One of the ways that OrthoExpress saves time and money on
treating a patient is by stacking the treatment. One example would be
correcting a class III tendency in the buccal segments and at the same time
widening the maxilla with a Split-Plate (RPE). There are many ways to "Stack the Treatment" both big and small. The idea is to use the widening of the maxilla to enhance correcting the class III bite. When widening the mid-palatal suture there are also adjustments taking place at the other sutures where the maxilla attaches to the cranial base.
1 - Applying class III mechanics during the widening of the maxilla takes advantage of the fact that all the sutures are loose. It also takes advantage of the fact that this treatment can be “stacked” with widening of the maxilla which is a time-consuming process. We not only do two things at once, but we take advantage of the loosened sutures in the maxilla. The class III mechanics will result in quicker correction of the bite relationship because of the loose sutures. So, in this case we not only do two things at once, but we get a synergistic benefit from the loosened sutures in the cranial base.
2 - This is month seven and the maxilla has been widened and the upper incisors have slowly tipped back until they are touching. Now we have to make a decision about removing upper bicuspids to make room for the cuspids.
3 - This is how the patient finished treatment. The maxilla had grown way further forward than we had anticipated. To compensate we took our lower central incisor to shorten up the lower arch to try to keep it under the upper arch. First bicuspids had been removed in the upper arch and and we had to leave about 3 mm of spaces could not be completely closed. If we had taken out second by cuspids in the upper arch rather than first bicuspids the spaces distal to the cuspids would not of been nearly as large. Taking out second bicuspids would have probably left about half the remaining space behind the upper cuspids.
4 - Treatment Steps:
Step 1: Put the lower braces on, and get the teeth lined up so that a large enough Arch wire can be placed to support class III elastics.
Step 2: Place the Split-Plate (rapid palatal expander or RPE) to start widening the upper arch.
Step 3: After the Split-Plate has widened about three millimeters, check the patient again to make sure the mid-palatal suture is widening as planned. Usually, you will know if the suture is widening because a space will start to develop between the upper central incisors.
Step 4: If the suture is widening appropriately, start class III elastics full-time to pull the maxilla forward as it continues widening. The elastics that I use place about 200 to 300 grams of force on each side of the mouth. Check the patient in two or three weeks to make sure the maxilla is moving appropriately. You can often get the change you want in 2-3 months. Sometimes you may want to also use a reverse headgear along with the class III elastics.
5 - The stacking of these two treatments, widening the maxilla and moving it forward at the same time, can saved a lot of time in treating borderline Class III patients. It is also an example of many ways that OrthoExpress stacks the treatment to save time. In my orthodontic my average treatment time was 19 months in this project. Stacking the treatment
6 - The upper incisor shows 8 mm from the NA line. The NA line is normally in front of the NB line which tells us that the mandible is growing faster labially than the maxilla. This puts us into a typical class III relationship of the maxilla to the mandible.
In these two tracings, here is what you need to look for. We are looking at the NA and NB lines. The NA line runs from Nasion to point A at the front of Maxilla and the NB line runs from Nasion to point B in the front of the Mandible.
The maxilla needs to be moved forward until the NA
is in front of the NB line which we will see in the next tracing.
7 - This Progress Tracing taken five months after the beginning of treatment. It was from this cephalometric tracing that the decision was made to remove upper first bicuspids. If the mandible had not grown adversely that would have been a good decision.
Now I wish we had taken out second bicuspids rather than first bicuspids. The result of the orthodontic treatment would have been faster and better.
In orthodontics, there are times that decisions must be made when you don't have all the information and you must take a chance and hope it works out.
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