The Plan of Action

After a couple of weeks I went back to Dr. Waese to get the blue print for my smile makeover, as I like to call it. What follows is the fine detail of it all complete with ortho-speak! Haha.


Pan:
8's are missing
TMJ is normal
No pathology visible

Ceph:
A-O concave midface: Pathognathic mandible

Verticle long lower face height

Lower incisor angulation retroclined

Interincisal angle obtuse

The lips are open slightly at rest: forced lip closure

Normal lip rise 8mm

There are dark spaces on both sides of the intra oral smile

Mouth breathing; low tongue posture

Scalloped marks on the sides of the tongue; white marks on the cheeks from possible cheek biting

Generalized mild recession of the gingiva

Loss of attached gingeva on the 43: generalized loss of attached gingiva possibly from tooth brush trauma (…but I seriously do it gently, I don't know why he thinks this??)

There is a crossbite of all the teeth except the maxillary centrals

Angle classification: class III
Overjet: 1mm Overbite: 10%
Crowding: maxilla -3mm Mandible: -12mm

Goals of Treatment:
1. Correct the crowding
2. Correct the crossbites
3. Balance the facial bones
4. Control the habits to protect the gingiva, TMJ and cheeks
5. Long term retention of the corrected problems

Treatment benefits:
- Crowding correction for periodontal and functional and aesthetic improvement
- Align crossbite teeth for better health and function
- Improve aesthetics by reducing the protrusion of the teeth and improve the position of the lips over the teeth
- Remove dental interference to improve jaw function
- Improve facial balance

Orthodontic strategy for treatment:

We will arrange for a surgical consulation for:

a. Surgically assisted Rapid Palate Expansion (SARPE)
b. Maxillary Leforte I surgical advancement (LeForte I)
c. bone implants suborbitally to increase the prominence of the cheeks (he said this would be very subtle just to keep things rounded out, and it will use the bone taken from my jaw. We're not talking Joker from Batman or anything here!)
d. Mandibular sagittal split reduction in size (BSSO)

2. I suggest a referral to the Cranial Institute for:

a. Diagnosis and treatment of poorly moving cranial bones (I went for one of these back in the
summer and she said probably 4-5 treatments would get me in good shape. I even noticed quite a difference after just one treatment…and I can tell I need to go back! I can really notice the tension has returned in my jaw and neck.)

b. Osteopathic support for post-surgical healing

3. To prepare for the braces we need to consider the effect of the habits on the dentition and oral structures. Since there is probably a cheek sucking or biting habit, an oral sheild will be needed to hold the cheeks away from the braces at night. This can be accomplished with a non-protrusive FFMP with buccal shields that extend from the occlusal bite pads and a lower labial shield. This will be made after the RPE surgery.

4. Separators will be placed for a RPE supported on the maxilliary 4's and 6's. The RPE will be made and placed for the surgeon to facilitate the RPE.

5. Cranial support is strongly suggested to help the healing at this time.

6. 1 month after the expansion has been done we will take impressions for a non-protrusive FFMP with buccal shields that extend from the occlusal bite pads and lower labial shield.

7. The lower braces can be placed while the maxilla is healing. The FFMP will be inserted for nighttime wear to protect the oral structures.

8. After 3 months the RPE will be removed and the upper braces placed. Continue the FFMP n.o. and the cranial support at less frequent interval.

9. The teeth will be decompensated: ie the lower incisors will be proclined and the upper teeth aligned. Note: if the lower incisors and cuspids appear to be at risk for gingival stripping, a single lower incisor may need to be removed to creat space for lower teeth alignment.

10. After alignment (about 15 months into treatment) the facial surgery will be done.

11. After 3 months the braces can be removed and retainers placed.

12. Retainers will consist of:
a. lower 3-3 retainer to keep the lower incisors straight
b. upper day time Hawley retainer to maintain upper arch width
c. Night time non-protrusive FFMP with buccal shields that extend from the occusal bite pads and lower labial shield.

13. Continued cranial support is suggested to long term maintenance to promote long term healing and control of the intra oral habits which may stem from the cranial abnormalities.

14. Possible graft somewhere on the bottom gums (can't read his writing)

Retention: extended