolar Bone Considerations for Adult Orthodontic Treatment Orthodontic Treatment in Patients with Active Periodontal Disease and Reduced Periodontium Orthodontic Treatment in Reduced Periodontium and Deficient Alveolar Ridge Orthodontic Tooth Movement Through Bone Grafting and Augmented Alveolar Ridge Orthodontic Treatment in Patients with Thin Periodontal and Dentoalveolar Phenotype Phenotype Modification and Augmentation for Adult Orthodontics Hard Tissue Augmentation Soft Tissue Augmentation Conclusion References Phenotype Modification Therapy: New Challenges and Opportunities Evolution of Appreciation of Gingival Tissues The Cognitive Clinical Approach to PhMT Improving Gingival Phenotype for Restorative Treatment Restoratively Driven Needs for Phenotype Conversion Restoratively Driven Needs for Phenotype Conversion in Patients with Dental Implants Orthodontic Driven Needs for Phenotype Conversion The Biology of SFOT/PAOO SFOT Decision Process and Clinical Management Conclusion: Incorporation of PhMT to Improve Clinical Outcomes References Regional Acceleratory Phenomenon in Surgically Facilitated Orthodontic Therapies Regional Acceleratory Phenomenon Overview Corticotomy and Orthodontic Methodologies Cell Types Involved in Alveolar Bone Modeling and Orthodontic Movement Osteoclasts Osteoblasts Osteocytes Mediators of Bone Resorption Activity RANKL and OPG Macrophage Colony-Stimulating Factor (M-CSF) Prostaglandins Cytokines Molecular Aspects of Surgical and Orthodontic Force Effects Upon Bone Resorption Mediators of Bone Apposition Activity Human Mesenchymal Stem Cells (MSCs) Transforming Growth Factor (TGF)-β1 VEGF Bone Morphogenetic Proteins (BMPs) The Role of Surgical Interventions in Bone Apposition Coupling of Resorption and Apposition in Selective Alveolar Corticotomies Combined with Orthodontic Treatment References Anesthesia Pain and Anxiety Control for Surgically Facilitated Orthodontic Treatment Procedures Introduction Risk Stratification in Periodontal Surgery Patient and Facility Selection What Are the Levels of Anesthesia Available to this Patient Population? Advantages of Providing General Anesthesia How Does Advanced Anesthesia Care Enhance the Quality of Surgically Facilitated Orthodontic Therapy (SFOT) Treatment? Moderate and Deep Sedation Newer Anesthetics for Deep Sedation Modern Inhalation Anesthetics in General Anesthesia Laryngeal Mask Airway (LMA) Video-Assisted Laryngoscopy Flexible-Tip Endotracheal Tubes Electroencephalograph-Driven Monitoring Management of Postoperative Nausea and Vomiting (PONV) as well as Post-surgical Pain Are Essential for the success of Ambulatory and Office-Based Anesthesia Management of Postoperative Pain The Value of the Surgical/Anesthesia Team Approach Facility Accreditation References SFOT Surgery Medical Workup, Risk Assessment, and Presurgical Considerations Introduction Comprehensive Radiographic Assessment: An Integral History Taking Component Addressing the Patient’s Systemic Health in Relation to Oral Status The Medical History Interview Airway Assessment and Management Capabilities Medication History and Potential for Drug Interactions Laboratory Testing of Whole Blood/Serum Stress and Mental Disorders and Their Bearing on SFOT Outcomes Psychological Appraisal as a Component of Medical History/Presurgical Testing Summary and Diagnosis Presurgical Workup. Putting It All Together Surgically Facilitated Orthodontic Therapy Case Setup and Planning. The Facially Prioritized Approach Introduction Facially Prioritized Interdisciplinary Workflow Jaws-to-Face Planning. Combining the Orthodontic, Periodontal, Surgical, and Restorative Team SFOT as an Adjunct to Orthognathic Surgery Restorative Leadership Importance of 3D Imaging in the Restorative-Surgical Workflow Salivary Diagnostics: Its Current and Future Impact on SFOT Outcomes and IDT Risk Assessment Periodontal Inflammation Risk Genetics Periodontal Inflammation Risk Influencers Objectives of Salivary Diagnostic Assessment How Does Periodontal Inflammation Risk Affect Surgical Decision-Making? CBCT and Risk Assessment Characterizing the Orthodontic Walls: Classifying Dentoalveolar Bone Phenotypes Background Crestal and Radicular Dentoalveolar Zones and Associated Bone Phenotype Classifications Rationale for Dentoalveolar Bone Phenotype Classification in SFOT Conclusion CBCT and Risk Assessment Risk Assessment in Orthodontic Tooth Movement. Using CBCT Imaging to Classify Dentoalveolar Bone Phenotypes, Dentoalveolar Bone Deficiencies, as well as Alveoloskeletal Discrepancies Introduction Surgically Facilitated Orthodontic Therapy (SFOT): A Systems-Focused Approach for Correcting Dentoalveolar Deficiences and Alveoloskeletal Discrepancies Key Questions for Clinicians in SFOT Treatment Planning Five Rationales for Considering SFOT Outcomes Alveoloskeletal Phenotype Considerations Occlusal Problems Limitations of CBCT in Assessment of DA and AS Phenotypic Details Use of CBCT for Diagnosis and Management of Periodontal Defects Why Use CBCT? Protocols and Policies for Safety in the SFOT Surgical Practice Room Setup and Instrumentation. Standardization of Practice for Reproducible Safety Patient Management Protocol: The Day of Surgery Workflow SFOT Instrumentation: Procedure-Specific Armamentarium Intraoperative Record Visualization Postoperative Patient Assessments Insurance Considerations SFOT Surgery Incision Design and Flap Management SFOT Surgery Managing Crestal Bone and Esthetic Crown Enhancement/Osseous Surgery and Indications for Biologic Width Positioning Around Natural Teeth Introduction Surgical Assessment of the Dentogingival Complex SFOT Surgery Dentoalveolar Bone Tissue Engineering Particulate Bone Grafting Options in SFOT. Overview Guided Periodontal Tissue Regeneration and Guided Bone Regeneration in SFOT. Historical Perspective Regeneration of Dentoalveolar Bone Deficiencies or Defects with and Without Attachment Loss in SFOT. Rationale The PASS Principles Balancing Clinical Evidence and Judgment Gingival Recession and Mucogingival Considerations in SFOT The Use of Barrier Membranes in SFOT Surgery The Addition of Antibiotics to Particulate Bone Grafts Additional Mucogingival Therapy Modalities SFOT Surgery Deciding on Corticotomy Surgery or Osteotomy SFOT Introduction Mechanism of Action Definitions: Corticotomy and Osteotomy Corticotomy: Combining Preference, Versatility, Sophistication, Staging, and Non-retractive Orthodontia Systemic Considerations Future Directions and Biomaterials Used in SFOT Additional for Barrier Membrane Considerations in Corticotomy SFOT and Combined Dentoalveolar Bone Augmentation Surgery Impact of Perioral Muscular Strain SFOT Surgery Management of Periodontitis in Interdisciplinary Dentofacial Therapy Involving SFOT Introduction Prognostic Considerations Baseline Mobility: A Key Prognostic Variable Staging SFOT and Pre-augmentation Considerations Use of Xenografts in Periodontal Surgery-Based SFOT Importance of (and Obstacles to) the Interdisciplinary Dynamic Restorative Considerations Within the SFOT Treatment Plan Post-SFOT Esthetic Considerations The Role of Temporary Anchorage Devices (TADs) and Anchor Plates Temporary Anchorage Devices Anchor Plates SFOT Surgery The Role of Bone Graft (BG) Enhancement/Biologics Via Growth Factors in SFOT Recombinant Human Platelet-Derived Growth Factor (rhPDGF) Bone Morphogenetic Proteins (BMPs) Platelet-Rich Fibrin (PRF) Platelet-Rich Plasma (PRP) Plasma Rich in Growth Factors (PRGF) [514, 843, 964, 984, 1034–1048] Enamel Matrix Derivative Protein (EMD) [75, 728, 736, 787, 788, 815, 958, 996, 1049–1063] Flap Closure and Suture Design Postoperative Management of SFOT Cases Complications CBCT Imaging and Defining Success The Deceptive Nature of Radiographic Bone Augmentation Success Versus Histologic Success That Can Maintain Mechanotransduction Long Term Questions the Clinician Should Ask/Answer When Interpreting a CBCT Scan Wound Healing, Osteoconduction, and Osteoinduction Outcome Considerations Assessment of Bone Graft Outcome Success Using CBCT Imaging Analysis—Critical Points for Evaluation Modeling of Case Types to Assist in CBCT Treatment Planning Seromas Summary and Future Directions References The Use of Temporary Anchorage Devices in Surgically Facilitated Orthodontics Introduction Historical Background in Osseous Anchorage Use of Mini-Implants Introduction of Surgical Miniplates Temporary Anchorage Devices (TADs) Micro-Implants and Mini-Implants Driving Design of Micro-Implants Applications of Micro-Implants for Skeletal Anchorage (Tables 1 and 2) Miniplates Design Clinical Examples of Miniplate Applications Clinical Examples of Micro-Implants Applications Discussion References Local Applications of Corticotomy and Bone Grafting for Difficult Orthodontic Tooth Movement Introduction Evolution of Alveolar Bone Surgeries for Orthodontic Treatment The Localized Nature of Regional Acceleratory Phenomenon (RAP) Local vs. Full Mouth Applications Clinical Indications of Local Corticotomy for Difficult Orthodontic Movements Clinical Indications of Local Corticotomy for Difficult Orthodontic Movements Molar Intrusion Molar Distalization/Uprighting Molar Mesialization and Bodily Movement Tooth Movement Through the Sinus Maxillary Transverse Deficiency and Posterior Crossbite Correction Anterior Crossbite Correction High-Positioned and Angled Canine Exposure Severe Tooth Rotation Implant Site Development Occlusal Plane Canting The Speed and Treatment Duration of Corticotomy-Assisted Orthodontics The Duration of the RAP and Periodontal Healing After Corticotomy and Bone Grafting Can We Gauge the “Ideal” Timing for Surgical Application and Orthodontic Activation? Additional Considerations Control of the Anchorage Iatrogenic Root Damage Patients with Reduced Periodontium and Thin Phenotype Clinical Considerations of Different Bone Grafting Materials Papillary Recession and Scar Formation Patient Acceptance to Local Application Conclusion References Part V: The Maxillofacial Perspective Overview and Perspective of TMJ Surgery in Skeletal Malocclusion Introduction How to Recognize a Patient with Temporomandibular Joint Pathology Pain Pain Pie 1 Pain Pie 2 Pain Pie 3 Basic Concepts in Joint Pain Complex Regional Pain Syndrome Orofacial Pain and “TMD” Diagnostic Nerve Blocks Does your Patient Have TMJ Pain? Temporomandibular Joint Anatomy Imaging Evaluation of the TMJ Foundation with MR The Piper Classification Piper Classification of Bone Pathology Evaluation of the TMJ Foundation with CT Joint-Based Occlusion The Static Occlusion The Dynamic Occlusion Changes in the Occlusion Related to TMJ Pathology Changes in the Skeleton Related to TMJ Pathology Changes in the Airway Related to TMJ Pathology TMJ Surgery Case Example 1.0 Summary Treatment Algorithm References Surgically Facilitated Orthodontic Treatment and Orthognathic Surgery The Four Fundamental Relationships Tooth-to-Tooth Tooth-to-Jaw Jaw-to-Jaw Jaws-to-Face References Contemporary Skeletal Surgery for Obstructive Sleep Apnea Introduction Stanford Sleep Surgery Algorithm: Past and Present Patient Evaluation—History, Physical, Nasal, and Pharyngeal Exam, Drug-Induced Sleep Endoscopy Distraction Osteogenesis Maxillary Expansion (DOME) Maxillomandibular Advancement Surgery Surgically Facilitated Orthodontic Therapy Conclusion Appendix Interdisciplinary Care Team Orthodontist Periodontist Sleep Surgeon Sleep Medicine General Dentist References Part VI: Putting It All Together. Case Presentations Case Presentations and Lessons Learned Case Presentations Arnie 2009—Case #1 Wayne 2012—Case #2 John 2014—Case #3 John 2014—Case #4