Download Early Orthodontic Treatment:

1/26/2015
Extraction/
NonExtraction
Records and
Ethics
Point/Counterpoint:
Class III
* Mini-Plates
Orthodontic Camouflage of Class III
Early Orthodontic
Treatment:
* Facemask
* Camouflage
Practice
Management
Sleep
Disordered
Breathing
Class III Treatment
Vertical
* Mini-Plates
* Orthopedics
* Camouflage
Marketing
Who,
When, Why and How to
Treat
Growers/Open
Bites
Class II
Treatment
Ectopic Teeth
Parent/Child
Management
Trauma
Orthodontic Goals:
For Class III camouflage-prioritization required
Reference--WITS
Goals/Options
Pts w Class III
Conditions
Timing
Non-growing
R
i
s
k
/
C
o
s
t
Initial
Differential
Diagnosis
F unction
R2 eliable/Realistic
E2 sthetics/Economic
S2 tability/Satisfaction
H ealth
Approach
Secondary
Differential
Diagnosis
Proffit/Ackerman
Class III Treatment Approaches
Double
Jaw Surg
R
i
s
k
/
C
o
s
t
$50-60K
S.O.F.T.
Procedure
Single Jaw
Surg
$8-10K
$40-45K
Orthodpedics
w plates
Distraction
w Plates
$3-5K
$12-16k
Camouflage-Non-growing
Camouflage
w
Orthopedics
Camouflage-Growing
Severity / R e w a r d
Severity / R e w a r d
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Treatment decision in adult patients with Class III
malocclusion: Orthodontics or orthognathics?
Stellzig- Eisenhauer, et al.:
AJODO: 2002; 122:27-38.
Treatment decision in adult patients with Class III
malocclusion: Orthodontics or orthognathics?
Stellzig- Eisenhauer, et al.:
AJODO: 2002; 122:27-38.
1.Key
Cephs
of 175— 87 non-surg;
surg. Group
reference
to 88
review
1.Key
Cephs
of 175— 87 non-surg;
surg. Group
reference
to 88
review
Treatment decision in adult patients with
Class III malocclusion:
Orthodontics or orthognathics?
AJODO: 2002;122:27-38.
Underestimation of Effectiveness
2. 20 linear, proportional and angular measures
discriminant analysis
3. “Research effort to provide cephalometric
yardsticks that would make the treatment
decision more objective.”
Wits showed highly significant differences
2. 20 linear, proportional and angular measures
discriminant analysis
3. “Research effort to provide cephalometric
yardsticks that would make the treatment
decision more objective.”
Camouflage Therapy
Craniofacial Characteristics
•
Median Wits for Class III non surg = - 4.71mm.
Median Wits for Class III surgical = - 12.97mm.
Only 2.3% of non surg misclassified
13.6% of surg misclassified
(Median Wits was =
-7.21mm for misclassified)
•
•
•
Moderate basal bone discrepancy:
Both jaws contribute60% maxillary retrusion/
40% mandibular excess
Adequate aveolar bone and gingivae for
incisor reangulation
Minimal mandibular asymmetry (< than 5mm)
Minimal max. vertical excess or deficiency
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Camouflage Therapy for Class III patients
Behavioral Characteristics of Patient
1.
2.
Existing facial proportion acceptable to patient (Needs to be
discussed as part of treatment planning options)
Proposed angular changes of teeth acceptable to patient
Camouflage Therapy
Underestimation of Effectiveness
Four General Types:
1. Camouflage thru differential extraction
2. Camouflage thru non-extraction
3. Camouflage—add teeth (eg. missing #7 and 10)
4. *Camouflage thru soft tissue procedures
(Cosmetic/Surgical)
The Orthodontist’s
10-15 Billion Dollar Decision
Reference--WITS
Camouflage or surgery? Class III adults
Goals/Options
Pts w Class III
Conditions
Timing
Non-growing
Measurement of WITS from Ceph w pt in centric occlusion
Pts w Class III
Conditions
Timing
Initial
Differential
Diagnosis
Initial
Differential
Diagnosis
Approach
Secondary
Differential
Diagnosis
Proffit/Ackerman
Class III camouflage?
Approach
Secondary
Differential
Diagnosis
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Orthodontic Goals:
For Class III camouflage-prioritization required
F unction
R2 eliable/Realistic
E2 sthetics/Economic
S2 tability/Satisfaction
H ealth (Minimally invasive)
Kourey, Epker: The aged face: the facial
manifestations of aging. IJAO&OS: 1991;681-95.
Ortho. camouflage (U4 ext) in adult Class II cases
can have a definite impact on facial aging.
Class III – Camouflage?
Classic case of goal prioritization
F. R. E.S.H.
Esthetics Versus Economics
$55,000 saved
Camouflage Therapy
Underestimation of Effectiveness
Other considerations w camouflage
recommendation:
“Youthful appearance has a welldefined mandibular line and good
definition between face and neck.”
“The aged face…
Kourey, Epker: The aged face: the
facial manifestations of aging.
IJAO&OS: 1991;681-95.
Author’s Note:
Many non-growing skeletal Class III’s can be well
treated with minimal compromise and significant
patient satisfaction through proper application of
the principles of camouflage therapy.
What are the key principles?
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Key Principles of Camouflage
For Class III patients
• Clear diagnosis of degree of skel problem
(Template for both doctor and patient understanding) Graber
• Explain options: “ideal versus practical”
(What are the downsides of practical plan—your view)
• In treatment plan write-up—indicate both plans and why
practical was chosen (risk/benefit issues; pt. Issues)
• Avoid over-retraction of lower incisors or protraction of
upper incisors
(Frequently requires non-x upper, & if crowding en. re-contouring
and gingival grafting to accomplish non-x goal on upper arch. Also
add congenitally missing teeth and enlarge small laterals.)
Checklist for Non-Growing Class IIIs
Craniofacial Characteristics
 Moderate basal bone discrepancy:
 Both jaws contribute-Example
60% maxillary retrusion
40% mandibular excess
 Adequate aveolar bone and gingivae for incisor
reangulation
 Minimal mandibular asymmetry (< than 5mm)
 Minimal max. vertical excess or deficiency
Behavioral Characteristics of Patient
 Existing facial proportion acceptable to patient (Needs
to be discussed as part of treatment planning options)
 Proposed angular changes of teeth acceptable to patient
Tx. Plan for 61 yr. Class III old male:
Initial tx. plan for 61 yr. Class III old male:
•
•
•
•
Extract upper 2nd bis
Decompensate incisors
Advance Max. approx 5mm
Set mandible back approx 3mm
ANB = -3.0
Wits = -15
Mx/Mn = 41
•
•
•
•
Extract Upper 2nd bis
Decompensate
Advance Max.
Set mandible back
Age 61:1, Wits -15
Therapeutic dx. with modified ORTA w post. bite plane
Age 61:1, Wits -15
62:11, Wits -8.5
During early Class III elastic traction Fax came from Florida: “…………………………….”
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Therapeutic dx. with modified ORTA w post. bite plane
Initial tx. plan for 61 yr. Class III old male:
•
•
•
•
Extract upper 2nd bis
Decompensate incisors
Advance Max. approx 5mm
Set mandible back approx 3mm
ANB = -3.0
Wits = -15
Mx/Mn = 41
Age 61:1, Wits -15
62:11, Wits -8.5
During early Class III elastic traction Fax came from Florida: “…………………………….”
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Therapeutic Diagnosis
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15 year follow-up
“Force systems are your medicine”
Weinstein/Haack
Growing
Class III Pts.
Timing
LABORATORY STEPS ORTA—Orthodontic removable traction appliance
Stone Model
1. Trim for vacuum form;
2. Relieve undercuts (except “retentive ridges”)
3. Check for retention of “retentive ridges”;
NOTE: use smaller retentive ridges with less retention when using biocryl for RTA
4. Make sure that “retentive ridges” are large enough on the tooth for adequate retention;
Then, when the model is poured up, lightly scrape plaster around the area of the “retentive
Durasoft Material (Great Lakes Orthodontic Products)
Essix “C”
2. Price @ $4.99 per sheet
Price @ $0.59 per sheet
Vacuum Form to model
1. Trim with diamond disc
2. Smooth edges with diamond bur
3. Be sure to leave > 2 mm under retentive ridges to aid in retention
Add Caplin Hooks (GAC) for elastic traction—heat & attach
Lower ORTA for Class III Traction
The Checklist Manifesto:
How to Get Things Done Right
Atul Gawande
“That means we need a different strategy for overcoming failure:
one that builds on experience and takes advantage of the
knowledge people have but somehow also makes up for our
inevitable human inadequacies. And there is such a strategy—
though it will seem almost ridiculous in its simplicity, maybe even
crazy to those of us who have spent years carefully developing
ever more advanced skills and technologies.”
It is the checklist.”
1. Heat Caplin hook (GAC International) with torch and place in the area of desired traction.
2. After inserting the hook into the plastic (essix, biocryl or durasoft) material, check the
underside to make sure that the hook is not showing through the plastic
3. Pull hook to be sure it’s attached to material securely; it should not be able to be detached
from elastic pull.
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Additional variables that need consideration:
(1) HGH therapy affects the growth of the
mandible more than the growth of the maxilla;
(Seldom discussed but can be critical)
19:3
(-13mm)
(2) the amount and pattern
ofafter
growth
during
15:5 Pretx (-8mm)
HGH administration are unpredictable, and
 Psychological factors of appearance
Hormone therapy & growth
 Transverse deficiency of maxilla (skeletal component);
(3) HGH therapy rarely affects dental maturity.
Am J Orthod Dentofacial Orthop.
2004 Jul;126(1):118-26.
space available (dental component)
 Clockwise growth & excessive mand. growth
 Asymmetrical growth
 True condylar hyperplasia
Short stature/Class III: Rx human growth hormone
Chapter 16: 75 + references
Class III: The Evidence on
Diagnosis and Treatment
J. Gahfari, et al:
Checklist (at Phase II ) for Class III-ing Pts.
Patient’s Name:___ __
Male
Female











Age ________Skel. Age_____
Family history
Yes
No_____________________
Initial diagnosis (mnd excess)
Yes
No (%Max vs. Mand)______
Response to Ph I
Good Fair
Poor__________
Diagnosis @ Ph II (Wits)
Better Same Worse
Facial balance
Mild
Mod.
Severe
Skeletal age @ Ph II
Favorable
Unfavorable__________
Growth pattern
Favorable
Unfavorable (asym/open)
Ging Health/Root length
Favorable
Unfavorable__________
Capacity to Camoflague
Favorable
Unfavorable__________
Compliance
Favorable
Unfavorable __________
Growth hormone
Yes
No
Phase II Decision Time:
Non-surg;
Thera dx; Wait & plan surg
• “Treat early for more effect”
• “Chin cup success is
• questionable”
• “Tx is better than no tx.”
• “ Over-treat for stability”
• “Forecasting growth is difficult”
.
Principles applied--5 case examples
Case #1
A. C.--Pre-Treatment
When a young patient is Class IIIing-what is the
role of camouflage in treatment management
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Checklist Phase II conference for Class III-ing Pts.
Wits -5 mm
Patient’s Name:___ _Alicia C_
Male
Female











Family history
Initial diagnosis (mnd excess)
Response to Ph I
Diagnosis @ Ph II (Wits)
Facial balance
Skeletal age @ Ph II
Growth pattern
Ging Health/Root length
Capacity to Camoflague
Compliance
Growth hormone
Age ________Skel. Age_____
Yes
No_____________________
Yes
No (%Max vs. Mand)______
Good Fair
Poor__________
Better Same Worse
Mild
Mod. Severe
Favorable
Unfavorable__________
Favorable
Unfavorable (asym/open)
Favorable
Unfavorable__________
Favorable
Unfavorable__________
Favorable
Unfavorable __________
Yes
No
Phase II Decision Time: Non-surg;
Orthopedics + Camouflage + Fx Shift Elim.
+ Clockwise rotation of “B” point ***
Checklist
Case #2:
Intervene now or wait? 4:1 female
Unilateral repaired cleft lip and palate
(at Phase II Conf.) for Class III-ing Pts
Patient’s Name:___ __Amber A.
Male
Female











Thera dx; Wait & plan surg.
Family history
Initial diagnosis (mnd excess)
Response to Ph I
Diagnosis @ Ph II (Wits)
Facial balance
Skeletal age @ Ph II
Growth pattern
Ging Health/Root length
Capacity to Camoflague
Compliance
Growth hormone
Phase II Decision Time:
Age ____ Skel. Age____
Yes
No__Unilateral cleft w D. A. C.
Yes
No (Max% >Mand)______
Good Poor____________________
Mild
Mod. Severe
Mild
Mod. Severe
Favorable Unfavorable__________
Favorable Unfavorable (asym/open)
Favorable Unfavorable__________
Favorable Unfavorable__________
Favorable Unfavorable __________
Yes
No
Non-surg;
Thera dx; Wait & plan surg.
Early intervention with AC reversal & very good growth
response allowed conservative correction.
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Case #3
8:11 Wits -8
1. Initial Diagnosis
2. Phase I—”Ther. Diagnosis”
3. GTRV @ 3 yrs. (Wits)
4. Green; yellow or red
5. Phase II or wait for surgery
Checklist #3
(at Phase II Conf.) for Class III-ing Pts.
All early Class III’s require Therapeutic Dx
Patient’s Name:___ Jamie_F.
Male
Female











Family history
Initial diagnosis (mnd excess)
Response to Ph I
Diagnosis @ Ph II (Wits)
Facial balance
Skeletal age @ Ph II
Growth pattern
Ging Health/Root length
Capacity to Camoflague
Compliance
Growth hormone
Age ________Skel. Age_____
Yes
No_____________________
Yes
No (%Max vs. Mand)____
Good Fair
Poor______________
Mild Mod. Severe
Mild Mod. Severe
Favorable
Unfavorable__________
Favorable Unfavorable (asym/open)
Favorable Unfavorable__________
Favorable Unfavorable__________
Favorable Unfavorable __________
Yes
No
Phase II Decision Time: Non-surg;
Thera dx; Wait & plan surg.
8:11 Wits -8
9:8 Wits -4
20:3 Wits -5
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Case #4:
Pre-tx. Lauren R. 9yrs.
@12 (-11)
@9 (-4.5)
Checklist #4
(at Phase II Conf.) for Class III-ing Pts.
@9 (-4.5)
All early Class III’s require Therapeutic Dx
Patient’s Name:___Lauren R __
Male
Female











Family history
Initial diagnosis (mnd excess)
Response to Ph I
Diagnosis @ Ph II (Wits)
Facial balance
Skeletal age @ Ph II
Growth pattern
Ging Health/Root length
Capacity to Camoflague
Compliance
Growth hormone
Phase II Decision Time:
Age ________Skel. Age_____
@12 (-11)
Yes
No_____________________
Yes
No (%Max vs. Mand)______
Good Fair Poor____________
Mild Mod.
Severe
Mild Mod.
Severe
Favorable
Unfavorable__________
Favorable
*Unfavorable (asym)
Favorable
Unfavorable__________
Favorable
*Unfavorable__________
Favorable
Unfavorable __________
Yes
No
Non-surg;
@15+ (-13)w Asym.
Thera dx; Wait & plan surg.
Case #5
@5.0 (-5.5)
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Checklist #5
Dad = (-7)
(at Phase II Conf.) for Class III-ing Pts
Patient’s Name:___Robin P__________Age ________Skel. Age_____
Male
Female










Family history
Initial diagnosis (mnd excess)
Response to Ph I
Diagnosis @ Ph II (Wits)
Facial balance
Skeletal age @ Ph II
Growth pattern
Ging Health/Root length
Capacity to Camoflague
Compliance
Yes
No_____________________
Yes
No (%Max vs. Mand)______
Good Poor_____________
Mild Mod. Severe
Mild Mod. Severe
Favorable
Unfavorable__________
Favorable
Unfavorable (asym/open)
Favorable Unfavorable__________
Favorable
Unfavorable__________
Favorable Unfavorable __________
Phase II Decision Time: Non-surg;
Surgical
Non-Surgical
Borderline
Thera dx; Wait & plan surg.
@5.0 (-5.5)
-14
-13
-12
-11
-10
M -9
e -8
a
-7
n
@16.0 (-2.5)
-6
W -5
i -4
t -3
s -2
-1
0
6
7
7.2
8
9
10
11
12
12.5
13
13.2
14
15
16
16.5
17
18
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Cephalometric Effects of Class III Treatment
A Comparison of ORTATM and Protraction Facemask
Kristin N. Moore, D.M.D.
Master of science in Oral Sciences Thesis Defense
Conclusions:
ORTATM provides orthodontists with
a useful noninvasive alternative
treatment modality to protraction
facemask in Class III malocclusion.
Similar dental and skeletal results
can be achieved by use of either the
protraction facemask or the ORTATM.
12
10
8
months
6
4
2
O.R.T.A.
0
ORTA
Protraction Facemask
@8.5 (-12)
At 13 (-5)
Case #8
Final Thought
Wits = -7
Jerome Groopman, MD: Second Opinions
“In
a predictable world,
clinical decision making
would be a well defined,
scientific exercise with
set methods for diagnosis
and treatment.”
Patient’s Name:___ Kathleen D.
Male











Age __14:2______Skel. Age__14:8___
Female
Family history
Initial diagnosis (mnd excess)
Response to Ph I
Diagnosis @ Ph II (Wits)
Facial balance
Skeletal age @ Ph II
Growth pattern
Ging Health/Root length
Capacity to Camoflague
Compliance
Growth hormone
Phase II Decision Time:
Yes (mild)
No_____________________
Yes
No (%Max vs. Mand)______
Good
Fair
Poor__________
Better Same Worse
Mild
Mod. (accepts) Severe
Favorable Unfavorable__________
Favorable Unfavorable (asym/open) neutral
Favorable Unfavorable__________
Favorable Unfavorable__________
Favorable Unfavorable __________
Yes
No
Non-surg;
Aggressive orthopedics ASAP:
• RPE; FBO; Facemask
• IPR lower arch
• Re-eval GTRV (Wits @ 4 mos)
Thera dx; Wait & plan surg.
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Measurement of WITS from Ceph w pt in centric occlusion
Reference--WITS
Pts w Class III
Conditions
Timing
Non-growing
Goals/Options/ Prioritize
Initial
Differential
Diagnosis
Approach
“Until more reliable diagnostic
methods are available, perhaps
orthodontists should view the
testing of treatment response
as a tool rather than a
shortcoming.”
Secondary
Differential
Diagnosis
R
i
s
k
/
C
o
s
t
Double
Jaw Surg
$50-60K
Single Jaw
Surg
$40-45K
S.O.F.T.
Procedure
$8-10K
Traditional
Orthopedics
Distraction
w Plates
$12-16k
Orthodpedics
w plates
$3-5K
Camouflage-Non-growing
Camouflage-Growing
Ackerman, Proffit-AJO, 1970
Severity / R e w a r d
Synopsis for use of camouflage for Class III
Achieving Objectives: Successes or Failures?
I. Prioritize goals for Class III patients—F.R.E.S.H.
II. Differential diagnosis— Max./Mand Diff.--*Wits
III. Effective therapeutic measures— ORTA + + +
IV. Treatment response— WITS Changes +++++
“…more logical to categorize patients as ‘responders (R) or nonresponders (NR).’”
In addition, post-treatment relapse patients should be categorized as
“adapters (A) and non-adapters (NA).”
Bell shaped curve—most favorable R and A at one end and most
unfavorable NR and NA at the other end of a normal distribution
curve.
Ackerman, JL (In 5th edition of Graber, Vanarsdall, Vig )
V. Additional variables--Checklist
(Apply the checklist before Phase II)
VI. Application of treatment principles—Individualize
87
88
POINT: CLASS III CAMOUFLAGE VS. ORTHODPEDIC THERAPY
Best minimally invasive outcomes frequently require incorporation of
both treatment modalities—not either/or!!!
Conclusion:
Since force systems are our medicine: Dose, duration
& compliance will effect outcome. It is suitable to increase
dose and duration if initial response not effective. Checklist
(variables) encourages objectivity & communication prior to Phase
II with incorporation of camouflage mechanism to complete
correction.
Our findings indicate: Dentoalveolar camouflage is a very
useful modality in a wide range of Class III skeletal dysplasias.
Minimal deleterious side effects were observed in periodontium.
Proper diagnosis and realistic treatment objectives are necessary!
Parents, patients and doctor must understand the limitations of the
camouflage mechanism.
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