Mod 5; Case 1

[Chad Carter (Course Director)]

Alice,

Good questions here

For prompt #1:

His lower chin seems to be to the left (also his lower midline is off to the left ~ 2mm)

– I agree. It’s tough to see that lower midline with how deep his bite is in the photos.

What is meant by “under rotated nasal tip?”

– This is a description that more crudely put would be “hook nose”. You can also say “ptotic nasal tip” though I don’t think his is droop. Thoughts on why we would include a nasal diagnosis?

(Reply on below and keep the discussion going. Think of all the ways we can impact nasal form with our treatment plans)

For prompt #2:

I know he has a steep cranial base; but it seems that he is slightly bimax retrusive. I understand that his mandible is MORE retrognathic and is the main component of his Skeletal Class II. But, after you adjust the numbers; his SNA is 79. Would it be wrong to say his mildy max retrusive?

– Good assessment! I agree that in the GLOBAL picture he is bimax retrusive. The FIRST impression I get when I look at the ceph is “probably normal maxilla”. The things that clue me in to slightly retrusive are 1)Cranial base adjustment 2) Deficient max incisal display (considering all other lip factors) 3) Nasal tip position.

For Prompt #6:

Regarding the objectives presurgically, can an answer be to maintain lower COS. Since we want to level the COS post-surgically in order to increase LAFH.

Yes, that’s a great pre-surgical plan to increase LAFH. In addition, his max central incisor position makes me think some downgraft of the maxilla will benefit his incisal display and LAFH both.

Keep it going! Everyone jump in as much as possible to workshop these cases.

[Pegah Kamrani]

Hi Chad, going off this response, is recommending a three piece lefort for this patient acceptable then? it would be for the transverse and for an anterior down graft to improve incisor display. I know its riskier which is why I want to ask. If not addressing incisor display surgically, would it be correct to suggest upper incisor extrusion with bracket positioning or increase RCOS on upper arch?

[Chad Carter (Course Director)]

Pegah,

Checking I’m looking at the correct case. Are you talking Module 5 Case 1?

I’m not seeing a 3 piece LeFort option for Module 5 Case 1

[Pegah Kamrani]

I was asking if it would be acceptable to suggest it and gave reasons as to why and if not, would it be acceptable to do the other options to inc incisor display?

[Chad Carter (Course Director)]

Pegah, Got it. I just wanted to make sure I was looking at the right case because sometimes I cross conversations. In this case, I would recommend addressing incisor display for sure. I don’t foresee that a 3-piece LeFort would be listed as a possible response in this case. Definitely getting the goal of increased incisor display though. They can down graft the maxilla as a single piece if your thinking that a downgraft will benefit this incisor display. That is more stable than a multipiece downgraft.

[Maria]

Have I done the math wrong for the cranial base adjustment?

(39-26=13 ; so adding 13 to SNA 74 + 13= 87) Wouldn`t that characterizes a protrusive maxilla?

For the nose facial diagnosis I also had doubts on how to describe it, I ended up describing as “Strong nasal dorsum projection” , would that be accepted?

[Maria]

Sorry, I see now I forgot to decrease 7degrees from the 13 on the math and then gives 6degrees to add SNA by the end. Thanks!

[Chad Carter (Course Director)]

Good work. Yup, strong nasal dorsum for sure. Worth mentioning when we can refer them to the team that treats that if they want to treat it!

[David Jensen]

Thank you for the responses