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.