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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

How difcult is that???

How difcult is that???


Discrepancy Index
DI < 10: easy

Rout ine record

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

DI > 30: very difficult

Discrepancy Index

How difcult is that???


DI?

Rout ine record

71 Very
Tx. Plan

= very, very

difcult!

Discrepancy Index

How difcult is that???

?
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 :

International Journal of Orthodontics & Implantology

Fig 2. Pretreatment intraoral photographs

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

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.

International Journal of Orthodontics and Implantology is an experience sharing magazine for worldwide orthodontists and Implantologists. Download it at http://iaoi.pro

29

Pre-Tx

Post-Tx

1.5 y FU

Free download at:

1. IAOI.PRO 2. Newtonsa0301

1.5 years follow-up...

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

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

A Severe Skeletal Class III Open Bite Malocclusion Treated with Non-surgical Approach
Drs. Sabrina Huang, Chris Chang & W. Eugene Roberts

International Journal of Orthodontics & Implantology

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.

International Journal of Orthodontics and Implantology is an experience sharing magazine for worldwide orthodontists and Implantologists. Download it at http://iaoi.pro

38

Pre-Tx

Post-Tx

1.5 y FU

Whats the % of

3 major

challenging CIII malocclusion?

60%
10% 30%

1. CIII Open bite (High Angle) 2. CIII Deep bite 3. CIII with Impaction
1. Anterior 2. Posterior

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

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

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

Bonding Position Torque Selection

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

Bonding Position Torque Selection

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

Buccal Shelf : Extra-radicular

14

18

2x12 SS

Buccal Shelf : Extra-radicular

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

1.5 years follow-up...

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

challenging CIII malocclusion?


1. CIII Open bite (High Angle)

60%

30%
10%

2. CIII Deep bite 3. CIII with Impaction


1. Anterior 2. Posterior

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
Steffen M, Haltom T. JCO 1987

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?
Steffen M, Haltom T. JCO 1987

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

1.5 years follow-up...

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

1.5 years follow-up...

Whats the % of

3 major

challenging CIII malocclusion?


1. CIII Open bite (High Angle) 2. CIII Deep bite

30% 60% 10%


10 5 5

3. CIII with Impaction


1. Anterior 2. Posterior
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
International Journal of Orthodontics & Implantology

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

challenging CIII malocclusion?


1. CIII Open bite (High Angle) 2. CIII Deep bite

30% 60% 10%


10 5 5

3. CIII with Impaction


1. Anterior 2. Posterior
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

Wait for auto-eruption

If you

Post-surgery

X X
X
Wait for auto-eruption
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

1. bone removal 2. force direction

3D Lever Arm

4 months = 8 mm
0

Minimally Invasive
20 20

24

2 KEYs:

20

1. bone removal 2. force direction

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
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

Correction of Crowding and Protrusion Complicated by Impacted Molars Bilaterally


Dr. W. Eugene Roberts

I J OI
International Journal of Orthodontics & Implantology

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.
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

Correction of Crowding and Protrusion Complicated by Impacted Molars Bilaterally


Dr. W. Eugene Roberts

I J OI
International Journal of Orthodontics & Implantology

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

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