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.