Orthotown January/February 2018 - 30

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Later, when I have more space in the upper-and of course more overjet with the upper
incisors coming forward-I would take another image to see where those cuspids are. I
would warn parents that surgical uncovering is very likely, especially for one of the cuspids.
But if the cuspids are better, then I would bond the upper laterals but with inclined (and
fl ipped) brackets to kick the roots to the mesial and away from the cuspids to "open the door
for those cuspids." And then I would be dealing with the Class II situation. Pitts uses a lot
of Herbst's, which work very well in his protocol but take a lot of time. I would live with
the retrognathic mandible and be satisfied with a dental correction and as much skeletal
correction I could get from a Forsus.
I know this is quite different from the way many of us were taught, but it's all about the upper
incisor to face and lips. I would do anything to avoid extraction in that upper arch given the face
and profile. I would be warning the patient and parents that we are going to take the time to give
him the best smile possible. My perhaps radical two cents. ■
12/10/2017

Fenrisúlfr
Member Since: 02/25/09
Post: 18 of 24

Would you mind sharing some examples of such cases that were treated non-extraction with
the Pitts protocol? Thanks.
The upper arch has about 12-14mm of crowding. Even with extractions, the incisors will
procline and there will certainly be no incisor retraction. In such a situation, what is the benefit
of treating it non-extraction? This will lead to a significantly increased IC and IM width. The
lack of stability and potential for dehiscence/fenestrations are other issues to consider. Any case
can be treated non-extraction, but at what cost? ■
12/10/2017

str8nerinva
Member Since: 03/12/08
Posts: 19 and 20 of 24

Fen, thank you for posting that case. As is typical of the cases that you present, excellent
treatment result with great records. In your case, I think the U3s are on the labial, which
makes treatment more straightforward. Your case had less crowding in the lower arch and
maybe more of a Class II molar relationship than mine, maybe making a stronger case for
extracting L5s for me.
As for your comments about natural head position, NHP has often been a bit elusive for my
staff to capture since more than a few young patients will cock their head during the pic. So, I
will typically reorient the ceph and profile photo so that Frankfurt horizontal (top of porion to
orbital on ceph and top of earhole and infraorbital rim on photo) is parallel to the top and bottom
of the screen to approximate NHP.
I think the profile photo on my patient is fairly well oriented relative to NHP, and here he
looks moderately mandibular deficient to me. When I look at FH on the ceph, your reorientation
looks tipped up to me.
But mandibular deficient or not, surgery is unlikely to be an option and a good result should
be able to be obtained with ortho alone. I think that a favorable response with growth and/or
Class II elastics/Forsus will be needed to get an excellent occlusal finish with extraction of four
bis, but you make a very good argument that this is the appropriate treatment plan.
Your reconsideration to extract U4s absolutely makes treatment more time- and effort-efficient
to get U3s into the arch. Extracting U5s will likely be a three-year case depending upon how U3s
respond after exposure. Extracting U4s just makes it more challenging to end up with an optimal
U incisal angulation. Thank you very much for your input!
I posted my response to Fen before I saw and read this post for Johnny SS. Interesting approach!
I, like Fen, would be most interested in seeing a couple of cases similar to this one treated with
the protocol described. Thanks. ■
12/10/2017

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