Chang, Chris HN - Point-Counterpoint Conservative Management of Class III Skeletal Malocclusion

Challenging CIII Made Easy
11
mm ?
Newtons A &
Chris Chang, DDS, PhD, ABO Certied Beethoven Orthodontic Center, Taiwan
He was told that only surgery can solve his problem.
Whats the % of
3 major
Honda Y., 20:08
challenging CIII malocclusion?

1. CIII Open bite (High Angle) 2. CIII Deep bite 3. CIII with Impaction
1. Anterior 2. Posterior
5 10 10 5 5 5
Good
10%
60%
prole
30%
8:45
I believe in case study...
How difcult is that???
20
08
1. Every case we review 2. Every KEY step we review 3. Be brutally honest to right our wrongs Pre-Tx

Discrepancy Index
DI < 10: easy
Rout ine record
DI = 10~20: moderate DI = 20~30: difficult
DI > 30: very difficult
Discrepancy Index

DI?
Rout ine record
71 Very
Tx. Plan
= very, very
difcult!
Discrepancy Index
?
How to measure the difculty level ???
A
X
os?
Discrepancy Index
Tx. Plan
B
X
Huge gap
?
X X
?
Is that difcult to x???
Tx. Plan
C
X
Believe me, its easy!
No Surger y Just scre ws
22
How & Tips???

22
Pre-Tx
Post-Tx
?
Lets walk through the detailed procedures...
How & Tips???

22
Pre-Tx
Post-Tx
?
KEY:
OP rotation + whole arch distalization by screws
Read & react 0 9
Pre-Tx
22
Post-Tx
20
14
0 Without Buccal Shelf Screws,
Initial
it would be very hard to x it.

22 9
Mechanics ?????
Dr. Rungsi
You did the impossible because you didnt realize it was impossible.
Steve Jobs
Mechanics ?????
13
20
Dr. Rungsi
9
Mechanics ????? Mechanics ?????
Dr. Rungsi
9
Mechanics ?????
Dr. Rungsi
12
20
Cha nge the OP

Dr. Rungsi
Cha nge the OP

Dr. Rungsi
14
22
Cha nge the OP

Dr. Rungsi
Cha nge the OP

Dr. Rungsi
The Wisdom of Managing Wisdom Teeth Part III: Methods of Molar Uprighting
Dr. John Lin
Highly Positioned and Transalveolar Impacted Maxillary Canine
Drs. Billy Su, Chris Chang & W. Eugene Roberts
A Severe Skeletal Class III Open Bite Malocclusion Treated with Non-surgical Approach Dr. Sabrina Huang, Lecturer, Beethoven Orthodontic Course (left)
Drs. Sabrina Huang, Chris Chang & W. Eugene Roberts Orthodontic Center (middle) Dr. Chris HN Chang, Director, Beethoven
Dr. W. Eugene Roberts, Consultant, International Journal of Orthodontics & Implantology (right)
I J OI
International Journal of Orthodontics & Implantology
Vol. 24 Oct. 1, 2011
Stability
???
This 20-year-8-month-old male presented with a chief concern of anterior cross bite and prognathic
and the lower incisors were inclined 94 to Md plane. The cephalometric values are summarized in the Table entitled Cephalometric Summary. The IBOI ( International Board of Orthdontists and
mandible. He has seen at least two other

orthodontists and was told that surgery is the only solution for his severe malocclusion. Oral soft tissues, periodontium, frena, and gingival health were all within normal limits. Oral hygiene was excellent. Medical and dental histories were noncontributory.
Implantologists) and American Board of Orthodontics

(ABO) discrepancy index (DI) was 71, as documented
Fig 1. Pretreatment facial photographs
in the DI worksheet. The patient was succesfully treated with a conservative camoogue method as documented in the nish records (Figs. 6-10).
Fig. 4-5. Pretreatment pano and ceph radiographs
Pretreatment facial photographs ( Fig. 1 ) showed a straight profile with protrusive lower lip. The pretreatment intraoral photographs ( Fig. 2 ) and study models (Fig. 3) revealed a molar relationship of bilateral Class III. The lower dental midline was shifted 1.5 mm to the right of the facial midline. A lingual cross-bite extended from the right 1 st molar to the left 1 st premolar. There was also an end-to-end cross-bite tendency extending from the left 2nd premolar to the 2nd molar. No contributing habits were reported, but the labial tipping of the mandibular incisors suggests a long-term maxillary lip trap. Intra-oral exam and the panoramic radiograph (Fig. 4) revealed impaction of the right
# mandibular third molar ( 32). All other third molars
The overall objective of treatment was to keep the vertical dimension of occlusion (VDO), and retract the mandibular incisors, to compensate for the prognathic mandible, in order to achieve a Class I molar and canine relationships with ideal overjet and overbite. The specic treatment objectives were
Fig 2. Pretreatment intraoral photographs
to : Maintain the A-P position of the maxilla. Maintain the position of the maxillary incisors and molars. Retract the mandible incisors and molars relative to the apical base of bone. Correct the anterior and posterior X-bite and align the midlines. Establish a normal overjet and overbite in a mutually protected, Class I occlusion. Retract upper and lower lips to improve facial
Fig 6. Postreatment facial photographs
were missing. Cephalometric analysis showed a skeletal Class III pattern, due to a prognathic mandible that was manifest as a 7-mm anterior cross bite. The ANB angle was 1.5 , the SN-MP angle was 36 ,
Fig 3. Pretreatment study models
Drs. John Lin, Kwang Bum Park (front row) with Chris Chang and Mark Ou (back row) in front of a collection of Fig 7. Postreatment intraoral photographs balance. rare books in the study room of Dr. Chang s. antique orthodontic On the desk lay Angle's busts made of bronze and colored glaze.
International Journal of Orthodontics and Implantology is an experience sharing magazine for worldwide orthodontists and Implantologists. Download it at http://iaoi.pro
28
29
1.5 years follow-up...

Dr. Sabrina Huang, Lecturer, Beethoven Orthodontic Course (left) Dr. Chris HN Chang, Director, Beethoven Orthodontic Center (middle) Dr. W. Eugene Roberts, Consultant, International Journal of Orthodontics & Implantology (right)
This 20-year-8-month-old male presented with a chief concern of anterior cross bite and prognathic
and the lower incisors were inclined 94 to Md plane. The cephalometric values are summarized in the Table entitled Cephalometric Summary. The IBOI ( International Board of Orthdontists and
mandible. He has seen at least two other

orthodontists and was told that surgery is the only solution for his severe malocclusion. Oral soft tissues, periodontium, frena, and gingival health were all within normal limits. Oral hygiene was excellent. Medical and dental histories were noncontributory.
Implantologists) and American Board of Orthodontics

(ABO) discrepancy index (DI) was 71, as documented
Fig 1. Pretreatment facial photographs
in the DI worksheet. The patient was succesfully treated with a conservative camoogue method as documented in the nish records (Figs. 6-10).
Fig. 4-5. Pretreatment pano and ceph radiographs
Pretreatment facial photographs ( Fig. 1 ) showed a straight profile with protrusive lower lip. The pretreatment intraoral photographs ( Fig. 2 ) and study models (Fig. 3) revealed a molar relationship of bilateral Class III. The lower dental midline was shifted 1.5 mm to the right of the facial midline. A lingual cross-bite extended from the right 1 st molar to the left 1 st premolar. There was also an end-to-end cross-bite tendency extending from the left 2nd premolar to the 2nd molar. No contributing habits were reported, but the labial tipping of the mandibular incisors suggests a long-term maxillary lip trap. Intra-oral exam and the panoramic radiograph (Fig. 4) revealed impaction of the right
# mandibular third molar ( 32). All other third molars
Dr. John Lin
The overall objective of treatment was to keep the vertical dimension of occlusion (VDO), and retract the mandibular incisors, to compensate for the prognathic mandible, in order to achieve a Class I
The Wisdom of Managing Wisdom Teeth Part III: Methods of Molar Uprighting Highly Positioned and Transalveolar Impacted Maxillary Canine
molar and canine relationships with ideal overjet and overbite. The specic treatment objectives were to :
Fig 2. Pretreatment intraoral photographs
A Severe Skeletal Class III Open Bite Malocclusion Treated with Non-surgical Approach
Drs. Sabrina Huang, Chris Chang & W. Eugene Roberts
Maintain the A-P position of the maxilla. Maintain the position of the maxillary incisors and molars. Retract the mandible incisors and molars relative to the apical base of bone. Correct the anterior and posterior X-bite and align the midlines. Establish a normal overjet and overbite in a mutually protected, Class I occlusion. Retract upper and lower lips to improve facial balance.
I J OI
Vol. 24 Oct. 1, 2011
Fig 6. Postreatment facial photographs
were missing. Cephalometric analysis showed a skeletal Class III pattern, due to a prognathic mandible that was manifest as a 7-mm anterior cross bite. The ANB angle was 1.5 , the SN-MP angle was 36 ,
Fig 3. Pretreatment study models
Fig 7. Postreatment intraoral photographs
28
Drs. John Lin, Kwang Bum Park (front row) with Chris Chang and Mark Ou (back row) in front of a collection of antique orthodontic rare books in the study room of Dr. Chang s. On the desk lay Angle's busts made of bronze and colored glaze.
29
Pre-Tx
Post-Tx
1.5 y FU
Free download at:
1. IAOI.PRO 2. Newtonsa0301
0) (~300,00 I J OI
The Wisdom of Managing Wisdom Teeth Part III: Methods of Molar Uprighting
Dr. John Lin
Highly Positioned and Transalveolar Impacted Maxillary Canine
A Severe Skeletal Class III Open Bite Malocclusion Treated with Non-surgical Approach
Drs. Sabrina Huang, Chris Chang & W. Eugene Roberts
Vol. 24 Oct. 1, 2011
Drs. John Lin, Kwang Bum Park (front row) with Chris Chang and Mark Ou (back row) in front of a collection of antique orthodontic rare books in the study room of Dr. Chang s. On the desk lay Angle's busts made of bronze and colored glaze.
38
Pre-Tx
Post-Tx
1.5 y FU
Whats the % of
3 major
60%
10% 30%
1. CIII Open bite (High Angle) 2. CIII Deep bite 3. CIII with Impaction
8:50
She was told that only surgery is ??? can solve her problem.
Prole
mm: Open bite & OJ
Guru I. 18:00
Humble request:
Surgery is NOT an option!
Pre-Tx
She was told that only surgery can solve her problem.
mm: Open bite & OJ
Guru I. 18:00
She was told that only surgery is ??? can solve her problem.
Prole
Guru I.
How to justify the
What is YOUR Tx Plan???
No
Surgery
difculty
level?
Prole is ????
67 + 10 = 77
DISCREPANCY INDEX WORKSHEET
P ATIENT CASE # (Rev. 9/22/08) TOTAL D.I. SCORE
EXAM YEAR ABO ID#
2009
DI = 77
4 pts. 2 pts.
What is YOUR Tx Plan???
OVERJET 0 mm. (edge-to-edge) 1 3 mm. 3.1 5 mm. 5.1 7 mm. 7.1 9 mm. > 9 mm. = = = = = = 1 pt. 0 pts. 2 pts. 3 pts. 4 pts. 5 pts.
LINGUAL POSTERIOR X-BITE 1 pt. per tooth Total = 0
BUCCAL POSTERIOR X-BITE 2 pts. per tooth Total = 0
Negative OJ (x-bite) 1 pt. per mm. per tooth = CEPHALOMETRICS Total OVERBITE 0 3 mm. 3.1 5 mm. 5.1 7 mm. Impinging (100%) Total = = = = 0 pts. 2 pts. 3 pts. 5 pts.
(See Instructions)
ANB 6 or -2 SN-MP 38 Each degree > 38 26 Each degree < -2 Each degree > 6
= = x 2 pts. = =
1 pt.
x 1 pt. = x 1 pt. = 1
ANTERIOR OPEN BITE
0 mm. (edge-to-edge), 1 pt. per tooth then 1 pt. per additional full mm. per tooth Total
Discrepancy Index
Each degree < 26 1 to MP 99 =
x 1 pt. = 1 pt.
Open bite Crowding Occlusion
LATERAL OPEN BITE 2 pts. per mm. per tooth Total
DI < 10: easy

OTHER
Each degree > 99
x 1 pt. = Total =
(See Instructions)
CROWDING (only one arch) 1 3 mm. 3.1 5 mm. 5.1 7 mm. > 7 mm. = = = =
DI = 10~20: moderate
1 pt. 2 pts. 4 pts. 7 pts.
Total
OCCLUSION
DI = 20~30: difficult
=
Skeletal asymmetry (nonsurgical tx)
Supernumerary teeth Ankylosis of perm. teeth Anomalous morphology Impaction (except 3rd molars) Midline discrepancy (3mm) Missing teeth (except 3rd molars) Missing teeth, congenital Spacing (4 or more, per arch) Spacing (Mx cent. diastema 2mm) Tooth transposition Addl. treatment complexities Identify:
x 1 pt. = x 2 pts. = x 2 pts. = x 2 pts. = @ 2 pts. = x 1 pts. = x 2 pts. = x 2 pts. = @ 2 pts. = x 2 pts. = @ 3 pts. = x 2 pts. =
Class I to end on End on Class II or III Full Class II or III Beyond Class II or III Total
DI > 30: very difficult

additional
= = = =
0 pts. 2 pts. per side pts. 4 pts. per side pts. 1 pt. per mm. pts.
Total
23 0 15 4 8
OB
OJ
X-bite ANB
SN-MP
1 to MP Others
No OGS
6 5 6 0 10
DI = 77 Insanely difcult
Tx. Plan
A
X X X X
Tx. Plan
KEYs
B
X X
Bonding Position
Alignment Marginal Ridge Root Angulation
Tx. Plan
C
X X
DI = 77 ?
Believe me, its NOT easy!
KEYs
1
2
Idealistic Tx Objectives
OJ X-bite
#17,15,24,27
KEYs
Bonding Position Torque Selection

Negative OJ -6 mm
1
2
Bonding Position
OJ X-bite
#17,15,24,27
OB
Maintain
ANB
Skeletal CIII
Torque Selection
Negative OJ -6 mm
OB
Maintain
ANB
Skeletal CIII
Open bite
Ant. open bite
SN-MP
Md Angle 35
Crowding
1 to MP
Maintain
3 4
Class III Elastics

Bite Turbo
Open bite
Ant. open bite
SN-MP
Md Angle 35
Crowding
Space discrepancy
1 to MP
Maintain
U (Low Q) L (High Q)
Space discrepancy
Occlusion
Bilateral Full CIII
Others
Midline off
+11
Post. Intrusion
Occlusion
Bilateral Full CIII
Others
Midline off
KEYs
1
2
Idealistic Tx Objectives
OJ X-bite
#17,15,24,27
KEYs

Negative OJ -6 mm
1
2
Bonding Position
OJ X-bite
#17,15,24,27
OB
Maintain
ANB
Skeletal CIII
Torque Selection
Negative OJ -6 mm
OB
Class III Elastics
Open bite
Ant. open bite
SN-MP
Md Angle 35
3 4
Class III Elastics

Bite Turbo
?
KEYs
Crowding
Space discrepancy
1 to MP
Maintain
Maintain
#36,46 GIC Skeletal CIII
ANB
Open bite
Ant. open bite
SN-MP
Md Angle 35
Crowding
Space discrepancy
1 to MP
Maintain
Occlusion
Bilateral Full CIII
Others
Midline off
Post. Intrusion
Occlusion
Bilateral Full CIII
Others
Midline off
U & L : 14 CuNiTi
1
2
Bonding Position
OJ X-bite
#17,15,24,27
Torque Selection
Negative OJ -6 mm
OB
Maintain
ANB
Skeletal CIII
Class III Elastics
Open bite
Ant. open bite
SN-MP
Md Angle 35
Crowding
Space discrepancy
1 to MP
Maintain
Occlusion
Bilateral Full CIII
Others
Midline off
Bite Turbo for posterior intrusion

(Glass Ionomer Cement type II)
KEYs
1
2
9
OJ X-bite
#17,15,24,27 Negative OJ -6 mm
3 4 5
Class III Elastics

Bite Turbo
Buccal Shelf
Maintain
OB
ANB SN-MP
Md Angle 35
Skeletal CIII
Open bite
Ant. open bite
Crowding
Space discrepancy
1 to MP
Maintain
2x12 SS
Occlusion
Others
Midline off
Screws
Bilateral Full CIII
Buccal Shelf : Extra-radicular
KEYs
1
2
9
OJ X-bite
#17,15,24,27 Negative OJ -6 mm
3 4 5
Class III Elastics

Bite Turbo
Buccal Shelf
Maintain
OB
ANB SN-MP
Md Angle 35
Skeletal CIII
Open bite
Ant. open bite
Screws
Crowding
1 to MP
Maintain
Space discrepancy
2x12 SS
Occlusion
Others
Midline off
Bilateral Full CIII
14
18
2x12 SS
21
Pre-Tx
9 6
Post-Tx
Pre-Tx
12 14
42
Post-Tx
21
17
21
42
Pre-Tx
Post-Tx
3rd molars
Correction of 3rd molar takes time!
42
-2011.12.23
Pre-Tx
Post-Tx
42
Pre-Tx
Post-Tx
NO Surgery
Pre-Tx Post-Tx
Hard to believe!
3 Keys
1. Screw on Buccal Shelf
To summary...
Initial
Mechanics ?????
Hard to believe!
Dr. Rungsi
3 Keys
1. Screw on Buccal Shelf 2. Posterior Bite Turbos 3. No CIII Elastics

Mechanics ?????
Guru I.
Hard to believe!
Dr. Rungsi
To summary...
Guru I.
Mechanics ?????
Mechanics ?????
Dr. Rungsi
Chris
Dr. Rungsi
Guru I.
Guru I.
14
Mechanics ?????
Mechanics ?????
Dr. Rungsi
Dr. Rungsi
Guru I.
Guru I.
14
Mechanics ?????
Mechanics ?????
Dr. Rungsi
Dr. Rungsi
Guru I.
Guru I.
17
Mechanics ?????
Change OP
Cha nge the OP
Dr. Rungsi
Dr. Rungsi
Guru I.
17
Guru I.
39
Cha nge the OP
Dr. Rungsi
Dr. Rungsi
Guru I.
18
Guru I.
42
Cha nge the OP
Dr. Rungsi
Dr. Rungsi
Guru I.
21
14
18
42
Cha nge the OP
Dr. Rungsi
Stability
???
Pre-Tx Post-Tx 1.5 y FU
years follow-up...
1.5
Good enough
???
Feu D, Oliveira BH, et al. Inuence of Orthodontic Treatment on Adolescents Self-Perceptions of Esthetics. Am J Orthod Dentofacial Orthop 2012;141 (June): 743-750.
Free download IJOI at IAOI.PRO
Whats the % of
3 major
10:02

1. CIII Open bite (High Angle)
60%
30%
10%
2. CIII Deep bite 3. CIII with Impaction

10
10
9:00
Class III Deep Bite + Impaction
NO
Class III Correction for growing child
10:02
Except:
Cl as s III Dx?
Leve l of Di ff ic ulty ?
Fu n c t i o n a l Dist urbance
Chris Chang Beethoven, Taiwan
Jessica F.
10:02
10:02
Class III Deep Bite + Impaction?
DISCREPANCY INDEX WORKSHEET

P ATIENT CASE # (Rev. 9/22/08) TOTAL D.I. SCORE
DI=54
54
= = = = = =
Problem Lists
Cl as s III Dx?
EXAM YEAR ABO ID#
2009
OVERJET 0 mm. (edge-to-edge) 1 3 mm. 3.1 5 mm. 5.1 7 mm. 7.1 9 mm. > 9 mm.
LINGUAL POSTERIOR X-BITE 1 pt. per tooth Total =
1 pt. 0 pts. 2 pts. 3 pts. 4 pts. 5 pts.
30
0
BUCCAL POSTERIOR X-BITE 2 pts. per tooth Total =
OJ
Negative OJ
X-bite
Narrow Mx.
Negative OJ (x-bite) 1 pt. per mm. per tooth = CEPHALOMETRICS Total OVERBITE 0 3 mm. 3.1 5 mm. 5.1 7 mm. Impinging (100%) Total = = = = 0 pts. 2 pts. 3 pts. 5 pts.
(See Instructions)
21
ANB 6 or -2 SN-MP 38 Each degree > 38 26 Each degree < -2 Each degree > 6
= = x 2 pts. = =
4 pts. 2 pts.
OB
Deep bite
ANB
Skeletal CIII
1 pt.
x 1 pt. = x 1 pt. = 1 x 1 pt. = = x 1 pt. = 1 pt.
ANTERIOR OPEN BITE 0 mm. (edge-to-edge), 1 pt. per tooth then 1 pt. per additional full mm. per tooth Total
Each degree < 26 1 to MP 99 Each degree > 99
Open bite
-
SN-MP
-
LATERAL OPEN BITE
Total OTHER
(See Instructions)
Pre-Tx
2 pts. per mm. per tooth Total
CROWDING (only one arch) 1 3 mm. 3.1 5 mm. 5.1 7 mm. > 7 mm. Total OCCLUSION Class I to end on End on Class II or III Full Class II or III Beyond Class II or III Total = = = = = 0 pts. 2 pts. per side pts. 4 pts. per side pts. 1 pt. per mm. pts.
additional
= = = =
1 pt. 2 pts. 4 pts. 7 pts.
Supernumerary teeth Ankylosis of perm. teeth Anomalous morphology Impaction (except 3rd molars) Midline discrepancy (3mm) Missing teeth (except 3rd molars) Missing teeth, congenital Spacing (4 or more, per arch) Spacing (Mx cent. diastema 2mm) Tooth transposition
Skeletal asymmetry (nonsurgical tx)
Addl. treatment complexities Identify:
x 1 pt. = x 2 pts. = x 2 pts. = x 2 pts. = @ 2 pts. = x 1 pts. = x 2 pts. = x 2 pts. = @ 2 pts. = x 2 pts. = @ 3 pts. = x 2 pts. =
Crowding
Mx. crowding
1 to MP
-
Total
Occlusion
Dental CIII
Others
Age
DI=54
Cl as s III Dx?
800 850 -50
ANB
-50
U1 to SN0 1130 IMPA 850
2 oz
E-line UL -2mm E-line LL 5mm
Acceptable Prole in CR
Slightly bimaxillary protrusion
Cl as s III Dx?
2 oz
Profile
FS
CO CR
Functional Shift
Keys to CIII Dx & Tx Planning
Profile
Profile Class
Class
FS
I have learned this 3-ring diagnosis from Dr. John Lin 27 years ago...
10:02
37
X
1. When? 2. How? 3. Stabi lity?
Cl as s III Tx Pl an?
Pre-Tx
Post-Tx
Acceptable prole in CR
Severely Slightly bimaxillary protrusion
What if the major mechanics was: CIII E
37
2 oz
Pre-Tx Post-Tx
CO
CR
37
Result?
Pre-Tx
Post-Tx
Pre-Tx
37
Post-Tx
How?
Lets walk through the detailed procedures...
37
H uge Ch ange
Low Torq ue on uppe r ant.
1. Hookes Law
Bite Turb os
Post: GIC-I I Ant: Resi n
Laws
2. Newtons Law no. 3 3. Newtons Law no. 1
Class III E will result in Bi-Max protrusion
3
Ope n Coil
Light force
20
12
BS screw is a better choice
26
34
3
Ope n Coil
Light force
37
Length???
36
> 11.5 bracket width
Should put
BS screws early in Tx.
31th
12
20
12
12
OPEN & wait

for
auto-eruption
Ope n Coil
Light force
36
How to settle?
36
M elastics
2~3
Steffen M, Haltom T. JCO 1987
2 oz
2 oz
Section the main AW
weeks
36
elastics
36
M elastics
2~3
2 oz
How long?
2 oz
weeks
36
elastics
Laws
1. Hookes Law 2. Newtons Law no. 3 3. Newtons Law no. 1
2 oz
How long?
Hard to believe!
Laws
1. Hookes Law 2. Newtons Law no. 3 3. Newtons Law no. 1
CR prole
2 stage-tx. (Functional disturbance)
Torque Selection Bite Turbo Open coil springs Elastics / Screws
If the direction of U3 is right, NO SURGERY
Hard to believe!
37
29
CR prole
2 stage-tx. (Functional disturbance) Torque Selection + Pre-Q -200 (Upper)
BS Screws: 31th
Bite Turbo Open coil springs Elastics / Screws
ASAP
37
20
29
29
37
Class III Dx + Tx planning + Prognosis
Profile Class FS
Dr. John Lin The one who invented this 3-ring diagnosis deserves the Nobel Ortho Prize.
BS Screws: 31th
There is nothing like writing to force you to think and get your thoughts straight.
Warren Buffett
iJOI 27
ABO CASE REPORT
Stability
???
iJOI 27
ABO CASE REPORT
iAOI Case Report
Early Intervention of Class III Malocclusion and Impacted Cuspids in late mixed dentition
HISTORY AND ETIOLOGY A 10 year 2 month girl was referred by her family dentist for orthodontic consultation (Figure 1). There was no contributory medical or dental history. Her chief complaint was a protrusive lower lip with the mouth closed. The relatively severe Class III developing malocclusion is documented in Figures 2 and 3. The patient and her parents desired comprehensive orthodontic treatment to achieve an ideal profile and alignment of the entire dentition (Figures 4-6). The pretreatment and posttreatment radiographic documentation is shown in Figures 7 and 8, respectively. Figure 9 illustrates the influence of the functional shift on facial esthetics, indicating that the patient is a good candidate for conservative management of this severe malocclusion in the late mixed dentition. The initial clinical examination in centric occlusion revealed a full Class III malocclusion with an anterior crossbite of about 5 mm (overjet -5 mm) and an overbite of 5 mm. The mandibular dental midline was 2 mm to the left of the facial and maxillary midlines (Figure 7); distally positioned maxillary incisors with blocked out canines were the contributing factors. All deciduous teeth were exfoliated except the lower right primary second molar (Figure 7). The pretreatment panoramic radiograph (Figure 7) revealed that both maxillary canines were superiorly positioned and blocked out. Although the treatment plan was to achieve an ideal alignment of the impacted cuspids (Figure 8), there was inadequate space for them to erupt. Figure 10 documents the cephalometric history of the treatment rendered. DIAGNOSIS Skeletal : Skeletal Class III with SNA 79, SNB 85 and ANB -6 (Figure 7 and Table 1). Normal mandibular plane angle (SN-MP 35, FMA 33). Dental : Right end-on Class III molar relationship Let full cusp Class III molar relationship
News and Trends in Orthodontics (left) Fig. 3. Pretreatment study models Fig. 9. Lateral profile in CO and CR position. Table 1 . Cephalometric summary Fig 2. Pretreatment intraoral photographs Fig. 7. Pretreatment pano and ceph radiographs show multiple impacted permanent teeth and retained primary molar. Fig. 8. Posttreatment pano and ceph radiographs show a balancing lip profile. Fig 1. Pretreatment facial photographs
ABO CASE REPORT
iJOI 27 Centric Occlusion (CO) Centric Relation (CR)
ABO CASE REPORT
iJOI 27
HISTORY AND ETIOLOGY A 10 year 2 month girl was referred by her family dentist for orthodontic consultation (Figure 1). There was no contributory medical or dental history. Her chief complaint was a protrusive lower lip with the mouth closed. The
Be prepared fo r reTx .
relatively severe Class III developing malocclusion is documented in Figures 2 and 3. The patient and her parents desired comprehensive orthodontic treatment to achieve an
Fig. 4. Posttreatment facial photographs
ideal profile and alignment of the entire dentition (Figures 4-6). The pretreatment and posttreatment radiographic documentation is shown in Figures 7 and 8, respectively. Figure 9 illustrates the influence of the functional shift on facial esthetics, indicating that the patient is a good candidate for conservative management of this severe malocclusion in the late mixed dentition. The initial clinical examination in centric occlusion revealed a full Class III malocclusion with an anterior crossbite of about 5 mm (overjet -5 mm) and an overbite of 5 mm. The mandibular dental midline was 2 mm to the left of the facial and maxillary midlines (Figure 7); distally positioned maxillary incisors with blocked out canines were the contributing factors. All deciduous teeth were exfoliated except the lower right primary second molar (Figure 7). The pretreatment panoramic radiograph (Figure 7) revealed that both maxillary canines were superiorly positioned and blocked out. Although the treatment plan was to achieve an ideal alignment of the impacted cuspids (Figure 8), there was age, a non-extraction treatment plan with a full fixed orthodontics appliance was indicated (Figure 9). A 0.022 slot Damon D3MX bracket system (Ormco) was selected because of the self-ligated feature for inducing light forces to increase arch width and create space for the unerupted teeth. To maximize the arch expansion effect, bite turbos were used to unlock the bite. Class III elastics were used to correct the A-P discrepancy by flattening the occlusal plane and opening the vertical dimension of occlusion (VDO). To enhance the camouflage effect, short Class III elastics with light force were initiated early in the treatment. To compensate for the side effects of Class III elastics, flaring of maxillary incisors and retracting mandibular incisors, low torque brackets were used on maxillary incisors and high torque brackets were bonded on mandibular incisors. Skeletal Class III with SNA 79, SNB 85 and ANB -6 (Figure 7 and Table 1). Normal mandibular plane angle (SN-MP 35, FMA Bilateral extra-alveolar bone screws( 2X12 mm, OrthoBoneScrew, Newtons A, Inc.) in the the buccal shelves were needed to achieve a Class I molar relationship in the final stage of treatment. Superimposed cephalometric tracings document the correction of the malocclusion (Figure 10). APPLIANCES AND TREATMENT PROGRESS 0.022 Damon D3MX brackets (Ormco) were bonded on maxillary teeth first because maxillary arch treatment was expected to take more time. NiTi open coil springs were placed to create space for the maxillary canines and the maxillary left second premolar. Bite turbos were bonded bilaterally on the maxillary 1st molars to facilitate arch expansion (Figure 11). In the 4th month of treatment, the arch wire was changed to .014X.025 CuNiTi and the activation of the NiTi open coil springs was retained. The maxillary incisors were protracted to an edge-to-edge position in the 7th month of treatment, and an anterior bite turbo were bonded on the lingual surface of mandibular central incisors to facilitate overjet and overbite correction (Figure 12 ). In the 11th month of treatment, the mandibular teeth were bonded with up-side-down low torque brackets
Fig. 10. Superimposed tracings show retraction of mandibular incisors, tip-back of mandibular molars, flaring of maxillary incisors, and favorable growth of the mandible.
Fig. 5. Posttreatment intraoral photographs
inadequate space for them to erupt. Figure 10 documents the cephalometric history of the treatment rendered. DIAGNOSIS Skeletal :
Fig. 6. Posttreatment study models
37
Whats the % of
3 major

1. CIII Open bite (High Angle) 2. CIII Deep bite
30% 60% 10%

10 5 5
3. CIII with Impaction

5
Pre-Tx
Post-Tx
1.5 y FU
10
9:10
There is nothing like writing to force you to think and get your thoughts straight.
Warren Buffett
The Wisdom of Managing Wisdom Teeth: Part II. Lower 2nd Molars Extraction to Prevent Painful and Risky Extraction of Horizontally Impacted 3rd Molars
Dr. John Lin
Johnny C. 14 01
Correction of Crowding and Protrusion Complicated by Impacted Molars Bilaterally

Dr. W. Eugene Roberts
I J OI
Vol. 23 JULY 1, 2011
Pre-Tx
37
Tx Plan
Johnny C. 14 01
? ?
os?
B C
Johnny C. 14 01
Tx Plan
B C
B C
Johnny C. 14 01
X X
B C
C
How to use CBCT in Imp acte d?
0
Video No. 2: Target without Bone
Key : Cover with Coe Pak
Screen Capture
Prevent epithelium over-growth to cover the opening
So with CBCT, we perfectly know where they are.
3 days later...
Step No. 1
Prevent epithelium over-growth to cover the opening
20 days later... 0 20
Days
OPEN & wait for

auto-eruption
60
40
40 days later...
2X12 mm SS, alveolar ridge
OPEN & wait for

auto-eruption
60 days later...
2X12 mm SS, alveolar ridge
Months 2 3
Low torque for labial root torque 9 9
Months 8 9
BS Screws for lower arch distalization + BT 9 9
Cut the soft tissue 9 9
BS Screws for lower arch distalization + BT 9 9
2X12 mm SS (Buccal Shelf) to retract Md.
15
-2010.08.10
15
months in Tx....
15
-2011.12.10
15
-2011.12.10
Read & react

0 3
15
15
-2011.12.10
Whats the % of
3 major

1. CIII Open bite (High Angle) 2. CIII Deep bite
30% 60% 10%

10 5 5
3. CIII with Impaction

5
10
9:15
15
-2011.12.10
Amazing Tx Plan...
15
We had xed CIII & impactions...
?
16 02
15
Tx. Plan?
Think 3D
16 02
Movie without Bone
Tx. Plan?
16
02
Tx. Plan?
Plan? OS
Tx.
X X
X X X
Dilacerated root
16
02
You r Plan?
Compound Odontoma
Wait for auto-eruption

16 02
Dilacerated root
5 months later...
Can you x it?
?
My Plan
Pre-surgery
L4
If you
Post-surgery
X X
X
16 02
20
13
Dilacerated root
0
mm
9
mm
OsteoBUR
13
mm
auto-eruption
Osteoclast from 1. Dental Follicle 2. PDL
20
13
Stop
auto-eruption
2 KEYs:
20 13
20
1. bone removal 2. force direction
Next step?
= Bone remodeling
Stop
auto-eruption
2 KEYs:
20
20
3D Lever Arm
4 months = 8 mm
0
Minimally Invasive
20 20
24
2 KEYs:
20
He was told it is impossible.

0
Really!
Force level for Forced eruption???

20
> 4 oz
24
& 0 moment???
20
20
24
20
Center
0
moment
Amazing progress...
How to Activate?
24 months = 17 mm
Dilacerated root
3D Lever Arm (2 joints)
6 Keys
to
Success
One more tip
1. Dx & Tx plan 2. Bonding Position
2 oz
3. Torque Selection 4. Wire Sequence & Timing 5. ELSE + Bite Turbo

1. Deep bite: Ant. BT 2. Open bite: Post. BT
How to Fabricate the 3D Lever Arm
6 Keys
to
Success
1. Dx & Tx plan 2. Bonding Position 3. Torque Selection 4. Wire Sequence & Timing 5. ELSE + Bite Turbo
46 sec.
6. Screws as a Back-up
Dr. John Lin

I J OI
Vol. 23 JULY 1, 2011
19x25 SS
Drs. Eugene Roberts and Chris Chang in front of a collection of antique orthodontic rare books in the study room of Dr. Chang s. On the desk lay two human skulls with impacted teeth & Angle's busts made of bronze and colored glaze.
News and Trends in Orthodontics has been renamed as International Journal of Orthodontics and Implantology. You can read more about this change in this issue of letter from the publisher.
I have learned more from writing cases than just treating them.
Dr. John Lin

I J OI
Vol. 23 JULY 1, 2011
Drs. Eugene Roberts and Chris Chang in front of a collection of antique orthodontic rare books in the study room of Dr. Chang s. On the desk lay two human skulls with impacted teeth & Angle's busts made of bronze and colored glaze.
News and Trends in Orthodontics has been renamed as International Journal of Orthodontics and Implantology. You can read more about this change in this issue of letter from the publisher.
Thank YOU
20
25
20

Chang, Chris HN - Point-Counterpoint Conservative Management of Class III Skeletal Malocclusion

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Challenging CIII Made Easy

He was told that only surgery can solve his problem.

Honda Y., 20:08

challenging CIII malocclusion?

I believe in case study...

How difcult is that???

How difcult is that???

How difcult is that???

Rout ine record

DI = 10~20: moderate DI = 20~30: difficult

DI > 30: very difficult

How difcult is that???

Rout ine record

How difcult is that???

Believe me, its easy!

No Surger y Just scre ws

How & Tips???

How & Tips???

Read & react 0 9

0 Without Buccal Shelf Screws,

it would be very hard to x it.

Cha nge the OP

Cha nge the OP

Cha nge the OP

Cha nge the OP

Highly Positioned and Transalveolar Impacted Maxillary Canine

Drs. Billy Su, Chris Chang & W. Eugene Roberts

Vol. 24 Oct. 1, 2011

mandible. He has seen at least two other

Implantologists) and American Board of Orthodontics

Fig. 4-5. Pretreatment pano and ceph radiographs

Fig 6. Postreatment facial photographs

Fig 3. Pretreatment study models

1.5 years follow-up...

mandible. He has seen at least two other

Implantologists) and American Board of Orthodontics

Fig. 4-5. Pretreatment pano and ceph radiographs

Dr. John Lin

International Journal of Orthodontics & Implantology

Fig 2. Pretreatment intraoral photographs

Drs. Billy Su, Chris Chang & W. Eugene Roberts

Fig 6. Postreatment facial photographs

Fig 3. Pretreatment study models

Fig 7. Postreatment intraoral photographs

Free download at:

1.5 years follow-up...

Highly Positioned and Transalveolar Impacted Maxillary Canine

Drs. Billy Su, Chris Chang & W. Eugene Roberts

International Journal of Orthodontics & Implantology

Vol. 24 Oct. 1, 2011

challenging CIII malocclusion?

mm: Open bite & OJ

Surgery is NOT an option!

mm: Open bite & OJ

What is YOUR Tx Plan???

EXAM YEAR ABO ID#

What is YOUR Tx Plan???

LINGUAL POSTERIOR X-BITE 1 pt. per tooth Total = 0

BUCCAL POSTERIOR X-BITE 2 pts. per tooth Total = 0

ANTERIOR OPEN BITE

Open bite Crowding Occlusion

LATERAL OPEN BITE 2 pts. per mm. per tooth Total

DI < 10: easy