My Courses Forums Synapse Orthodontics: General BONUS CASE 1 – Part 2 of 2

  • BONUS CASE 1 – Part 2 of 2

    Posted by Chad Carter (Course Director) on February 5, 2023 at 9:01 am

    Next set of questions!

    Part 2

    1) Domain 4: Critique the post-treatment records. What treatment effects do you observe?

    2) Domain 4: What additional records are indicated at this time for this patient?

    3) Domain 4: How will future growth affect current treatment results?

    4) Domain 4: What is appropriate retention for this patient?

    5) Domain 3: What is the next phase of treatment for this patient?

    6) Domain 2: How will you assess the timing on the final phase of treatment for this patient?

    (I’ve posted both the initial and the progress comp 8 photos here for comparison)

    Pegah Kamrani replied 5 months, 2 weeks ago 6 Members · 20 Replies
  • 20 Replies
  • Avatar

    Joti Kaler

    Member
    February 5, 2023 at 10:11 am

    • 1) Domain 4: Critique the post-treatment records. What treatment effects do you observe?

    ◦ More full buccal corridor

    ◦ bilateral posterior open bite

    ◦ occluding heavy on the anteriors due to inadequate Overjet and overbite

    ◦ class III

    ◦ inadequate space and alignment for UR3

    ◦ more maxillary incisor display

    ◦ lower lip is less protrusive

    • 2) Domain 4: What additional records are indicated at this time for this patient?

    • mounted models

    • lateral ceph

    • pano

    • hand wrist

    • 3) Domain 4: How will future growth affect current treatment results?

    • He will lose minimal overjet and have negative overjet

    • retroclination of lower anteriors

    • proclination of upper anteriors

    • possible open bite due to vertical growth

    • possible posterior crossbite

    • 4) Domain 4: What is appropriate retention for this patient?

    • U/L Hawley to allow for occlusal settling

    • 5) Domain 3: What is the next phase of treatment for this patient?

    • Growth and guidance until he is done growing to assess for orthognathic surgery.

    • 6) Domain 2: How will you assess the timing on the final phase of treatment for this patient?

    • Hand wrist radiograph

    • Serial cephs

    • consult with oral surgeon

    • growth chart from physician

    • Avatar

      Chad Carter (Course Director)

      Member
      February 5, 2023 at 10:48 pm

      Nice! Yes, he had some effect but it’s definitely not the overjet accomplished that I’d aim for.

      Anyone thinking Bollard plates in a Class III grower?

      • Avatar

        Ritika Singh Singh

        Member
        February 11, 2023 at 6:38 pm

        Big thank you for the Bonus case. It is so helpful to keep working on new cases to jog our brains.

        I was thinking of Bollard miniplates (Bone anchored orthopedic appliance), as it is considered a better treatment option for Class 3 hyperdivergent patient, esp. vertical control, helping with the compliance factor and constant force application. But I wasn’t sure, if it will fall in “traditional treatment methodologies” as per ABO examiners, so I was skeptical about mentioning it.

        For this patient, hyperdivergence creates a problem while using FM Therapy + RME as it will increase the vertical. So what other treatment options can we mention and how do we talk about vertical control?

        • Avatar

          Chad Carter (Course Director)

          Member
          February 12, 2023 at 1:47 am

          Ritika, excellent thoughts.

          I think Bollard Plates / BAMP (Bone Anchored Maxillary Protraction) are plenty main-stream. DeClerk has been a featured key speaker at AAO several times and is on the reading list so it’s not fringe stuff.

          What are your thoughts on the vertical control on Class III grower? Is it wait for surgery or wait for growth and see where it goes? Anyone wanting to try chin-cup???

        • Avatar

          Ritika Singh Singh

          Member
          February 12, 2023 at 1:25 pm

          I think during the growing stage, mini-implants are the only best method for vertical control. But its best for growth to complete, and then plan for surgery, as any correction achieved during growing stage can be lost with late mandibular growth in a Class 3 patient.

          • Avatar

            Chad Carter (Course Director)

            Member
            February 14, 2023 at 11:57 pm

            Ritika, I agree! TADs to control vertical eruption if at all possible. Sometimes we get control, sometimes we don’t … or as a mentor of mine says “sometimes we just get lucky on growth”

  • Avatar

    Joti Kaler

    Member
    February 5, 2023 at 10:14 am

    THANK YOU SO MUCH!!!!! Having extra practice along with discussion is so helpful. I know it must be a lot of work finding records and discussing these cases- I’m sure everyone else in this group along with me really appreciate it!

  • Avatar

    Ritika Singh Singh

    Member
    February 11, 2023 at 6:30 pm

    1) Domain 4 – Critique the post-treatment records? What treatment effects do you observe?

    1. Maxillary advancement

    2. Maxillary incisor proclination

    3. Maxillary arch expansion

    4. Class 1 molar relation

    5. Slight retroclination of mandibular incisors

    6. Lateral open bite

    7. Slight increase in lower face height

    2) Domain 4 – What additional records are indicated at this time for this patient?

    1. Lateral Cephalogram

    2. Family history (to know a predilection for Class 3)

    3. Height-weight chart

    4. Hand-wrist radiograph

    5. Panoramic radiograph

    3) Domain 4 – How will future growth affect current treatment results?

    1. Predilection towards skeletal Class 3 discrepancy, can result in late mandibular growth thereby outgrowing the skeletal correction achieved with the current treatment.

    2. Pt. has a hyperdivergent tendency, which can worsen as the mandible grows in AP direction resulting in clockwise rotation of mandible and increase in vertical dimension

    4) Domain 4 – What is appropriate retention for this patient?

    1. Frankel 3 appliance

    2. Maxillary Hawley with Adam’s clasp and Mandibular wraparound retainer

    5) Domain 3 – What is the next phase of treatment for this patient?

    1. Non-extraction comprehensive orthodontic treatment

    2. Level and align maxillary arch

    3. Align mandibular arch

    4. Close residual spaces

    5. Achieve bite settling

    6. Monitor the pt. for growth completion, to plan forward with Orthoganthic surgery, based on unfavorable growth occurrence

    6) 1Domain 2 – How will you assess the timing on the final phase of treatment for this patient?

    1. Assess growth completion using following indicators –

    Serial Lateral Ceph

    Hand-wrist radiograph

    Height-weight chart

  • Avatar

    Maria Jividen

    Member
    February 14, 2024 at 10:30 am

    Hi! Thanks so much for the extra practice! Is there any way that you, as the moderator / instructor, can post how you would respond to the Bonus Case 1 questions (part 1 and part 2)?

  • Avatar

    Maria Jividen

    Member
    February 14, 2024 at 10:32 am

    I apologize in advance for the long post, but I am a little confused about a few things:

    1. “Q3: How will future growth affect current treatment results?”

    1. Would the patient’s hyperdiv growth be considered ‘favorable’ for his class III pattern? Obviously we want to control vertical to prevent open bite development, but I wrote something like this: ‘Hyperdivergent growth pattern can be considered somewhat favorable for this class III patient, because the condyle has the potential to grow more posteriorly causing a CW rotation of the mandible (less forward growth → less severe class III). However, the patient has minimal OJ so growth / eruption of molars need to be carefully controlled to prevent open bite development’. … I may be overthinking this

    2. What kind of answer are you looking for here?

  • “Q5: What is the next phase of treatment for this patient?”

    1. Would you recommend waiting until second molars erupt? Or waiting until all permanent teeth have erupted? Or should we not be waiting because as time passes, chance of following decreases:

    1. obtaining skeletal correction of Class III (i.e. with Bollard plates)

    2. and/or re-directing growth (hyperdivergence)

  • As an alternative to starting phase II now, I did list “Continue retention of phase I until growth is complete and then assess for surgical correction vs ortho compensation.” Is this a fair statement to include on the Exam?

  • I was originally thinking Bollard plates for phase II as well. But then looking at the patient’s profile, his upper lip looks quite full, upturned even, with an acute NLA. Wouldn’t advancing his maxilla / anterior teeth with Bollard plate worsen his profile?

  • What would you ideally do for phase I treatment of a hyperdiv class III patient? Isn’t 8 yo / CVMS 1 or 2 too young to be placing TADs? Would you attempt the RME and FM knowing that this might worsen the patient’s hyperdivergence?

  • We are supposed to intervene early to address hyperdivergence, correct? Because it’s identifiable early and just gets worse without intervention. What are some general interceptive treatment strategies for a hyperdiv pt? I can only think of HPHG (not for a class III pt though) and chin cup (which, from what I understand, it’s realistic)

  • Is there a Bolton discrepancy here? I thought the laterals looked quite small

  • Avatar

    Chad Carter (Course Director)

    Member
    February 19, 2024 at 11:30 am

    Maria,

    Sorry for the slow reply. Your post and one other one got buried in all my open tabs.

    I’ll comment in bold along with your post here and hope that helps with clarity.

      1. “Q3: How will future growth affect current treatment results?”

      1. Would the patient’s hyperdiv growth be considered ‘favorable’ for his class III pattern? Obviously we want to control vertical to prevent open bite development, but I wrote something like this: ‘Hyperdivergent growth pattern can be considered somewhat favorable for this class III patient, because the condyle has the potential to grow more posteriorly causing a CW rotation of the mandible (less forward growth → less severe class III). However, the patient has minimal OJ so growth / eruption of molars need to be carefully controlled to prevent open bite development’. … I may be overthinking this. I like your thoughts here. The suggestion I have would be to bullet them out for responses rather than paragraph form. The key thing for his future growth is that just because he is in a slightly better spot now – he will still likely outgrow it. We have prevented “restriction” of the maxillary growth with bit correction but his long term growth will impact outcomes and our next treatment decision.

      2. What kind of answer are you looking for here?

    • “Q5: What is the next phase of treatment for this patient?”

      1. Would you recommend waiting until second molars erupt? Or waiting until all permanent teeth have erupted? Or should we not be waiting because as time passes, chance of following decreases: I agree following and waiting for permanent teeth to erupt. For the exam the information I have read says that we assume full patient compliance and follow-up.

      1. obtaining skeletal correction of Class III (i.e. with Bollard plates)

      2. and/or re-directing growth (hyperdivergence)

    • As an alternative to starting phase II now, I did list “Continue retention of phase I until growth is complete and then assess for surgical correction vs ortho compensation.” Is this a fair statement to include on the Exam? Absolutely! I’ve seen too many Class III growers that were treated with comprehensive ortho WAY TOO early, had extractions or extreme compensation and then outgrew that and needed surgical correction but then you had to go an DECOMPENSATE all the compensations somebody built in when they were 12 or 13 and still growing Class III.

    • I was originally thinking Bollard plates for phase II as well. But then looking at the patient’s profile, his upper lip looks quite full, upturned even, with an acute NLA. Wouldn’t advancing his maxilla / anterior teeth with Bollard plate worsen his profile? There should be some downward growth of the maxilla as well and the nose will keep growing as well. I think facial impacts would be minimal based on the Bollard cases I’ve done.

    • What would you ideally do for phase I treatment of a hyperdiv class III patient? Isn’t 8 yo / CVMS 1 or 2 too young to be placing TADs? Would you attempt the RME and FM knowing that this might worsen the patient’s hyperdivergence? What are your thoughts on too young to place TADs? I believe in this patient’s treatment the thoughts were targeted at getting as much skeletal effect from the Facemask and limiting dental compensations that come with Facemask therapy.

    • We are supposed to intervene early to address hyperdivergence, correct? Because it’s identifiable early and just gets worse without intervention. What are some general interceptive treatment strategies for a hyperdiv pt? I can only think of HPHG (not for a class III pt though) and chin cup (which, from what I understand, it’s realistic). There are not many options that I know of! Which is tough. Yes Chin cup could be helpful and and I would not do HPHG for a Class III. The most predictable ones I understand currently are Bollard Plates once permanent canines have erupted and follow up for several years. Then TAD assisted intrusion of max and man molars for dealing with the vertical. (There are the biteplates and magnets and other random items but I’ve not used those and understand they are not predictable) – Other folks have thoughts on this?

    • Is there a Bolton discrepancy here? I thought the laterals looked quite small. There sure could be. Definitely worth listing as suspected and then I would calculate it when able to measure permanent canines.

    • Avatar

      Pegah Kamrani

      Member
      August 24, 2024 at 5:34 pm

      Hi Chad! where can we see part 1 questions to this case? Can’t find it in the general discussions. thanks!

      • Avatar

        Chad Carter (Course Director)

        Member
        August 24, 2024 at 8:07 pm

        Pegah, I bumped the Part 1 of this case to the top of the thread for General Discussions. Do you see it there? It had fewer comments so it was buried at the end of the dicussions.

        Good job tackling the bonus cases!

        Carter

  • Avatar

    Maria

    Member
    August 25, 2024 at 1:34 pm

    1) Domain 4: Critique the post-treatment records. What treatment effects do you observe?

    1-Overjet is decreased

    2-Overbite is decreased

    3-Patient is on edge to edge bite

    4-Anterior and lateral open bite

    5-Maxillary canines rotated (lack of space for proper alignment)

    6-Anterior crossbite was corrected

    7-Rotations present on mandibular canines and premolars

    8-If patient was in phase 1 treatment only there was improvement but needs a phase 2 treatment

    9-Nasiolabial fold slight decreased showing an improvement on maxillary projection

    10-Mandible continued to grow (needs to be monitored for longer time for any late mandibular growth)

    2) Domain 4: What additional records are indicated at this time for this patient?

    1-CBCT image to check condylar assessment and airway anatomy

    2-PA ceph to access any asymmetries

    3-Hand-wrist radiography to check on SMI stage of growth

    4-Tongue posture evaluation (check on any tongue tie or tongue thrust)

    5-Compare serial of cephalometric x-rays to access growth status

    6-Tec-99

    7-Updated panoramic image

    8-Family history on maxillary/mandibular growth

    9-CR/CO shift evaluation

    3) Domain 4: How will future growth affect current treatment results?

    1-If patient still growing mandible will grow more and shift downward and forward decreasing overjet and possibly leaving patient with anterior and posterior crossbites

    2-If less growth of maxilla will stay retrusive, so need to monitor patient growth to determine if will be surgical case to correct Class III skeletal

    3-If patient continue growing hyperdivergent tendency bite could open more

    4) Domain 4: What is appropriate retention for this patient?

    1-Removable upper and lower Hawleys

    2-Monitor growth yearly to evaluate when patient`s growth is complete</p>

    <p>3-Myofunctional therapy possibly needed if patient has tongue thrust habit</p><p><br></p>

    <p>5) Domain 3: What is the next phase of treatment for this patient?</p>

    <p>1-Reevaluate after growth is complete</p>

    <p>2-Comprehensive orthodontic treatment </p>

    <p>3-Bonding of brackets in all maxillary and mandibular teeth (second to second molars)</p>

    <p>4-Level and align</p>

    <p>5-If after growth is complete, the overjet is decrease and patient Class III skeletal will need to prepare for orthognathic surgery with maxillary advancement and mandibular counterclockwise rotation</p><p><br></p>

    <p>6) Domain 2: How will you assess the timing on the final phase of treatment for this patient?</p>

    <p>1-Access updated cephalometric image to determine CVMS stage</p>

    <p>2-Compare serial of cephalometrics and superimpose to determine if patient is still growing</p>

    <p>3-Timing of final phase of treatment should start once patient`s growth is complete

    4-Hand-wrist x-ray will be helpful to determine growth status

    5-Acess family history on growth

    Also, I saw in the discussions that skeletal anchorage with mini-plates or TADs were included. Would that have to necessarily be included in our answers as alternative for orthognathic surgery for an answer to be considered fully proficient by the boards? I understand the rationale but also seems like the patient will outgrow any corrections since a phase 1 was already attempted.

    Thank you!

    • Avatar

      Chad Carter (Course Director)

      Member
      August 26, 2024 at 8:17 pm

      Maria,

      Very thorough! On the additional records I do not order Tec-99 scans for adolescent patients. I do order them for adult patients and that is where I find value for checking asymmetric growth or Class III growers. We then have used this to decide on orthognathic surgery as normal, a condylar shave or total joint replacement.

      Also in my practice I use CBCT sparingly for progress records. I bring that up because ADA does have the ALARA principle for radiology. I have not seen a stance from ABO on this but we are a speciality under the umbrella of the ADA. I work with craniofacial cases regularly and my surgeons cite literature that CBCTs on young kids have a negative impact (sorry I don’t have their lit source).

      To your TADs question. I think he will outgrow. However, Bollard plates are now an accepted standard for maxillary protraction/mandibular restriction. I’ve seen great success with some and borderline success. Not sure what you’ve seen. Funny thing about this kid…it’s not genetic in his family! His dad is a solid Class I. His mom is a severe Class II with radical Vertical Maxillary Excess that was a double jaw surgery.

      Look forward to hearing other’s inputs as well!

      CBC

      • Avatar

        Maria

        Member
        August 27, 2024 at 9:44 am

        Thank you so much for your answer!

        That is great information! Yes, I have seen great results with Bollard plates as well and totally agree! Sometimes I just have a hard time trying to know what the ABO wants us to include in the answers. This is my second attempt on the exam, and I felt last time I overexplained many topics, that is why I was asking about the plates, so I know if for being fully proficient according to ABO if that had to be included.

        • Avatar

          Chad Carter (Course Director)

          Member
          August 29, 2024 at 11:52 am

          Thanks for being open about that Maria. Based on everything I’ve seen your responses are spot on.

          One thing I did to limit me from spending too much time on responses was to limit myself to writing 10 or so bullets. That was my personal cue to then move on so that I had time to analyze and cover the next question

      • Avatar

        Pegah Kamrani

        Member
        August 28, 2024 at 3:47 pm

        Hi Chad,

        I’m trying to understand when we would mention Bollard plates/tad intrusion for this case. Is this something we would say that we would do in phase 2 for this patient? Is it something we ever do early? assuming its when max canines erupt, it’ll be around 11-13 years so I’m guessing its a phase 2. should we also mention that its more so an attempt to avoid surgery down the road but its not a guarantee? also for tec 99 scan for purposes of this exam, Is it correct to say its for cases of asymmetric growth/abnormal condylar morphology? thank you!

        • Avatar

          Chad Carter (Course Director)

          Member
          August 29, 2024 at 11:54 am

          Your guidelines for the Tec99 are what I see as evidence based.

          Bollard Plates need eruption of man canines and can be done as a phase 1.5 even where they are in place for a while and then bond up. I’ve even left them in for continued elastic wear during retention with eventual removal when 3rd molars are taken out.

          • Avatar

            Pegah Kamrani

            Member
            August 29, 2024 at 6:28 pm

            thank you so much!!

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