Case 2 prompt 9, 10

[Chad Carter (Course Director)]

Anish, yes you guys are all putting in long days studying… which will pay off! Plus, everyone still has work and clinic to do as well.

I have not seen any sample cases published by the ABO or anything in their testing guidelines where they ask for items “in sequence”. The key is identifying each criteria in need of correction and a plan to make it happen.

Was there some more detail you are looking for or does this answer your question?

[Anish Gala]

Yes tried to edit my answer but the OP forum is glitchy. Can you walk me through prompt 9response.

[Chad Carter (Course Director)]

Here is my take on this case and the responses for Prompt 9:

The question asks “Identify the potential side effects of the treatment mechanics utilized in this picture.”

So then I think in my mind this is a Domain 3 question (Treatment Implementation and Management). A mentor of mine calls Domain 3 questions a test of wisdom – the board is asking you to recognize what is an unwanted effect and potentially how to recover from those effects in order to finish the case.

Composite 8 Analysis:

Soft Tissue Front/Profile/Smile – Nothing standing out to me other than he has shaved and has a more relaxed joyful smile than initial photos – so we see a bit more incisor.

Max Occlusal Photo – I see a Nance in place. There is acrylic touching the back of the U1s which makes me think this is a biteplate as well. Sure enough I look at the front and see he’s occluding on something and no Turbos. So a Nance with a bite plate which in my experience is for anchorage and opening bite in the anterior.

Man Occlusal Photo – Bread and Butter Ortho – Bands on the L6s and brackets – early aligning phase, Nothing stands out to me.

Buccal Shots – Now it gets interesting. So U4s were extracted. There is no continuous archwire, just segmentals from U6s to U5s. On top of that the U6 wire segment is in the auxiliary tube on the band but then through the bracket slot on the U5 – strikes me as a bit odd. Then it looks like the segment wire has a hook on it and some kind of elastic tugging on the canine.

Note about records: Yup this particular photo is blurry. That is a site function working on. I looked at the photos and was trying to discern if that was elastic or steel tie lacebacks to the canines. I do see there is no archwire to those canines.

Now that I’ve analyzed the case I use my magic to think about all the stuff that’s going to happen. The goal seems to be retraction of maxillary canines with increased anchorage provided by Nance on the max. On the man, the goal seems alignment.

So what will I have to recover from based on these mechanics:

1) Distal Tipping of the Canines – with no archwire through the slot and a straight elastic pulling on the canine there will be distal tipping rather than my ideal sliding.

2) Extrusion of Maxillary Incisors – no archwire in place and no contact opposing teeth teeth will extrude (This is least intuitive one in my opinion because the hope is that Nance with bite plate is giving some vertical stop to those max teeth)

3) Intrusion of Premolars – with the auxiliary wire going through normal slot on premolar and auxiliary slot on molar band the max premolars are going to intrude.

4) Bite Deepening – so if max incisors extrude and max premolars intrude then the bite will be getting deeper.

5) Lateral Posterior Open Bite – imagine you are done with the Nance – have the Canines Class I and so it’s served it’s anchorage purpose. You remove the Nance and Boom! Max Premolars intruded and contact on molars so there will be lateral posterior open bite.

The best practice for “Case Management” Domain 3 questions is to look at your wild transfers. From the objectives set by the board I’d say you’re guaranteed to see some sort of case that is “out of control” and needs management to reign in. I’ll get another case in the Bonus section (Under General Discussion) for management practice.

[Adedolapo Ayediran]

Isn’t the nance with bite plate going to provide a vertical stop to mandibular incisors instead to intrude them, versus vertical stop of max incisors? Am I missing something?

[Chad Carter (Course Director)]

Adedolapo,

Yes, the nance with bite plate is PRIMARILY to open the bite and intrude mandibular incisors. What I mention above is that depending how you have the acrylic up on the lingual surfaces of the maxillary teeth that you might get some side effect of holding the maxillary teeth vertically as well. A great orthodontist always told me “It’s all about the side effects, Carter!” She is known for being a master of getting the primary role of an appliance or mechanic but then also looking for and mastering use of the secondary, tertiary, etc. side effects that come from our mechanics as well.

Thanks!

Carter

[Adedolapo Ayediran]

Ok, I see your perspective now.

Thanks