BONUS CASE 3!

[Joti Kaler]

Domain 1: List all of the dental problems for this patient.

• class III canines and molars

• maxillary incisors are proclined

• Edge to edge bite, inadequate overjet

• uncoordinated arches, upper is ovoid and lower is round

• accentuated curve of wilson

• edge to edge bite, inadequate overbite

• midlines are not coincident

• bilateral posterior open bite with left being more severe

• patient has accentuated curve of spee on left side of mandible and left side is flat

• lower left 6 is infraoccluded

• protrusive incisors in maxilla and mandible

Domain 1: What is the facial / soft tissue diagnosis for this patient?

• Patient has convex profile, bimax protrusive

• acute NLA

• protrusive and prominent lips

• normal labiomental fold

• normal chin throat angle and length

• chin deviates to left

• full buccal corridors

• non consonant smile arc, can see lateral open bite on left

• longer lower anterior facial height

• lip competence

Domain 1: What is the skeletal diagnosis for this patient?

• skeletal class III

• prognathic mandible

• asymmetric mandible with right condyle longer than the left

• open vertical tendency

• hyperdivergent tendency

• long lower anterior facial height

• short ramus

• increase AFH: PFH

Domain 2: What are the objectives for the maxillary dentition?

• retrocline and retract incisors

• achieve class I canines and molars

• gain positive overjet

• upright molars

• coordinate arch with mandible

• extrude left posterior

Domain 2: What are the objectives for the mandibular dentition?

• maintiain incisor proclination

• retract incisors

• class I canines and molars

• gain positive OJ and OB

• coordinate arch with maxilla

• center midline with maxilla

• upright molars

• correct curve of spee on left

• close bilateral open bite

Domain 4: What is your advice regarding treatment of this patient and the root resorption present?

• identify when the root resorption occured, if recently then take a break from orthodontic movement 4-6 months

• minimize treatment time

• minimize movement on the upper incisors

• inform patient that root resorption will be a risk with orthodontic treatment

Domain 4: Assuming the patient is treated, how can the existing root resorption be managed?

• regular visits with dentist

• minimize force to these teeth

I def didn’t know the answer to the last one!

[Chad Carter (Course Director)]

Nice work up!

For the last one, I had in mind that LIGHT LIGHT forces are key. So if patient understands risk and then progress panos every 4 months to check it resorption reinitiates.

[Antonia Alfonso-Pagan]

I seem to struggle summarizing. This looks like a PFE case, type II in which quadrants are affected at different degrees.

Domain 4. Advice

1.Inform patient of the findings, no treatment is always an option.

2.Have an informed consent if patient decides to have orthodontic treatment

3.Consider genetic testing for PTRH1 which has been associated with marked root resorptions

4.Advice patient to have pre surgical evaluation with OMFS to review surgical options such as surgery first approach.

5.Take at least 3 months of no movements

6.Minimize treatment time

Domain 4. Manage

1.Use only light forces for tooth movements

2.Take xrays in 4-6 mo to compare root length

3.Take progress records every 4-6 mo to document changes

4.Closely monitor changes in root length and mobility

5.If orthodontic treatment is to be performed, use only light forces and stop forces to place patient in passive stage for 3-4 months if further resorption is detected.

6.Consider virtual planning for surgery first, patient may be a candidate

7.Consult with OMFS the surgical options such as surgery first, multipiece, etc, to avoid long pre surgical phase.

8.Consider IPR, non-extraction, to improve the axial inclinations and avoid long treatment times. (Some compensations may have to be accepted to avoid long treatment time and avoid further root damage).

9.Another option is to use segmental orthodontics in preparation for multipiece Le Fort I which will correct position of maxilla in all planes. Space must be made for the surgical cuts.

10.Single implant on opposing arch can be placed to evaluate if there is movement of the teeth on opposing arch. This will allow evaluation of individual teeth without engaging and affecting the entire dental arch during the evaluation of movements.

[Chad Carter (Course Director)]

What a great write up Antonia!

I love the PFE discussion and detailed management.

[Antonia Alfonso-Pagan]

Single TAD (i wrote implant)