sábado, 27 de octubre de 2012

Antes y Después:


 3. EXTRACCION DE 4 PREMOLARES: 14, 42, 35, 44.

sábado, 7 de mayo de 2011

Discusion de situaciones clinicas con un amigo ortodoncista en San Diego (2):

Dr. Chen:  Different situation now.  In cases where there is BOTH a 3-5 mm Class II molar AND also has upper palatal constriction with bilateral crossbite (let's assume non-extraction treatment) an adolescent with permanent dentition, what is your approach?  Fix the crossbite first with RPE, then elastics?  Use the RPE and a headgear simultaneously?  Use the headgear only and expand the facebow?  I can offer what I am experimenting with now.....If the upper constriction is skeletal in nature, then I am delivering an Upper RPE with Bands on the Upper 4s soldered together.  I still fit and cement individual band on the U6s but I use Open coil Springs to distalize against the RPE with the OCS from U4s to U6s.  This way, i can expand and distalize at the same time.  I saw this at a lecture by Dr. Roncone, the GAC In-novation guy and i thought there was some merit to this approach.  What is your thoughts and what have you tried?

Dr. Nischli I correct the cross-bite first with a RPE, and then I re-evaluate the occlusion. 
Some times the Class II improves as you correct the cross-bite. ( Check: American Journal of Orthodontics and Dentofacial Orthopedics Vol. 138, Issue 5, Pages 582-591) 
I have tried expanding until I overcorrect a few millimeters and then using a Head-gear.
I've also tried the head-gear with an expanded inner bow, but I don´t think it accomplishes much. 
Your technique of distalizing with open coils sounds good, but I would´t use it on hyper-divergent patients, adding the expansion to the distalization could create an open bite. 
Dr. Chen:  What is your current philosophy on providing Phase I Class II correction for early/mid mixed dentition kids?  When do you do it and when do you postpone it?

Dr. Nischli: I do not correct Class II´s early. To me there is zero added value in doing so. I don´t use any functional apliances... I wait until the late mixed dentition and then I can use a Forsus ( which to me is not a functional appliance because I don't expect any mandibular growth per se, but you'll get a dento-alveolar antero-posterior change..., and it also has a head-gear effect)
I do use a headgear in the early or late mixed dentition. A very common treatment plan in my office for Class II´s would be: Cervical Traction Gear, Lower Lingual Arch... and just wait for more teeth to erupt and for growth. If the patient complies, It's a beauty, otherwise I'll fix it later with either elastics or Forsus.

jueves, 5 de mayo de 2011

Discusion de situaciones clinicas con un amigo ortodoncista en San Diego:

Hi Arie
I've been meaning to ask you about your techniques/philosophy when it comes to Class II treatment.  I really appreciate your insight and experience as you are really good at  explaining WHY you decide the way you choose to do things.  I've been trying to get better at deciding how to treat Class II patients by taking into account age, facial type, cephalometric vertebral development and soft tissue profile.

Dr. Chen: 1.  I am comfortable extracting Upper 4s when the upper lip is protrusive in a Class II 5 mm case with 5-10 mm OJ.  However, in patients where the upper lip cannot be retracted too much due to flatter facial profiles of thin lips etc, i can always open up the discussion for surgery, especially for an adult.  However, on an adolescent patient, what is your approach?
Do you explain that you will try non-extraction treatment (Class II elastics only), but there may be limitations of the overject correction?  Have you had any success with these types of cases using any Forsus, Herbts type appliances?.  Do you try to distalize non-extraction using headgear, Pendulum, or other distalizing appliance?  Personally, i have not developed a good enough thought process and rationale as to which approach may be best for which type of case.  Any advice that can lead to a more organized thoughtful approach?
Dr. Nischli: I agree, I base mainly my treatment plans for Class II's in lip protrusion... (I love Gianelly´s vertical reference line instead of diagnosing by lower incisor angulation)

For kids, I use a cervical head-gear. If second molars are present, I don't count on a lot of distalization, a couple mm at most, but if you get the patient on time, I think that the distalization together with the orthopedic effect can get you a nice profile change. 

In adult patients I do mention orthognatic surgery, however, the acceptance for mand. advancement surgery (at least in Mexico, or in my office) is rare... 

If mandibular advancement is not accepted, I'd rather just align the teeth and leave a Class II relationship instead of flattening the profile. If the upper lip is protrusive, I'll extract upper bicuspids (some times 4's, some times 5's)
In adolescents, I like to use a FORSUS. The changes are mostly dento-alveolar (I don't believe un Mandibular Orthopedics at all) but yo do get to correct these 4-5mm Class II's and improve the profile.

When I do use one of these Class II correctors, I like to prepare the lower arch with negative torque to avoid excessive lower incisor proclination (and possible gingival recession).
I don't use any functional appliances. I don't think there is much added value in starting treatment earlier with a functional, so, I may try a head-gear and if that doesn't work go for a Forsus or Class II elastics depending on the amount of correction and compliance.

martes, 3 de mayo de 2011

Introducción al Blog

Este blog es creado para discutir y comentar casos de ortodoncia, así como diversas filosofias de diagnostico y plan de tratamiento.

Principalmente, mi filosofia ortodóntica está enfocada en un diagnóstico clínico, basándonos en la posición antero-posterior de los labios y mentón. Esto a diferencia del enfoque clásico el cual basa muchas de las decisiones diagnosticas en la posición cefalométrica del incisivo inferior.

Para mi es muy importante mencionar que esta filosofía, viene del Dr. Anthony Gianelly de Boston University.

domingo, 1 de mayo de 2011

Casos 1: Laterognasia

Esta paciente se presenta referida por el cirujano maxilo-facial buscando una opción de tratamiento no quirúrgica.

Mordida cruzada en anterior y en posterior izquierdo.

Perdida de 26. Clase III Molar y Canina (3mm aprox.)

Clase I sólida

Ligera Falta de Espacio

Overbite 0%, Overjet 0mm

El plan de tratamiento fue extracción de un lateral inferior derecho para retraer incisivos inferiores a un overjet positivo. No se planeo la corrección de la Clase III izquierda.


La corrección antero-posterior de la Clase III izquierda hubiese incrementado el Overjet debido a la discrepancia de Bolton creada por la extracción del Incisivo Inferior, por lo tanto se decidió no corregirla