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Module Case I
I have a couple questions for this case:
3. the labiomental fold is shallow- I said it was deep. the lower lip protrudes and the angle is less than 90. I felt it got more shallow once the extractions were done. Can you explain why it is the other way?
4. Normodivergence was the answer for the vertical. FMA is 28 indicating an open bite so I attribted it to hyperdivergence. I can understand the hyperdivergence is a stretch but how would you explain the FMA being 28?
8. I missed this one! Due to the anterior open bite, i expected treatment requiring vertical control. Intruding molars and extruding incisors with some counterclockwise rotation of the mandible. Additionally the maxilla looked slightly constricted so just getting some archwire rounding/expansion.
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20 Replies
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Joti, thanks for getting the discussions going!
(To all who are reading, be sure to post any question as well! Even post the wild crazy stuff – there is nothing too embarrassing – take time to ask all the “what if questions. We all have a little tendency as orthodontist to “get stuck in our heads”. I’m not a “social media” person but these discussion groups are for sharing and take time to answer and explain things to others. This is perfect Board Exam practice! The board wants you explain on the exam to them)
Alright on to the questions – I’m going to to do them as some separate replies below.
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3. the labiomental fold is shallow- I said it was deep. the lower lip protrudes and the angle is less than 90. I felt it got more shallow once the extractions were done. Can you explain why it is the other way?
More than angle, I find the description of “a symmetric shallow S curve” represents the Labiomental Sulcus well. There are a couple pieces for this patient: yes, that lower lip is everting slighting; for sure, there is mentalis strain; and those are full lips …. but that that soft tissue chin looks thin as well. With the slight vertical tendency she has, with the mentalis strain, and a weak soft tissue chin that is setting up the picture of a shallow mental labial fold.
Holdway’s Soft Tissue Article has a nice discussion on this. I’m posting the article and a summary of it here.
In addition the textbook “Contemporary Treatment of Dentofacial Deformity” has a section in Chapter 4.
Deep Mentolabial folds tend to show up more with Brachyfacial, deep bite, Class II.
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Joti, this is great thinking on the vertical dimension!
4. So for thinking of norms remember 1 standard deviation encompasses most of our population. I completely agree that at an FMA of 28 degrees I start thinking… hey this is going in the vertical direction. First, the board is NOT trying to trick you. The cases we review and discuss as a community are to help us discuss. The ABO is focused on standards not tripping you up an FMA of 27 or 29 degrees. A great mentor always said “we don’t treat numbers”. Now, if I was typing the answers I would actually type it as “Normodivergent with vertical growth trend”. Anything that is “borderline” is not going to be a pass or fail response.
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Hi Chad, I also thought this was a hyperdivergent skeletal pattern. With the norm being 24, and the standard deviation being 4.5, 29 would fall outside of that standard deviation. I hear you when you say the board is not trying to trick uss, but I just want to clarify– when looking to diagnose hyperdivergent vs normodivergent vs hypodivergent, we should be looking at FMA, correct?
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Leah,
Yes, FMA is my go to for divergence…. and always a good ortho eye getting your “impression” of the case. Remember that if you are using SN-MP to be mindful of steep/shallow cranial base adjustments.
Good work!
Carter
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Thank you, Chad.
A steep cranial base would make SN-MPA increased/over-exaggerated, correct? Ie. a steep cranial base would make someone SN-MPA appear more hyperdivergent than their FMA would?
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Correct – there’s a video in later modules going over this as well
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This reply was modified 2 years, 2 months ago by Chad Carter (Course Director).
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This reply was modified 2 years, 2 months ago by
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Joti, final comment here on #8 point.
8. Excellent observation! You are spot on. Did other people have similar ideas on vertical control?
I would absolutely mention vertical control for a case like this on boards. Just because it wasn’t used in this particular example doesn’t mean it’s not true. The ABO is very big on vertical control and you are showing case management wisdom in thinking about that.
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Thank you for all the detailed responses! Everything makes sense- I need to work on the labiomental fold. Thank you for posting the article and summary!
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Excellent! Glad it helped.
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For Prompt #9, I had:
1. greater wings of the sphenoid are not accurately superimposed 2. cribiform plate is not accurately superimposed 3. There should be more apposition at orbital floor, and less resorption of nasal floor 4. Inner cortical plate not accurately superimposed 5. Missing inferior alveolar nerve canal landmark
what do you think of these responses?
Also, can you speak to what IS normal movement of porion? Should we expect no change or movement at all? Is this a stable landmark? Thanks
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Leah,
Nice responses here! I’ll make comments below your five resposnes.
1. greater wings of the sphenoid are not accurately superimposed
Good observation. Now what could cause this? It is a primary landmark for superimposition but tracing the wings can be tricky because they are a “double image” in the ceph. Midline structures are much more reliable in tracing so that is why locking in on the anterior wall of sella turcia is so reliable.
2. cribiform plate is not accurately superimposed
Good observation! I’d go with tracing error here as well. Remember there is always the decision to trace up following the Cribiform plate but sometimes since it’s a perforated structure you can’t visualize it as well and in a tracing you may opt to trace the lower form.
3. There should be more apposition at orbital floor, and less resorption of nasal floor
Yes! Sharp eye!
4. Inner cortical plate not accurately superimposed
I think this is a tracing error as well so could even add “unable to superimpose accurately due to tracing error”
5. Missing inferior alveolar nerve canal landmark
Yes! Good identification! – One thing to remember is that Board is a living breathing organization and so superimpositions have changed through time. This one was without IAN but that is now something we use.
Also, can you speak to what IS normal movement of porion? Should we expect no change or movement at all? Is this a stable landmark?
My thoughts: 100% Porion is stable. There is no remodeling in that area. Now what can be tricky is tracing it because it’s a twisty canal through the bone and remember head tilt left or right in the machine could affect it as well – so same comment as other double sided / non-midline structures.
Strong work,
Carter
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For Prompt #10, where it says “give the rationale for observed dental changes” does this just mean they want us to distinguish between treatment effect vs growth? I thought the question was asking us WHY that happened. For example, maxillary and mandibular incisors were retracted due to premolar extractions.
For prompt #11, when asked to “give the rationale”, here, you mention extractions. Why was it not mentioned in #10? Also for #11, it says “extractions led to a deepening of labiomental sulcus”, but I think treatment reduced the labiomental sulcus (ie. made it more shallow). Can you explain?
Thanks!! Sorry for all the questions!
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Leah,
Replying to your comments here:
For Prompt #10, where it says “give the rationale for observed dental changes” does this just mean they want us to distinguish between treatment effect vs growth? I thought the question was asking us WHY that happened. For example, maxillary and mandibular incisors were retracted due to premolar extractions.
THOUGHTS: Yes, in the samples from the ABO the phrase “Give the rationale for observed dental changes” it is there code for exactly what you said “Distinguish between treatment effect vs. growth”. This is how we figure if we really dentally corrected a Class II or did we do amazing in our growth analysis or did we just get lucky (Growth is wonderful in helping our appearance as magicians!).
For prompt #11, when asked to “give the rationale”, here, you mention extractions. Why was it not mentioned in #10? Also for #11, it says “extractions led to a deepening of labiomental sulcus”, but I think treatment reduced the labiomental sulcus (ie. made it more shallow). Can you explain?
THOUGHTS: You could mention extractions in #10 and have that as the treatment effect. I agree the labiomental sulcus appears more shallow. [HEADS UP TO EVERYONE! – These cases have some gray areas just like this one which is why discussion is so helpful. BUT – the board will be as cut and dry as they can make it…. remember it’s tons of orthodontists involved so they have shown cases we can agree on better. Finding those sample cases can be pretty darn tough]
“Thanks!! Sorry for all the questions!”
No worries at all! Keep them coming! Remember – if you have a question then someone else probably does as well or will benefit from your thoughts.
All the best,
Carter
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I was also stuck on the labiomental sulcus aspect of Module 1 Prompt 11 and caught myself staring at the before and after photos for a while… haha
I looked through the comments/uploads from last year’s comment (to Joti) and this year’s comment (to Leah) – please let us know if you have any other tips / tricks / norm values to consider for labiomental sulcus. I feel like I can really easily identify when it’s deep on a brachyfacial class II div 2 patient, but I agree that this one seemed like it could maybe be argued either way (that it deepened after exts and tx OR that it became more shallow after exts and tx). I was leaning towards what you and Leah agreed on – that it became more shallow. Thanks again!!
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Nidhi
For module case 1 prompt 11 do we need to mention the numbers from Buschang article for the normal growth pattern or can we just say that this is due to treatment effect?
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Nidhi,
You certainly wouldn’t be wrong to say something like
“U6 erupted 5mm same as expected with growth”
or
“U6 erupted 7mm – 5mm from growth and 2mm from extrusive treatment effect”
This would be a style choice in my opinion. The sample questions provided by the boards show more simple responses. “U6 by growth” or “U6 extrusive treatment effect” without asking for specific numbers.
Again, think of answering efficiently and managing time through the exam. 4 hours flys by!
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I have a few questions regarding this case as well. I apologize if they are redundant I tried to search through the feeds to limit repetition, but need some more specific clarification on a few of the prompts.
Prompt 1:
1. Would statural height be accepted, or should we list the chart considering weight is not reflective of growth?
2. Would inquiring about if the patient has started her menstrual cycle be an acceptable answer for diagnostic information as well as Buschang emphasizes the relation of PHV and menses.
Prompt 2:
1. For midline deviation, the ABO website says be specific regarding facial midline and the midlines to each other. Would it be more acceptable to state the upper midline is coincident with the facial midline, while the lower midline is deviated 2mm to the right of the facial midline?
2. Would it be correct to say ectopic eruption of the maxillary second premolars, or because they are in the correct area just significantly blocked out that is covered when we say significant crowding?
Prompt 3:
1. The response indicates obtuse NLA? Isn’t the norm for females 95-100? When looking she appears less than 90 to be so I was thinking NLA was normal or even slightly acute.
Prompt 4:
1. Does the patient not have a steep mandibular plane with FMA being slightly increased, and a slight hyper-divergent growth pattern?
2. Generally speaking, how are you indicating any transverse diagnosis’ with a lateral ceph/PANO, don’t we need a PA or CBCT? Or are you solely going off the extra/intra oral images?
Prompt 5:
1. Can you elaborate on the response to increase chin projection in this patient? Although her ANB indicates she’s skeletal CL 2 the overall positions of the mandible in the lateral cep is ideal to me, it seems more of a dentoalevolar protrusion in terms of her overall facial balance.
Prompt 8:
1. In prompt 5 you say you want to increase the chin projection of this patient, but then in this prompt you say allow normal growth expected in mandible in AP and vertical, can you elaborate.
Prompt 10:
1. Just more of a generic question, when the superimpositions are inquiring whether the changes were growth/treatment/etc will these typically be follow up questions on cases where we have already answered questions regarding their growth potential or will supplemental exhibits be given such as a hand wrist or lateral cep to eval the vertebrae? I’d assume responses would be different for those who are growing individuals vs those who may be adult with no more growth potential.
Thank you!
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Dr Sawsan,
I’m pasting your questions below and then adding my comments after them. My general comment is absolutely use your judgement as an orthodontist! We’ve put time into developing this course because we find value in continuing to workshop cases in the ABO style as a community. The cases we’ve drafted are not from the ABO or to be taken as gospel. Their based on our review of the guidelines each year and an understanding of the ABO requesting we used a standard language as board certified orthodontists.
Prompt 1:
1. Would statural height be accepted, or should we list the chart considering weight is not reflective of growth?
You could put height. Can you think of the reason a height-weight chart is used rather than height alone? (Yes, weight gain is not indicative of maturation growth otherwise I still would be considered growing. Ha!)
2. Would inquiring about if the patient has started her menstrual cycle be an acceptable answer for diagnostic information as well as Buschang emphasizes the relation of PHV and menses.
Absolutely, I ask this question all the time of female patients (well I ask the parents).
Prompt 2:
1. For midline deviation, the ABO website says be specific regarding facial midline and the midlines to each other. Would it be more acceptable to state the upper midline is coincident with the facial midline, while the lower midline is deviated 2mm to the right of the facial midline?
Sure, that’s how I write it on my clinical exam as well.
2. Would it be correct to say ectopic eruption of the maxillary second premolars, or because they are in the correct area just significantly blocked out that is covered when we say significant crowding?
I’d understand what you were saying if you called the max second premolars ectopic.
Prompt 3:
1. The response indicates obtuse NLA? Isn’t the norm for females 95-100? When looking she appears less than 90 to be so I was thinking NLA was normal or even slightly acute.
If that’s what you’re eyeballing then it’s fine to call it that. Remember it’s not about “Scoring 100%” on these responses. It’s about enough agreement that you are recognized as treating to board standards. Selecting cases for review in an exam is very challenging because all answers need to evident enough that hundreds of orthodontists can agree on the same diagnosis. I wouldn’t get lost in the weeds on this one. Personally, I still call her obtuse but when I identify what is at fault – then it’s due to her upturned nasal tip.
Prompt 4:
1. Does the patient not have a steep mandibular plane with FMA being slightly increased, and a slight hyper-divergent growth pattern?
I’ve argued this point as well before. “Technically” she is within a standard deviation of normal. But you bet the whole farm that I am going to treat her as hyperdivergent because I’m concerned about the vertical.
2. Generally speaking, how are you indicating any transverse diagnosis’ with a lateral ceph/PANO, don’t we need a PA or CBCT? Or are you solely going off the extra/intra oral images?
A PA Ceph or CBCT can be used for measuring a transverse radiographically. There are many other ways that do not involve radiographs: 1) Using extraoral images to evaluate buccal corridors 2) Using intraoral images to evaluate crossbites / curve of Wilson / curve of Monson 3) Measuring casts with intermolar and intercanine widths. These are just a few key ones I use. I’m sure others could chime in with their thoughts as well.
Prompt 5:
1. Can you elaborate on the response to increase chin projection in this patient? Although her ANB indicates she’s skeletal CL 2 the overall positions of the mandible in the lateral cep is ideal to me, it seems more of a dentoalevolar protrusion in terms of her overall facial balance.
I can’t really say to treat differently if that is where you treat for a skeletal relationship (for example there are many Ceph analsyses out there are some folks view an acceptable relationship differently). My target favors the Steiner angles which are what the ABO is referencing as well.
She might appear to have dentoalveolar protrusion from the soft tissue and that’s were the ceph helps us out. I reference the incisor angles and linear protrusion measurements and she is 100% normal… so why do her lips look so full? Well it’s due to a deficient chin position, thats why the lips look protrusive as well. It’s not the positioning of the teeth at the heart of the matter.
Prompt 8:
1. In prompt 5 you say you want to increase the chin projection of this patient, but then in this prompt you say allow normal growth expected in mandible in AP and vertical, can you elaborate.
Yes, we want to increase chin projection. We already assessed she is about to hit peak growth and we look at the mandible morphology and can tell she is reasonably a “good grower” for correcting a Class II. So, we want to increase the chin projection and by applying our growth assessment and understanding her growing trend, then she will do the growing to increase the chin projection.
If instead, growth was ceased and we wanted to increase chin projection then we’d have to consider surgery.
Prompt 10:
1. Just more of a generic question, when the superimpositions are inquiring whether the changes were growth/treatment/etc will these typically be follow up questions on cases where we have already answered questions regarding their growth potential or will supplemental exhibits be given such as a hand wrist or lateral cep to eval the vertebrae? I’d assume responses would be different for those who are growing individuals vs those who may be adult with no more growth potential.
The ABO doesn’t say how many questions will be on each case. The sample cases they’ve put up sometimes have 2 questions and sometimes 6 or 7.
Page 6 of the Study Guide from the ABO Website says:
“Candidates
will have 4 hours (240 minutes) to complete the question sets for at least 6 different scenario
cases (but no more than 10) in the Pearson VUE system. Each scenario case is comprised of 1 –
6 questions. Each question will have case records that will be available as exhibits.”All of those cases and questions are to target the 13 tasks within the 4 testing domains.
We have drafted these cases to help us all focus on those 4 domains and the 13 tasks so you are better calibrated for the exam instead of walking in cold and not feeling comfortable with the format.
Thoughts? Additions? Helpful?
Keep it up! Just a week to go.
Carter
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Carter,
Thank you so much for the clarifications, it was extremely helpful!
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