Advice on a case

[Hemali Kothari]

Dear All,

It was so good to see everyone!! I have a case I've been thinking about and wanted to get everyone's input on.

She is missing U1s. straight profile, low smile line, end on cl II right and left.

Space remaining for U 1s is only 9mm. 3 mm crowding in Mn, Mn midline to L 3mm, U midline coincident, 3 mm OJ, shallow OB.

ANB 1.7, SN-MP-35.1 (high angle).

Here are the pano and photos and ceph.

Obviously, there are two options- Mesialize or distalize. But I have limited access to TADs so I am wondering if I use a pendulum to distalize, will I create an open bite? I need about 9 more mm space for U 1-1. Seems to be good bone in upper anterior so she can get implants. OR...since she is high angle and open bite tendency, do I mesialize?

Please let me know your thoughts. I can get TADs if its absolutely critical so let me know your thoughts either way.

Thanks :)

Hemali

[Steven Prince]

Hi Hemali

Cool and interesting case. I think distalizing that much with a pendex really difficult almost impossible in my experience. We find when then 7's are erupted we don't distalize much. ( yes Carolyn it does matter :) haha. But also the 8's are there so if you distalize with tads I would probably extract those. Maybe an easier treatment if she wants to do implants is to extract upper 4's and then lower right 5 and lower left 4 if you are trying to correct class II in right. Also it might be better for bone development to move the laterals into central position and open space for the laterals. That way canine get to class I you develop the bone for centrals and then it becomes a missing lateral case. Of course crowns or veneers for the 1s. 

The other option of closing space not a bad idea. I think you might be able to get there with a lower incisor extraction and some ipr on the lower to help with overjet. A set up would help a lot in this case :) Obviously if finances are an issue I think this would be a good treatment.  

Just some thoughts 

Steve 

Sent from my iPhone

<image.png>

<image.png>

<image.png>

--

---
You received this message because you are subscribed to the Google Groups "ASDOHortho2014" group.
To unsubscribe from this group and stop receiving emails from it, send an email to asdohortho201...@googlegroups.com.
For more options, visit https://groups.google.com/d/optout.

[Jeremiah Sturgill]

Hemali, neat case, here are my thoughts:

The LL2 and LL3 are gemination?  That's what it looked like to me on the xray.  I think I would go for mesializing the 2s into the 1s spot and having veneers/build ups on the 2s to make them ideal height and width, having 2 or even 4 veneers would be much cheaper than implants and crowns.  She is already close to FS class II on the right so I think it would be possible by the time you procline the upper incisors.  As for anchroage I think you could use TADs on the palatal side to anchor the 6s with a TPA bar and push everything off of that, once fully mesialized then pull the 6s forward.  If you can't use TADs then I would try Cl III els, which might give you enough anchorage, if you wanted to go really old school you could always have her wear a PM facemask for anchorage to during the mesialization if you don't have TADs.  Anyways, that would be my plan bc/ I think it will work out well to help retract her lower lip and protract the upper and if you open space I think you will open her bite or atleast make her a little more high angle.  It will also be cheaper to have veneers on the 2s and 3s then the implants.  just my 2 cents

Dr. Sturgill

__ 

Jeremiah Sturgill, DMD, MPH, DHEd

1206 Willow Lawn Drive  

Richmond, VA 23226

804-282-0505 

Dr.St...@GardnerGrins.com 

[Steven Prince]

I still think you would have to do something on the lower for overjet. Lower incisor, exrractions, or heavy IPR/ARS. Also I think that according to the E-line, she could tolerate a little lip retraction which will happen when you try to close 9mm of space on the upper. I think closing the space would be the quicketst and most efficient treatment plan

[Jeremiah Sturgill]

Yea, definitely some IPR...maybe you can cut that gemeniation in half? :)

Dr. Sturgill

__ 

Jeremiah Sturgill, DMD, MPH, DHEd

1206 Willow Lawn Drive  

Richmond, VA 23226

804-282-0505 

Dr.St...@GardnerGrins.com 

[Hemali]

Thanks for the help!! 

Yes, the LL 2 and 3 are gemination or fusion! Nice catch!  I think it was the first time I had seen that when I did her exam! Based on the input, I will close the space. I think if I do it like beads on a string and use class III elastics it will help. And IPR on lower or lower incisor as needed. I think the parent will be happy to save money on implants. Thanks for the help :)

I have another case I'll email tmw. I'm thinking about ext L4s only but I've never done that so I'm a little nervous and just wanted to confirm it. 


Jeremiah-- what happened with that parent and the enameloplasty thing? Your anteriors looked good in the picture you sent. That's really scary that she over-reacted like that. Did the dentist take your side in the situation? 

Hemali

[Jeremiah Sturgill]

So she came over and saw Dr. Gardner and he told her he thought it looked great and if anything he would maybe do more enameloplasty, but she was still reall yupset so he said he would pay for veneers on the upper 1s, so she is going to the dentist to consider veneers!!!! We are calling the general dentist today to see what they decided...i think if he's smart he wont do anything, because obviously they are crazy

[Steven Prince]

Wow that is crazy nuts. Did you tell her before that you were doing e plasty??

Sent from my iPhone

[Jeremiah Sturgill]

So we heard back from the GP, he told the pt he thought it looked great and he wouldn't suggest any treatment.... so he sent them home and said come back in 2 weeks and told the mom " if you can point to exactly what you want done then I will do a bonding"  ....so yet to be determined

Dr. Sturgill

__ 

Jeremiah Sturgill, DMD, MPH, DHEd

1206 Willow Lawn Drive  

Richmond, VA 23226

804-282-0505 

Dr.St...@GardnerGrins.com 

[Payam Owtad]

Hey guys, 

It was cool to read all your discussion s and suggestions on this case. I agree with everything that you guys suggested :-) 

Good luck Hemali on this case. 

Payam

[Hemali]

Oh good! Thankfully the GP was reasonable. 

I wanted your opinion on this situation I had today- patient has an impacted LL5. Never got it exposed because of finances. Now is it 24 of 24 months in treatment and account is over $1,000 past due. But LL5 is the same. My office is demanding I debond the patient because pt will never pay the balance (or now the over treatment fees) if I keep going. But is it ethical to leave an impacted tooth and just debond the patient?? She does have poor oh and bad compliance. And we have documentation that we referred her for exposure many months ago. Any advice?!

Sent from my iPhone

[Payam Owtad]

This is a tricky situation. If it was in my own office I had it exposed myself with proper documentation from patient and at on charge a long time ago. But in this situation I think as long as you inform patient and keep a good documentation and written communication with the office manager, I think as long as the patient understands and accepts, ethically it is fine. I believe it falls in the autonomy principle category. 

Payam 

[Jeremiah Sturgill]

Hemali,so I talked to Graham about this bc/ he was on the ethics committee for VDA

He said you CANNOT choose to remove braces from a pt for non payment, he said actually orthodontists have been sued for assault and battery if you remove braces w/ out the pt's full consent bc/ of non-payment.  He said you have to dismiss the pt for non-payment (completely legal) w/ the braces on with a certified letter and in the letter you have to offer FREE emergency care and ethically should also put in the letter you will remove the braces for FREE as well.  Then if/when they come in for removal they have to sign an early release form which says they want the braces off....

On the other hand he said the OH is a reason YOU can choose to remove the braces early w/ out the pt giving consent, he said if your OH is really well documented then you could use that as the main reason, but he said if it's not well documented and the chart has more documentation about being late on payment than poor OH then it wouldn't really stand up in court bc/ it would be too obvious that the real reason is the late payment not OH

Hope that helps, I definitely learned from it

Dr. Sturgill

__ 

Jeremiah Sturgill, DMD, MPH, DHEd

1206 Willow Lawn Drive  

Richmond, VA 23226

804-282-0505 

Dr.St...@GardnerGrins.com 

[Hemali]

Thanks Jeremiah!!

That's really great insight! I'll make sure I have a signed early debond consent.