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[Steven Prince]

Hey guys,

Here is a little nice case I was hoping for opinions. Surgical is still on the table of course. I literally walked right into this consult and had no time to gather my thoughts.  And headgear is not an option to help with the vertical. So no ABO answers please, just real world no headgear suggestions. haha.

Steve

PS and yes I have been tracing my cephs when I have second. well lets say  have traced at least ten so far. haha

[Payam Owtad]

Steve joon, 

Here are my quick thoughts (let me know if I am way off from what you are thinking)

- Palatal Expansion (RPE or Quad Helix) to correct posterior x.bite

- Bracket positioning with open bite pattern; Slightly higher bracket positioning for Upper Anteriors. 

- Posterior bite turbos early on, on 7s, 6s, 5s (obviously the turbo on 5 will be little tall) to induce intrusion of posterior segment and avoid creating vertical side effects and opening the bite more than what it is

- Start with light Cl III triangular Elastic (3-6 / 3) 1/4” 4 oz as soon as you are on a 16 or 18 NT then heavier (3/16” 6 oz) when in 19x25 ss.

- Do not use rectangular wire in the mandibular arch PC lower on a 18ss as the lower final wire (potential need for IPR); if Patient is not compliant with elastics then a lower incisor extraction might help to achieve positive OJ. 

- Maintain and if possible increase the Upper anterior torque, by BCT wire bending, close spaces segment by segment (2-2 first, lace 2-2, the 3-2, then lace 3-3 then mesialize 4,5, so fort and so on; not continuous PC U 6-6.  

*** definitely discuss with family about the future potential growth as he is a high angle CL III case and anything can happen with his growth pattern. 

By the way one of the treatment options always could be “No Treatment” :) 

Let me know what are your thoughts about my suggestions, 

Thanks, 

Payam 

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[Hemali]

Steve,

Sorry I didn't get a chance to really look at this sooner. 

Here are some thoughts:

1) let the family know of facial/skeletal issues: chin deviation to left and slight maxillary cant 

2) if family is concerned about this, then wait for few years and then start off with pre-surgical Ortho

3) otherwise, I would use a bonded RPE for maxillary expansion. It would prevent the vertical from opening more and may even intrude some. While in expander run some anterior vertical elastics. Patient has a low-ish smile line and can tolerate some extrusion. After expansion, keep posterior bite turbos on 6,7s throughout treatment.

4) then level, align and stay in 018ss on lower throughout treatment and use PC on round wire to retrocline lower anterior slightly to help create OJ. 

5) use elastics as needed. If you have trouble establishing good OJ, then keep space for upper lateral buildups

6) if patient grows unfavorably, then do surgery. 

Hope that helps some!! Let us know what you decide and how it goes!

Hemali- joon hahaha :) 

[Jeremiah Sturgill]

Yea, I agree with everyone....definite open bite potential.  I had a case almost exactly like this last week and I didn't get a chance to see the photo/xray before because we have a new assistant who didn't know I was supposed to review it in the office before meeting the pt, so she led me into the room and all of a sudden I was trying to explain to mom the tx plan while looking at the photos for the first time and trying to come up with a plan, haha..awful!

Anyways, I would do a RPE and add bite turbos to the 5/6/7 because it's the same effect as a bonded except easier to eat/chew and cheaper lab bill...level and align, stay in round lower and class III els from day 1, also do bonded tongue spurs PRN and tell parents he may finish w/ underbite due to growth.

--that's my new thing for cl III pts, I've been telling parents there's always a chance when we finish they may have an underbite due to growth...that way they expect the worst and if you deliver edge to edge they are happy :)

In our office we finish Cl III pts with retainers that have Cl III els cut outs for essix or hoods on Hawley so they can wear els during retention if the bite starts going more cl III, sometimes it works well and seems great, but others it's awful bc/ the retainers can be a pain to adjust and stay in

[Payam Owtad]

Great Plan :) if possible I’d be curious to see how the treatment will progress.

Payam 

[Steven Prince]

Thanks everyone for the suggestions. Im just curious if you guys have actually put bite stops 7,6,5? I don't htink I have ever seen this done, and although it makes sense it theory is it practical? what about just the 7's and having a strong AW on the upper, wouldn't that get you close to the same effect? I know bonded probably makes the most sense but my boss is against those for a variety of reasons and I kind of agree. I hated working with them in residency.

Steve

[Carolyn Gardiner]

Hey guys, 

Sorry I'm a little late in the game! Just enjoying life... No real excuse :)

A few thoughts:

1. Steve what is family hx of class 3?

2. If you don't do a bonded rpe or bite turbos, you could always do rpe then do tads for posterior intrusion if needed. Anyone know of a low-lying tpa with tongue pressure actually works..not sure if there is evidence to back that up! This case will open up guaranteed so you have to have something to control it! 

3. Don't forget to mention extraction of lower bis in the future if class 3 is bad enough and they cannot do sx.

4. Never tried the bite turbo thing... Sounds like a crazy Payam idea that he would use and close the bite perfectly :) It seems like bite turbos on only the 7s will really only help with preventing the 7s from extruding ... Even with a heavy wire I would think you would get some extrusion of the 4,5,6 ... Just my opinion though...

Have a good week guys! 

Carolyn 

[Jeremiah Sturgill]

Steve,

I have done the bite turbos here on phase I cases who need vertical control, but I tyically do the BU on the 7 really small and sometimes just do it on the 6 and 7 or the 5 and 6, bc/ 3 teeth sometimes is too much depending on the way the bite comes together.....

Carolyn,

The TPA off the palate w/ TADs I think has evidence, because it worked on my case (n=1) and i'm doing it on another case here at the office, so I'm about to have an n=2 :)

Dr. Sturgill

__ 

Jeremiah Sturgill, DMD, MPH, DHEd

1206 Willow Lawn Drive  

Richmond, VA 23226

804-282-0505 

Dr.St...@GardnerGrins.com 

[Payam Owtad]

I know the idea 7,6,5 bite turbos sound crazy, I was also hesitating first to use, until I was forced in a Obese 300 pound young boy with more than 4 broken bracket each visit, to use this pattern of bite turbos and actually it worked. The boy loves eating and eats everything, poor OH open bite tendency. I started placing Turbo only on 6s, then 7s and finally added 5s. For the last 2 months that I have the 7,6,5 bite turbos, there are no broken brackets and bite is deepening in a desired fashion. So I feel positive in cases like Steve’s case using this method. It is important to balance the bite and contacts with the turbos in place. 

However, we know this is just an unfinished case report at the bottom of hierarchy of Evidence Pyramid (Dr Seuss :-) and I don’t have much to back it up ! while I definitely feel comfortable using it again.  

The TAD idea sounds good to, but according to the experience with one of my Dr Papademetriou patients in school, to close the open bite I wouldn’t only do Upper TADs , I would also place TAD in the lower arch to hold the lower molars from extrusion. 

I also think the 7s Bite turbos, with heavy wire is also a good idea, but maybe it would be better to take advantage of light wires for biologically intruding the posterior teeth. 

Payam