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Case 2 Treatment Plan
I’m torn here on how I’d answer this question on the boards. I think for that question we had a ceph but no measurements, but L1’s looked close to idea to me. In practice, a Herbst with an expander would be my pick for sure.
However, we defined this case as mild maxillary retrusion, mandibular retrusion. With the headgear effect + lower IMPA (latter shown to be 95, WNL but increased) I’d almost be included to pick a surgical treatment plan (protract maxilla, slight asymmetric adv BSSO) because of those two factors if we were talking “text book ideal” even if in the real world that would be crazy.
Thoughts? Am I overthinking?
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5 Replies
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Dane, I love the Herbst plan. I find it magical when we unlock that anterior deepbite and let growth work how we can shift things (well maybe we just get lucky with growth!)
With growth at CS4 a surgical plan would not be warranted by Boards standards. It should definitely be a CS5-6 or serial cephs to go towards a surgical plan for boards. [Now real world, craniofacial anomalies and some radical other cases go to surgery earlier] I do love you statement about “the ideal” but this case illustrates staying away from extractions for a Class II grower w/ retrusive or normal maxilla.
Also don’t worry about records, the instructions for the Board and the sample questions show you will have a full set of records available the entire time you are working on a case.
Good luck!
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Glad I asked – thanks for the comments!
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Good luck! You’ll crush it!
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Also had the same thought process as Dane here.
In private practice I would also have picked functional appliance or Class II mechanics.
But for an ideal world board standards I was afraid they would not consider that option because of the seemed ideal inclination of mandibular incisors in ceph. And also thought the same thing about not having the ceph tracing and we had to eye ball, is that possible to happen in the real exam?
I wrote for the ideal treatment plan to wait until growth is completed and then prepare patient for orthognathic surgery, maxillary 3-piece Le fort with anterior impaction and BSSO advancement. I know is total overkill in private practice, but I thought boards would request that as ideal.
Maybe I am overthinking as well 😓
Thank you!
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Maria,
My experience is that the ABO and Ortho as a whole has evolved past the Tweed obsession with 90 degree IMPA. There are many ways to compensate. As I mentioned to Dane above, this is a one off of an untraced ceph. No example we have seen from the ABO shows untraced cephs.
On my clinical exam I evaluate every patient and mark if it’s dental alone or if I recommend surgery. I will treat cases non-surgically but I actually discuss that surgery is my recommendation and the patient is signing choosing dentoalveolar alone (“Orthognathic surgery recommended and declined”).
Based on the incisors, pano and ceph I don’t think she has an excess in the premaxilla. If she wanted to go for surgery I’d still be looking at a single piece LeFort. With that BSSO, I bet we’d through in a sliding genio as well.
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