Beruflich Dokumente
Kultur Dokumente
53:579-587, 1995
Treatment Alternatives
Four options exist for those individuals seeking correction of increased overjet. Patient concerns and clinical findings are key factors in narrowing the choice.
Treatment should not be considered if the outcome is
unlikely to meet patient expectations, or if local factors
such as dental or periodontal health indicate a prosthetic alternative. Growth guidance may be suggested
for the prepubertal patient having a favorable growth
pattern. Although there is mounting evidence that the
skeletal impact is negligible clinically, a combination
* In private practice.
Address correspondence to Dr Thomas: 5501 Fortune's Ridge Dr,
Suite H, Durham, NC 27713-9355.
1995 American Association of Oral and Maxillofacial Surgeons
0278-2391/95/5305-001553.00/0
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580
A key part of the preliminary decision-making process involves an unbiased explanation of the alternatives and the associated cost and risk versus benefit
with each. Intellectual honesty is paramount during
both the initial encounter and the subsequent discussion of alternatives. Because it is natural for clinicians
to seek solutions in the context of training and experience, care must be taken to avoid inappropriate influence on patient perceptions and attitudes. This may be
especially difficult for the orthodontist presented with
a patient who is initially expecting limited orthodontic
treatment only to discover there is a significant underlying skeletal imbalance. If there is some uncertainty
regarding alternatives at the initial visit, diagnostic records should be suggested and definitive answers deferred. A sensitive, carefully structured, global discus-
PAUL M. THOMAS
58"1
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FIGURE 1. A, Normal facial proportions are evident in this frontal view of the patient. The slightly high smile line is a function of the lip
elevating over procumbent incisors during animation. B, In this profile view an acute nasolabial angle suggests that a component of maxillary
protrusion contributes to the Class II malocclusion. C, D, E, The maxillary and mandibular arches are well-formed with no crowding to suggest
the need for extraction. The full Class II malocclusion, with l0 mm of oveljet, will require extraction for camouflage, however, and is at the
limit of orthodontic correction.
o f which specialist the patient happens to contact. 17 Although somewhat tongue-in-cheek, this statement, in reality, m a y be disturbingly accurate. W i l m o t et al analyzed
a series of dentofacial patients' motivations for orthodontic or surgical treatment and examined the association
of these motivations with the severity of the skeletal
malocclusion. Patients in this study, especially those with
Class II relationships, were more motivated for orthodontic treatment than surgery. This is not surprising because
most individuals would prefer the least invasive treatment
PAUL M. THOMAS
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EPIDEMIOLOGY
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FIGURE 2. A, This frontal view suggests relatively normal transverse and vertical facial proportions. B, Mandibular deficiency is
evident on the profile view. Maxillary lip support is within normal
limits. C, D, E, The crowding in the lower dental arch suggests that
extraction may be necessary. Expansion is likely to procline the
incisors beyond the limits of good periodontal support. The occlusal
relationships and overjet are actually less severe than seen in the
patient in Figure 1 due to forward drift of the posterior mandibular
teeth. Correction, however, would require extraction in both arches,
with the likelihood of lower incisor retraction and residual overjet.
F, The cephalometric tracing shows components of both maxillary
protrusion and mandibular deficiency. The maxillary incisors are
already slightly upright and further retraction is best avoided.
PAUL M. THOMAS
585
FIGURE 2 (Cont'd). G, Treatment simulation confirms the undesireable profile changes that would result from orthodontic camouflage.
The nasolabial angle is markedly obtuse and there is inadequate chin projection. H, An advancement genioplasty helps with profile appearance
in the orthodontic camouflage simulation, but the lips are still undersupported. This may be an acceptable alternative, depending on the patient's
concerns and motivation for seeking treatment. L This computer-assisted treatment simulation demonstrates the result from extraction of the
lower first premolars, space closure, and surgical advancement of the mandible. The soft tissue relationships have better balance in the noselip-chin region.
586
ation of the perceived benefit from orthognathic surg e r y versus the cost and risk.
PAUL M. THOMAS
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