Fig. 6 Fig. 8 Fig. 10a Fig. 7 Insertion of expansion appliances. Fig. 9 Creating canine space. Fig. 10b b Improve his nasal breathing. b Restore his posture. b Stabilize the left TMJ. b Expand the upper and lower dental arches. b Reevaluate his mouth breath-ing, posture, sleep and ADHD symptoms Phase 2 treatment goals for Alex included: b Straight wire series. b Guidance of the canines into the dental arches. “in my PRaCTiCe Today, i would noT PeRfoRm a lingual fReneCTomy wiThouT PReoPeRaTiVe myofunCTional TheRaPy and myofunCTional TheRaPy duRing The healing and ResToRaTiVe Phase foR The Tongue, as ReaTTaChmenT and sCaRRing aRe a signifiCanT PRoBlem wiThouT aPPRoPRiaTe TheRaPy. neVeRTheless, aT The Time, wiThouT haVing a myofunCTional TheRaPisT as a ResouRCe, The TReaTmenT was giVen To The BesT of ouR aBiliTy as The Tongue needed an immediaTe Release To allow his denTal exPansion To ConTinue.” this should help to alleviate the distalizing postural effect on the mandible and especially the left TMJ. The lower arch will be fitted with a Williams expander, which would be activated with a key in similar fash-ion to the Hyrax appliance. The upper Hyrax appliance was to be acti-vated once a day, and the lower Williams appliance will be activated twice a week. My preference is to activate the upper appliance 12 turns for 3 mm in sequential days, then pausing to allow the lower arch to catch up on its schedule of twice a week turns. This keeps the arches coordinated and avoids crossbites and scissors bites being introduced during the expansion phase. Once the lower arch has caught up to the upper arch, another similar expansion phase is repeated until the desired expansion is achieved in each arch based on pre-operative arch width analysis and visual evaluation on orthodontic recall. b Opening the deep bite. b Correction of the dental malocclusion to a Class I. Before beginning Phase I, it was recommended that Alex begin utiliz-ing saline nasal drops to improve his nasal airway and be seen for allergy evaluation to determine if any aller-gies were contributing to and aggra-vating his nasal obstruction. He was also referred to physical therapy to work on his posture restoration, cervical and shoulder dysfunction and improper breathing. Once this was resolved, he would then be fitted with an upper RPE Hyrax appliance with reverse pull face gear arms to advance the maxilla TReaTmenT Plan Case summaRy and analysis Phase I orthodontic treatment began with expansion of the upper arch and the lower arch. An RPE Hyrax with reverse pull (RP) arms was used on the upper arch (Fig. 6) and on the lower arch a Williams expander was used. (Fig. 7) The goal for upper expansion was the 8 mm dimension of the expansion screw with the lower to follow. Reverse pull face gear was dispensed with instructions. At Alex’s first re-evaluation during his expan-38 Summer 2020 JAOS
Journal of the American Orthodontic Society Summer 2020: Page 38
