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Extraction/ NonExtraction
Records and
Ethics
Point/Counterpoint:
Class III * Mini-Plates
Orthodontic Camouflage of Class III
Early Orthodontic Treatment: * Facemask
* Camouflage
Practice Management
Sleep Disordered Breathing
Class III Treatment
Vertical
* Mini-Plates * Orthopedics * Camouflage
Marketing Who, When, Why and How to Treat Growers/Open Bites Class II Treatment
Ectopic Teeth
Parent/Child Management
Trauma
Orthodontic Goals: For Class III camouflage-prioritization required
Reference--WITS Goals/Options
Pts w Class III Conditions
Timing Non-growing
R i s k / C o s t
Initial Differential Diagnosis
F unction R2 eliable/Realistic E2 sthetics/Economic S2 tability/Satisfaction H ealth
Approach
Secondary Differential Diagnosis Proffit/Ackerman
Class III Treatment Approaches
Double Jaw Surg
R i s k / C o s t
$50-60K
S.O.F.T. Procedure
Single Jaw Surg
$8-10K
$40-45K
Orthodpedics w plates
Distraction w Plates
$3-5K
$12-16k
Camouflage-Non-growing
Camouflage w Orthopedics
Camouflage-Growing
Severity / R e w a r d
Severity / R e w a r d
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Treatment decision in adult patients with Class III malocclusion: Orthodontics or orthognathics? Stellzig- Eisenhauer, et al.: AJODO: 2002; 122:27-38.
Treatment decision in adult patients with Class III malocclusion: Orthodontics or orthognathics? Stellzig- Eisenhauer, et al.: AJODO: 2002; 122:27-38.
1.Key Cephs of 175— 87 non-surg; surg. Group reference to 88 review
1.Key Cephs of 175— 87 non-surg; surg. Group reference to 88 review
Treatment decision in adult patients with Class III malocclusion: Orthodontics or orthognathics? AJODO: 2002;122:27-38.
Underestimation of Effectiveness
2. 20 linear, proportional and angular measures discriminant analysis 3. “Research effort to provide cephalometric yardsticks that would make the treatment decision more objective.”
Wits showed highly significant differences
2. 20 linear, proportional and angular measures discriminant analysis 3. “Research effort to provide cephalometric yardsticks that would make the treatment decision more objective.”
Camouflage Therapy Craniofacial Characteristics •
Median Wits for Class III non surg = - 4.71mm. Median Wits for Class III surgical = - 12.97mm. Only 2.3% of non surg misclassified 13.6% of surg misclassified (Median Wits was =
-7.21mm for misclassified)
• • •
Moderate basal bone discrepancy: Both jaws contribute60% maxillary retrusion/ 40% mandibular excess Adequate aveolar bone and gingivae for incisor reangulation Minimal mandibular asymmetry (< than 5mm) Minimal max. vertical excess or deficiency
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Camouflage Therapy for Class III patients
Behavioral Characteristics of Patient 1. 2.
Existing facial proportion acceptable to patient (Needs to be discussed as part of treatment planning options) Proposed angular changes of teeth acceptable to patient
Camouflage Therapy Underestimation of Effectiveness Four General Types: 1. Camouflage thru differential extraction 2. Camouflage thru non-extraction 3. Camouflage—add teeth (eg. missing #7 and 10) 4. *Camouflage thru soft tissue procedures (Cosmetic/Surgical)
The Orthodontist’s 10-15 Billion Dollar Decision
Reference--WITS
Camouflage or surgery? Class III adults
Goals/Options
Pts w Class III Conditions
Timing Non-growing
Measurement of WITS from Ceph w pt in centric occlusion
Pts w Class III Conditions
Timing
Initial Differential Diagnosis
Initial Differential Diagnosis
Approach
Secondary Differential Diagnosis Proffit/Ackerman
Class III camouflage?
Approach
Secondary Differential Diagnosis
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Orthodontic Goals: For Class III camouflage-prioritization required
F unction R2 eliable/Realistic E2 sthetics/Economic S2 tability/Satisfaction H ealth (Minimally invasive)
Kourey, Epker: The aged face: the facial manifestations of aging. IJAO&OS: 1991;681-95. Ortho. camouflage (U4 ext) in adult Class II cases can have a definite impact on facial aging.
Class III – Camouflage? Classic case of goal prioritization
F. R. E.S.H.
Esthetics Versus Economics $55,000 saved
Camouflage Therapy Underestimation of Effectiveness Other considerations w camouflage recommendation:
“Youthful appearance has a welldefined mandibular line and good definition between face and neck.” “The aged face… Kourey, Epker: The aged face: the facial manifestations of aging. IJAO&OS: 1991;681-95.
Author’s Note: Many non-growing skeletal Class III’s can be well treated with minimal compromise and significant patient satisfaction through proper application of the principles of camouflage therapy. What are the key principles?
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Key Principles of Camouflage For Class III patients
• Clear diagnosis of degree of skel problem (Template for both doctor and patient understanding) Graber • Explain options: “ideal versus practical” (What are the downsides of practical plan—your view) • In treatment plan write-up—indicate both plans and why practical was chosen (risk/benefit issues; pt. Issues)
• Avoid over-retraction of lower incisors or protraction of upper incisors (Frequently requires non-x upper, & if crowding en. re-contouring and gingival grafting to accomplish non-x goal on upper arch. Also add congenitally missing teeth and enlarge small laterals.)
Checklist for Non-Growing Class IIIs Craniofacial Characteristics Moderate basal bone discrepancy: Both jaws contribute-Example 60% maxillary retrusion 40% mandibular excess
Adequate aveolar bone and gingivae for incisor reangulation Minimal mandibular asymmetry (< than 5mm) Minimal max. vertical excess or deficiency Behavioral Characteristics of Patient Existing facial proportion acceptable to patient (Needs to be discussed as part of treatment planning options) Proposed angular changes of teeth acceptable to patient
Tx. Plan for 61 yr. Class III old male:
Initial tx. plan for 61 yr. Class III old male: • • • •
Extract upper 2nd bis Decompensate incisors Advance Max. approx 5mm Set mandible back approx 3mm
ANB = -3.0 Wits = -15 Mx/Mn = 41
• • • •
Extract Upper 2nd bis Decompensate Advance Max. Set mandible back
Age 61:1, Wits -15
Therapeutic dx. with modified ORTA w post. bite plane Age 61:1, Wits -15 62:11, Wits -8.5
During early Class III elastic traction Fax came from Florida: “…………………………….”
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Therapeutic dx. with modified ORTA w post. bite plane
Initial tx. plan for 61 yr. Class III old male: • • • •
Extract upper 2nd bis Decompensate incisors Advance Max. approx 5mm Set mandible back approx 3mm
ANB = -3.0 Wits = -15 Mx/Mn = 41
Age 61:1, Wits -15 62:11, Wits -8.5
During early Class III elastic traction Fax came from Florida: “…………………………….”
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Therapeutic Diagnosis
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15 year follow-up
“Force systems are your medicine” Weinstein/Haack
Growing Class III Pts. Timing
LABORATORY STEPS ORTA—Orthodontic removable traction appliance Stone Model 1. Trim for vacuum form; 2. Relieve undercuts (except “retentive ridges”) 3. Check for retention of “retentive ridges”; NOTE: use smaller retentive ridges with less retention when using biocryl for RTA 4. Make sure that “retentive ridges” are large enough on the tooth for adequate retention; Then, when the model is poured up, lightly scrape plaster around the area of the “retentive Durasoft Material (Great Lakes Orthodontic Products) Essix “C” 2. Price @ $4.99 per sheet Price @ $0.59 per sheet Vacuum Form to model
1. Trim with diamond disc 2. Smooth edges with diamond bur 3. Be sure to leave > 2 mm under retentive ridges to aid in retention Add Caplin Hooks (GAC) for elastic traction—heat & attach
Lower ORTA for Class III Traction
The Checklist Manifesto: How to Get Things Done Right Atul Gawande “That means we need a different strategy for overcoming failure: one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy— though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.”
It is the checklist.” 1. Heat Caplin hook (GAC International) with torch and place in the area of desired traction.
2. After inserting the hook into the plastic (essix, biocryl or durasoft) material, check the underside to make sure that the hook is not showing through the plastic 3. Pull hook to be sure it’s attached to material securely; it should not be able to be detached from elastic pull.
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Additional variables that need consideration:
(1) HGH therapy affects the growth of the mandible more than the growth of the maxilla;
(Seldom discussed but can be critical)
19:3 (-13mm) (2) the amount and pattern ofafter growth during
15:5 Pretx (-8mm) HGH administration are unpredictable, and
Psychological factors of appearance
Hormone therapy & growth
Transverse deficiency of maxilla (skeletal component);
(3) HGH therapy rarely affects dental maturity.
Am J Orthod Dentofacial Orthop. 2004 Jul;126(1):118-26.
space available (dental component) Clockwise growth & excessive mand. growth Asymmetrical growth
True condylar hyperplasia
Short stature/Class III: Rx human growth hormone
Chapter 16: 75 + references Class III: The Evidence on Diagnosis and Treatment J. Gahfari, et al:
Checklist (at Phase II ) for Class III-ing Pts. Patient’s Name:___ __ Male Female
Age ________Skel. Age_____
Family history Yes No_____________________ Initial diagnosis (mnd excess) Yes No (%Max vs. Mand)______ Response to Ph I Good Fair Poor__________ Diagnosis @ Ph II (Wits) Better Same Worse Facial balance Mild Mod. Severe Skeletal age @ Ph II Favorable Unfavorable__________ Growth pattern Favorable Unfavorable (asym/open) Ging Health/Root length Favorable Unfavorable__________ Capacity to Camoflague Favorable Unfavorable__________ Compliance Favorable Unfavorable __________ Growth hormone Yes No
Phase II Decision Time:
Non-surg;
Thera dx; Wait & plan surg
• “Treat early for more effect”
• “Chin cup success is • questionable” • “Tx is better than no tx.” • “ Over-treat for stability” • “Forecasting growth is difficult”
.
Principles applied--5 case examples
Case #1
A. C.--Pre-Treatment
When a young patient is Class IIIing-what is the role of camouflage in treatment management
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Checklist Phase II conference for Class III-ing Pts.
Wits -5 mm
Patient’s Name:___ _Alicia C_ Male Female
Family history Initial diagnosis (mnd excess) Response to Ph I Diagnosis @ Ph II (Wits) Facial balance Skeletal age @ Ph II Growth pattern Ging Health/Root length Capacity to Camoflague Compliance Growth hormone
Age ________Skel. Age_____
Yes No_____________________ Yes No (%Max vs. Mand)______ Good Fair Poor__________ Better Same Worse Mild Mod. Severe Favorable Unfavorable__________ Favorable Unfavorable (asym/open) Favorable Unfavorable__________ Favorable Unfavorable__________ Favorable Unfavorable __________ Yes No
Phase II Decision Time: Non-surg;
Orthopedics + Camouflage + Fx Shift Elim. + Clockwise rotation of “B” point ***
Checklist
Case #2:
Intervene now or wait? 4:1 female Unilateral repaired cleft lip and palate
(at Phase II Conf.) for Class III-ing Pts
Patient’s Name:___ __Amber A. Male Female
Thera dx; Wait & plan surg.
Family history Initial diagnosis (mnd excess) Response to Ph I Diagnosis @ Ph II (Wits) Facial balance Skeletal age @ Ph II Growth pattern Ging Health/Root length Capacity to Camoflague Compliance Growth hormone
Phase II Decision Time:
Age ____ Skel. Age____
Yes No__Unilateral cleft w D. A. C. Yes No (Max% >Mand)______ Good Poor____________________ Mild Mod. Severe Mild Mod. Severe Favorable Unfavorable__________ Favorable Unfavorable (asym/open) Favorable Unfavorable__________ Favorable Unfavorable__________ Favorable Unfavorable __________ Yes No
Non-surg;
Thera dx; Wait & plan surg.
Early intervention with AC reversal & very good growth response allowed conservative correction.
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Case #3
8:11 Wits -8 1. Initial Diagnosis 2. Phase I—”Ther. Diagnosis” 3. GTRV @ 3 yrs. (Wits) 4. Green; yellow or red 5. Phase II or wait for surgery
Checklist #3
(at Phase II Conf.) for Class III-ing Pts.
All early Class III’s require Therapeutic Dx Patient’s Name:___ Jamie_F. Male Female
Family history Initial diagnosis (mnd excess) Response to Ph I Diagnosis @ Ph II (Wits) Facial balance Skeletal age @ Ph II Growth pattern Ging Health/Root length Capacity to Camoflague Compliance Growth hormone
Age ________Skel. Age_____
Yes No_____________________ Yes No (%Max vs. Mand)____ Good Fair Poor______________ Mild Mod. Severe Mild Mod. Severe Favorable Unfavorable__________ Favorable Unfavorable (asym/open) Favorable Unfavorable__________ Favorable Unfavorable__________ Favorable Unfavorable __________ Yes No
Phase II Decision Time: Non-surg;
Thera dx; Wait & plan surg.
8:11 Wits -8
9:8 Wits -4
20:3 Wits -5
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Case #4:
Pre-tx. Lauren R. 9yrs.
@12 (-11)
@9 (-4.5)
Checklist #4
(at Phase II Conf.) for Class III-ing Pts.
@9 (-4.5)
All early Class III’s require Therapeutic Dx
Patient’s Name:___Lauren R __ Male Female
Family history Initial diagnosis (mnd excess) Response to Ph I Diagnosis @ Ph II (Wits) Facial balance Skeletal age @ Ph II Growth pattern Ging Health/Root length Capacity to Camoflague Compliance Growth hormone
Phase II Decision Time:
Age ________Skel. Age_____
@12 (-11) Yes No_____________________ Yes No (%Max vs. Mand)______ Good Fair Poor____________ Mild Mod. Severe Mild Mod. Severe Favorable Unfavorable__________ Favorable *Unfavorable (asym) Favorable Unfavorable__________ Favorable *Unfavorable__________ Favorable Unfavorable __________ Yes No Non-surg;
@15+ (-13)w Asym.
Thera dx; Wait & plan surg.
Case #5
@5.0 (-5.5)
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Checklist #5
Dad = (-7) (at Phase II Conf.) for Class III-ing Pts
Patient’s Name:___Robin P__________Age ________Skel. Age_____ Male Female
Family history Initial diagnosis (mnd excess) Response to Ph I Diagnosis @ Ph II (Wits) Facial balance Skeletal age @ Ph II Growth pattern Ging Health/Root length Capacity to Camoflague Compliance
Yes No_____________________ Yes No (%Max vs. Mand)______ Good Poor_____________ Mild Mod. Severe Mild Mod. Severe Favorable Unfavorable__________ Favorable Unfavorable (asym/open) Favorable Unfavorable__________ Favorable Unfavorable__________ Favorable Unfavorable __________
Phase II Decision Time: Non-surg;
Surgical
Non-Surgical
Borderline
Thera dx; Wait & plan surg.
@5.0 (-5.5)
-14 -13 -12 -11 -10
M -9 e -8 a -7 n
@16.0 (-2.5)
-6
W -5 i -4 t -3 s -2 -1 0 6
7
7.2
8
9
10
11
12
12.5
13
13.2
14
15
16
16.5
17
18
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Cephalometric Effects of Class III Treatment A Comparison of ORTATM and Protraction Facemask
Kristin N. Moore, D.M.D. Master of science in Oral Sciences Thesis Defense
Conclusions: ORTATM provides orthodontists with a useful noninvasive alternative treatment modality to protraction facemask in Class III malocclusion. Similar dental and skeletal results can be achieved by use of either the protraction facemask or the ORTATM.
12 10 8
months
6 4 2
O.R.T.A.
0 ORTA
Protraction Facemask
@8.5 (-12)
At 13 (-5)
Case #8
Final Thought
Wits = -7
Jerome Groopman, MD: Second Opinions “In
a predictable world, clinical decision making would be a well defined, scientific exercise with set methods for diagnosis and treatment.”
Patient’s Name:___ Kathleen D.
Male
Age __14:2______Skel. Age__14:8___
Female
Family history Initial diagnosis (mnd excess) Response to Ph I Diagnosis @ Ph II (Wits) Facial balance Skeletal age @ Ph II Growth pattern Ging Health/Root length Capacity to Camoflague Compliance Growth hormone
Phase II Decision Time:
Yes (mild) No_____________________ Yes No (%Max vs. Mand)______ Good Fair Poor__________ Better Same Worse Mild Mod. (accepts) Severe Favorable Unfavorable__________ Favorable Unfavorable (asym/open) neutral Favorable Unfavorable__________ Favorable Unfavorable__________ Favorable Unfavorable __________ Yes No
Non-surg;
Aggressive orthopedics ASAP: • RPE; FBO; Facemask • IPR lower arch • Re-eval GTRV (Wits @ 4 mos)
Thera dx; Wait & plan surg.
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Measurement of WITS from Ceph w pt in centric occlusion
Reference--WITS
Pts w Class III Conditions
Timing Non-growing
Goals/Options/ Prioritize
Initial Differential Diagnosis
Approach “Until more reliable diagnostic methods are available, perhaps orthodontists should view the testing of treatment response as a tool rather than a shortcoming.”
Secondary Differential Diagnosis
R i s k / C o s t
Double Jaw Surg $50-60K
Single Jaw Surg $40-45K
S.O.F.T. Procedure $8-10K Traditional Orthopedics
Distraction w Plates $12-16k Orthodpedics w plates $3-5K
Camouflage-Non-growing
Camouflage-Growing
Ackerman, Proffit-AJO, 1970
Severity / R e w a r d
Synopsis for use of camouflage for Class III
Achieving Objectives: Successes or Failures?
I. Prioritize goals for Class III patients—F.R.E.S.H. II. Differential diagnosis— Max./Mand Diff.--*Wits III. Effective therapeutic measures— ORTA + + + IV. Treatment response— WITS Changes +++++
“…more logical to categorize patients as ‘responders (R) or nonresponders (NR).’” In addition, post-treatment relapse patients should be categorized as “adapters (A) and non-adapters (NA).” Bell shaped curve—most favorable R and A at one end and most unfavorable NR and NA at the other end of a normal distribution curve. Ackerman, JL (In 5th edition of Graber, Vanarsdall, Vig )
V. Additional variables--Checklist (Apply the checklist before Phase II)
VI. Application of treatment principles—Individualize 87
88
POINT: CLASS III CAMOUFLAGE VS. ORTHODPEDIC THERAPY Best minimally invasive outcomes frequently require incorporation of both treatment modalities—not either/or!!!
Conclusion: Since force systems are our medicine: Dose, duration & compliance will effect outcome. It is suitable to increase dose and duration if initial response not effective. Checklist (variables) encourages objectivity & communication prior to Phase II with incorporation of camouflage mechanism to complete correction. Our findings indicate: Dentoalveolar camouflage is a very useful modality in a wide range of Class III skeletal dysplasias. Minimal deleterious side effects were observed in periodontium. Proper diagnosis and realistic treatment objectives are necessary! Parents, patients and doctor must understand the limitations of the camouflage mechanism.
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