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 Class III - Skeletal change after treatment

Orthodontics From: Doug Depew Sent: Wednesday, March 21, 2001 07 18 Subject: Re: Class III - Skeletal change after treatment Looking for comments from the group. 16 year old male patient. One year out of treatment. Shows up for "retainer check" with an edge to edge anterior bite and slight posterior openbite. Pre-treatment he was NOT Class III although his mother says an Uncle is Class III. Took study models. Hand-holding models interdigitate into a perfect Class I bite as they did when finished treatment. Class III elastics were not used or needed during treatment. Obviously we have some Class III post treatment growth. Questions: 1) What are you feelings dealing with this? The right thing to do in my mind is continue retainer wear (as he has been), wait till 18-19 yrs. of age, and have a mandibular set-back done. I prefer not to compensate by flaring maxillary incisors and opening lateral incisor space. 2) What are my obligations from a professional and financial point of view? I had performed the treatment I was paid to do and should not have to re-treat a case that had post treatment problems I could have no control over. Feel free to email me directly as well as the group. Thanks, Doug Depew
From: Priscila Lima Ribeiro Sent: Tuesday, March 27, 2001 05 21 Subject: class III-skeletal change after tx Doug I agree with you that what happened is mandible growth, and since the boy is 16 and has class III in family, mandible will grow more. If the anteriors were not edge to edge I would feel free to wait as you have the idea, however this anterior relations bother me. I would compare growth of mandible in new rx to maybe see what growth to expect. If his upper incisors are angulated ok, and his lip can hold, I would compenste by flaring incisors and somehow think of a way to hold lower incisors until finish growth. That however would make way to other ortho tx after surgery, if he will do surgery. About obligations, whenever a patient comes with one year of tx finished using retainers and has some growth effect altering the tx result, what I do is to retake ortho tx to correct it not having the patient pay the tx, as if he was beginning, but he pays the maintenance (monthly visits) normally. I think it comes as a cortesy to the patient, although I cannot be blamed for continuous growth. However I would put to the parents that after surgery that's another thing and I think I would charge other tx altogether. Close to that just happened and the parents understood. Boy, 13 years, class I began in 94 and finished in july 95, nice and easy tx, no extraction. Used upper retainers ok, and lower lingual arch that in 97 changed to 3-3 and had third molars extracted. Now he came back with lowers out of line, with new rx I showed how mandible grew and upper incisors pushed lower incisors to occupy less space. I explained that's a new tx , its going to take less time than the first obviously, and charged as a new patient. No complaints. - Priscila
Don't ignore the possibilities of early class III intervention... Dr D Carter writes Doug Depew's questions, about late mandibular growth causing a class III malocclusion and ruining his nice result, remind me of the old economic maxim; "it's a recession when your neighbor loses his job, it's a depression when you lose yours". Welcome to the depression? No. This is why we give informed consent, and why all of us must have a clause in our informed consent, which states something to the effect that late stage growth changes may change our results unfavorably regardless of how well the case was treated or retained. >It's not Doug's fault. Blame the 4 grandparents. I would continue the retention of teeth on the individual jaws, and have the family discuss surgical treatment timing with a maxillofacial surgeon now. Don't be surprised if they get nervous about the prospects of further mandibular hyperplasia after surgery. Recent research has shown late mandibular growth in males up to the mid twenties. And, while we have successfully treated similar cases in the past by "condylar shaves", apparently that is not always the answer. It does not guarantee cessation of condylar growth. I often counsel such families that theirs is the angst of the modern concept of the physician presenting the facts and alternatives, and the patient making the ultimate decision. Not easy. We recently diagnosed a case of unilateral condylar hyperplasia in a 17 year old male who had been nicely treated in another office, only to grow an asymmetric mandible with deviation of the mandibular arch to the contra lateral side. On the affected side, there is a 6mm open bite at the molars and premolars. Disarticulating the models, it is possible, as in Depew's case, to fit the teeth together. This proves to the patient that the problem is not "relapse" of the orthodontic result, but late mandibular growth. After much agonizing, the family opted to see the surgeon with a wish for summer surgery. After discussion with him, they cancelled the appointment to bracket the teeth because the surgeon wanted to wait until the (arbitrary) age of 18. I am happy that the family and the surgeon have entered into a collaborative effort to time treament, because I don't have to feel the entire burden of responsibility. As to fee questions, yes we charge our regular fee for combined orthodontic/orthognathic surgery treament. And it is higher fee than ortho only, because there is MORE RESPONSIBILITY. We are - or should be - payed for our intelligence, planning, coordination, counseling, and our clinical treatment. I am reminded of a consultant's story about a project for IBM in which, as he drove for several hours across a southwestern desert, an elegant solution came to him. After it was accepted and instituted by the company, he billed them something like 25,000 dollars. For one hour of thinking and several hours of presentation. The company gladly paid his bill, considering it a bargain since his solution saved them millions. If he had used the union mentality of time, or even the insurance based thinking of usual and cus tomary, he would have been paid only a fraction of the real woth of his work. As dentists, we must lose the old industrial age concept of time or tooth based fees, and think as problem solvers in an information age. Fees should reflect not only costs and time, but the elegance and innovation and correctness of the solution. Finally, this is a perfect case to spark a discussion on early treatment once again. How can one honestly purport to treat an 8 or 9 year old who may have facial growth until late teenage, without discussing retention and the distinct possibility of more treatment in most cases? Or, put another way, in our adult orthodontic practice nearly half of our patients had some previous ortho, most had full appliances. In my humble opinion, kids should be treated during the last year or two of facial growth. 11 for girls, 13 or 14 for boys. I await the fusillade of arrows - Dick Carter Portland OR USA.
From: Paul M. Thomas Sent: Tuesday, April 03, 2001 04 26 Subject:Class III growth No arrows from me....the contemporary early treatment research indicates (generally speaking) that prolonged two phase treatment is a "practice management decision" ....to quote Lysle Johnston. -=Paul=- Paul M. Thomas
I fully understand your position on early care but there is still a narrow gate that you can go through with regard to early class III that is valid and supported by clinical findings. I have on my desk at the moment a case (age 8 female) that demonstrates a convexity of A point nearly two standard deviations behind what would be expected. Condylion-A point is nearly two standard deviations short, while condylion-gnathion is normal. SNA is is 79 dgs with norm being 83 dgs while SNB is the same as the norm for the age. While some may disagree with the the measurements selected - most would say that we have an eight year old with a dental occlusion of class III and a skeletal class III due to maxillary retrusion. The upper incisors will erupt into crossbite with the lowers without intervention and the maxillary posterior dentition is in near crossbite. I can provide maxillary expansion providing needed space for lateral eruption and using the same appliance plus a facemask, I can advance A point correcting the anticipated anterior crossbite. One year of facemask in a compliant child will result in overcorrected (end-on) 6 yr. molar occlusion and no crossbites posterior or anterior. Leaving the anterior crossbite until 11 yrs. in this female would result in a well established class III malocclusion with ectopic laterals due to maxillary constriction (untreated). You can then unravel the crossbite,expand the palate and align the teeth - and if you can get her to wear the facemask you may have a little time to advance A point depending on her level of skeletal maturity. Treatment of the 8 yr. old is a convenience factor of cooperation and correction of the molar occlusion happens faster in the young maxilla. You also have the advantage of time on your side in the event that more than one round of facemask is required . Yes, you do need to hold the expansion with a Hawley or quadhelix and perhaps wear the facemask over an extended period depending on an element of relapse that is sure to come. You go into these cases with full understanding that a later phase will be needed to align the teeth and in rare cases this could include surgery - you do it verbally and in writing. Over the past 15 years of facemask use and careful case selection, I have one case that should have surgical correction after attempted early care. I do not believe that would have been true without early intervention. Class III 's come in many forms and case selection is important. I do not believe this approach works well with true mandibular overgrowth. The RMO VTO has been very helpful to at least show the direction of growth even though the quantity is harder to define. I further believe that the (functional effect) of anterior crossbite is a factor that accelerates the mandibular position making the case look worse that need be by age 11 or 13 yrs. We would not consider placing a functional appliance to advance the lower arch in a class III case but that is just what I see happening when we allow anterior crossbites to presist for that 4 year span between 8yrs and 12 yrs. - it has other harmful effects as well. I am sorry to say that this is not an area that lends itself to research very well due to the great number of variables, not the least of which is growth. wavel wells ped. dent. Oklahoma
From: Nordstroms Sent: Saturday, March 31, 2001 20 48 Subject:early tx of III Early TX does not seem economical for Dr. or parent's time / money unless you consider this aspect ... Using memory pulse / oximeter find that patient is apneic. Patient is not performing that well in school, and is now developing her personality and self-esteem ... which hinges around her slowness, facial form, bed-wetting, etc. Early intervention has facilitated significant positive change for these patients, but may require a longer active treatment. Adolescent treatment is significantly more efficient ... but can the surgery correct the personality and scholastic history? Darick Nordstrom
From: Dennis Dionne Sent: Sunday, April 01, 2001 10 03 Subject: Case selection in Cl.3 patients Dear Colleagues: I think that we can all agree that sweeping statements can easily overlook discrete clinical situations. Probably a majority of clinicians would agree that, where possible, it is best/easier/less expensive to await full eruption of most of the permanent teeth. However, there is no paucity of evidence to support the position that early intervention can sometimes have a profound effect on future growth, and there is the rub - what cases? I must confess that I share the opinion of our well-spoken pediatric dentist friend, Dr. Wells, in reference to early correction of Cl.3 malocclusions, be they dental or skeletal, provided that if we are to chase a skeletal Cl.3 problem we are relatively confident that there is a mid-face deficiency as a component of the problem ( see Turley et al). Should the problem be true mandiular prognathism, then watchful waiting is in order with surgical correction the likely outcome in the future. However, is it not true that in the majority of pre-pubescent clinical Cl.3 patients there is at least some element of midface deficiency? The argument then becomes one of correcting what you can when you can, in terms of compliance and skeletal ' plasticity'. True, the mandible may continue to grow - in that case you have at least likely minimized the degree of bone movement necessary for later correction, surely a worthwhile goal. I suppose that a frank discussion of these eventualities with the parents/patient will at least help them decide which path to follow, but in my practice it really is a rewarding option to offer - I don't profess to always get the results I would hope for, but usually early expansion/protraction in such cases has been effective in improving facial balance, gaining positive overjet, and stopping deleterious forward mandibular deflection that otherwise would aggravate the underlying Cl.3 growth pattern. Just my two cents worth. By the way, thank you to everyone for your insights- I learn quite a bit from these give-and-takes. Dennis Dionne, Orthodontist , Canada
From:CHRIST JL Thursday, April 05, 2001 06 17 Dear Paul and others, I would like to comment on the early treatment line being discussed in the past couple of issues of the study club. With all due respect, Lysle Johnston's article from which you quote addressed Class II correction, not Class III intervention, and was biased from the outset. But I get ahead of myself. I feel that early treatment is an important part of all orthodontist's practices but must be undertaken with specific goals and specific time frame in mind. While this sounds logical and straight forward, few practice it. During diagnosis and treatment planning, the orthodontist must ask whether this treatment will either eliminate the need for future treatment altogether or make future treatment so much more predictable or simple that it is worthwhile doing now. If the answer is no, future treatment should not be undertaken. A prudent clinician will also present to parents different alternatives and some idea of the outcome for each alternative. In the Class III mid face deficient patient, numerous studies have shown a success rate of 65-70 percent. I would appreciate as a parent the opportunity to digest the options for my child. A 65-70 percent chance of correction with a reverse headgear (within certain time constraints and not years of treatment as Johnston discussed) versus observation followed by surgery or camouflage at a later date may sway me to try early treatment. As was pointed out earlier, if I don't make it, then my surgical correction may be easier. If I do make it, I have won big time. The prudent clinician would also inform the parent that this is one phase of two phases of treatment. My argument is that all early treatment is not 'bad' if presented in a fair and informed manner. Another quote Paul, "If all you have is a hammer, every thing looks like a nail." John Christensen , Durham, NC

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