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Mandibular Prognathism with Unilateral Crossbite—Treatment

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Mandibular Prognathism with Unilateral Crossbite—Treatment message board Mandibular Prognathism with Unilateral Crossbite—Treatment Not Going Well Townie “3MOrtho” wonders how to treat a young boy with a slew of problems such as mandibular prognathism and a mild protrusion of the mandibular incisors 3Mortho Member Since: 11/18/07 Introduction: Post: 1 of 11 The patient is a 10-year-old boy with mandibular prognathism, unilateral crossbite, spacing in the lower arch, minimal crowding in the upper arch, skeletal Class III, and mild protrusion of mandibular incisors. The treatment was started with Delaire mask and RPE. At the end of this treatment (9 months) he had a tete-a-tete bite in the front and the upper arch was successfully expanded. Treatment was continued with Class III and open bite elastics, but the patient is not compliant in wearing the elastics. His second year in treatment, there is deviation of the mandible to the right and the bite cannot be closed with elastics. How would you proceed with the treatment? Would you extract in this case? n 14 DECEMBER 2017 // orthotown.com message board 10/4/2017 Fenrisúlfr Member Since: 02/25/09 What was the rationale for the early intervention/Phase 1? Any discussion re: surgery? Given his Post: 2 of 11 age, and pending a shift, the Class III is likely to significantly worsen with continued mand. growth. A prudent option may be to correct the transverse completely, alleviate any slides and then remove appliances. Once there has been cessation of growth, he can then be evaluated for surgical correction. n 10/4/2017 Shwan Member Since: 08/02/10 There is skeletal mandibular asymmetry that will worsen with time. I hate these cases. You are Post: 3 of 11 essentially fighting against the growth and you will probably lose if your only weapon is elastics. I will present two options: surgery (best) or unilateral lower premolar extraction. Tough situation. Good luck. n 10/4/2017 orthothai Member Since: 10/14/13 Sorry for your trouble. A Delaire mask is supposed to be used until an overcorrection is achieved Post: 4 of 11 in prevision of both the relapse and the fact the mandible will continue to grow. Personally, I aim 16 DECEMBER 2017 // orthotown.com for a positive overjet of 2mm if possible. Ten years old is way too young to start fixed appliances on a Class III patient, especially with a boy who will have the mandibular growth spurt around two years later than girls. Asymmetry of the mandible is genetic in nature and cannot be corrected without orthognathic surgery. In Cambodia, almost all patients refuse surgery and treating those asymmetric cases with orthodontics alone is time consuming. If going for ortho alone you have to be clear with the patient that it is a compromise treatment. For treating your case I have unfortunately no solution. Whatever you do, the mandible will continue to grow and you will not be able to finish the case, or if you do, you will have relapse right away. On this case, I would say bite the bullet, explain to the parent that if the Delaire therapy was successful, the fixed appliance treatment is not and has to be discontinued until the end of growth. Not comfortable to do but beats the alternative of trying to do ortho on the case for X years and not be able to finish. P.S. Whatever you do, do not extract. n 10/4/2017 justinudm I have to agree with everything already said. Way too early for comprehensive treatment in Member Since: 09/29/14 a Class III prognathism case. The transverse needs to be corrected now. It appears there is still Post: 5 of 11 a functional shift going on. Fix the transverse and debond. Wait for growth to stop if not slow and re-evaluate for further treatment. Bite the bullet and tell the parents that growth is unfavorable and you need to wait it out. n 10/5/2017 emac Tough case. I can’t tell from the records, but if the unilateral crossbite is from the lower being Member Since: 11/21/11 asymmetric, then upper expansion will be difficult and in my hands, it never works out very Post: 6 of 11 well. It may seem odd, but sometimes I have left a molar in crossbite as it just seems to fit and is more stable in that location. Remember setting up dentures in posterior crossbite? Whenever I expand in a case like this, I find the upper anterior flattens and my underbite gets worse, and an open bite starts. I believe you are seeing that. If I were treating this, I would remove the arches and let the case settle for a couple of appointments. Then regroup. I would go to small SS round wires and try some elastics to pull the teeth into occlusion. Maybe some lower Class I chain. Try and get the lower tipped back a little. Let the right-side posterior find its place. It may not end up on the cover of a journal, but you may avoid surgery and give the patient a nice result. I tell patients that my goals are aesthetics, function, and stability. In this case, pick two. n 10/9/2017 jwkortho De Clerck miniplates would be an option at his age and eruption for an improvement and Member Since: 11/24/08 an attempt at improving the Class III. However, if he won’t wear elastics, then it’s a waste of Post: 7 of 11 everyone’s time and money. n 10/9/2017 justinudm I agree that this is great treatment in the right situation. In cases of true mandibular prog- Member Since: 09/29/14 nathism, all you would be doing is creating a bimax prognathism (i.e. Homer Simpson face.) Post: 8 of 11 For the best facial aesthetics with a mandibular prognathism, the case will need a mandibular set back. This case, when you look at the ceph, is actually a maxillary retrognathia. I would love to see a smiling profile picture to confirm this. If the maxilla is retrognathic, then yes to bone plates if the patient will wear elastics. orthotown.com \\ DECEMBER 2017 17 message board As to the upper teeth retracting when you expand, yes this will happen with true skeletal expansion because you will be increasing arch length (circumference of half circle is proportional to diameter of half circle) and there will be increased space to resolve crowding and/or retract teeth. If there is no crowding, as in this case, the upper anteriors will retract. All good points to ponder. n 10/9/2017 whiskeyriver Member Since: 02/05/13 I agree with everyone that you are fighting growth which is usually a no-win situation. Post: 9 of 11 Coupled with noncompliance and you have a real headache. Probably hoping the dad gets a new job and has to move. I have used the CS 2000 springs from DynaFlex to bail myself out on noncompliant cases. They come in 10mm and 7 mm lengths. If you overstretch the springs they break right in the middle and they are expensive. A couple of times I fell on my sword and took the appliances off. Closed the fee, gave retainers and offered to retreat the case for half the fee again if they agree to undergo surgery. Thus far, two have come back as young adult males and went to surgery. n 10/9/2017 tom525 Member Since: 06/18/08 Went to Dr. De Clerck’s course twice and started doing bone anchors for Class III two years Post: 11 of 11 ago. These are a few shots of a transfer case whose mother really wanted to try anything but surgery for her 13.3-year-old daughter. She was too old for Hugo’s profile but I was impressed with what happened in her case. About a year between cephs. Last photos are 18 months into treatment. Left lower plate came out after 15 months n 10/23/2017 What would you do? Search: “Mandibular Prognathism” It seems as if there is no easy way around treating this patient. Curious to see how this case turned out or have questions for the original poster? Head to orthotown.com and search “mandibular prognathism”—this message board will be the top result. 18 DECEMBER 2017 // orthotown.com.
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