Orthotown January/February 2020 - 20

message board
socoortho
Member Since: 03/21/08
Post: 3 of 6

Thank goodness she appears to have a low upper lip-secondary to her Class III maxillary
retrusion. If implants are placed in her late teens, she'll have exposed threads and an unsightly
situation in a few years. I would not work with a GP on this case; a periodontist will be able to
do multiple grafts and touchups, and deal with all the hard- and soft-tissue problems. Can this
GP create a midline papilla? And yes, she'll need the services of a prosthodontist for a lifetime.
My periodontist constantly reminds me that implants aren't forever and should be delayed as
long as possible on a young person. Unfortunately, that's not the message that patients usually hear.
Regarding the orthodontic treatment: If pros and perio can position the incisors on the ceph
for you, you'll be able to tell if you need heavy IPR or you need to extract a lower incisor, and
how much anterior leveling will be required.
Thank you for posting this challenging case. I know it is late in treatment-planning this
young woman, but I wonder if moving the lateral incisors into the central positions would have
been a better long-term solution. ■

12/19/2019

justinudm
Member Since: 09/29/14
Post: 4 of 6

This is such a tough situation. The low-angle, slight Class III skeleton due to a maxillary
retrognathia is working against you. The Class III AP dimension results in a need for excessive
upper incisor flare, while the low-angle vertical component limits the interocclusal space available.
First, are we sure vertical and AP facial growth are complete? Have you taken serial cephs to
verify this? Anterior implants in a possibly still growing Class III scares me.
The lower arch has a COS. On the buccal photos, it looks like L3-3 have possibly overerupted.
Maybe leveling the COS and the resultant down-and-back rotation of the mandible will give a
little more interocclusal space. That with either IPR or the lower incisor extraction you suggested
may do the trick.
A CBCT with an experienced prosthodontist can show you several simulated implant
placements and their respective emergence profiles. You can also play around with what lower
incisor position is needed to achieve the desired implant placement (both intrusion and how
much retraction is needed).
I have to second the notion that this is not a great implant case for a GP. I'm not sure of the
best way to say that to the GP, but this child needs to be put in the hands of a few really good
specialists (perio and prosth, in addition to you). Please keep us posted on this case. This is true
high-end specialty work, and a great learning case. ■

12/21/2019

dhmjdds
Member Since: 11/16/04
Post: 5 of 6

I have only seen this patient one time, so I do not have serial cephs. I agree that growth could
be continuing, and that waiting as long as possible to place implants is ideal. (Also that two
implants next to each other in the anterior maxilla is always problematic.)
One complicating factor is that her insurance only pays for ortho through age 19, so of
course the parents want to maximize that by starting ortho ASAP. Another complicating factor
is that her DDS is a very close friend of her family, so my even suggesting involving additional
specialists is a touchy conversation.
I haven't heard back from her dentist yet about what he plans, so it is altogether possible that
he does not plan to place the implants himself. ■
12/23/2019

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