Causes: Class III malocclusions can arise from mandibular protrusion, maxillary retrusion, or both.
Studies on Maxillary Retrusion: Various studies report the contribution of maxillary retrusion to Class III malocclusions in individuals with normal mandibles, with percentages ranging between 19.5% and 37%.
Treatment Focus: This recognition has led to introducing treatments like the orthopedic facemask for maxillary protraction.
Alternate Rapid Maxillary Expansion and Constriction (Alt-RAMEC)
Protocol: Expands and contracts the maxilla alternately (1 mm/day for a week each, repeated for 7–9 weeks) using a two-hinged rapid maxillary expander.
Rationale: Mimics the rocking mechanism in tooth extraction, disarticulating circum-maxillary sutures without over-expansion.
Alt-RAMEC Protocol Details
Activation Phase:
The expansion screw was turned twice daily at a rate of 0.20 mm per turn.
This phase lasted for 1 week, ensuring the maxilla was progressively expanded.
Deactivation Phase:
The screw was then turned twice daily in reverse at a rate of 0.20 mm per turn.
This phase also lasted for 1 week, gradually constricting the maxilla back.
Repetition:
The activation and deactivation sequence was repeated for a second cycle.
After each week-long activation or deactivation phase, the patients were examined to monitor proper opening or closing of the screw, ensuring precision in the procedure.
Post-Protocol Guidance:
Following the completion of the Alt-RAMEC cycles, patients were instructed to wear the Reverse Headgear (RH). This is a common adjunct in orthopedic facemask therapy designed to enhance maxillary protraction after the suture disarticulation achieved by Alt-RAMEC.
Results of Alt-RAMEC
Comparison with RPE:
Alt-RAMEC: Achieved an average anterior movement of point A by 5.8 mm in cleft patients over 9 weeks.
RPE: Achieved only 2.6 mm movement after 1 week.
Suture Opening: Experimental studies confirmed that Alt-RAMEC opens circum-maxillary sutures more extensively than 1 week of RPE.
Clinical Implications
Parameter
A/D-RPE Group
RPE Group
Comparison with Previous Studies
Maxillary Advancement (Point A)
4.13 mm (T3)
2.33 mm (T3)
Greater movement in A/D-RPE group, similar to Liou and Tsai (2005) findings.
Anterior Movement of Point A
Significant difference (greater in A/D-RPE)
Observed, but lesser than A/D-RPE
Liou and Tsai (2005), Merwin et al. (1997), Kapust et al. (1998), Sung & Baik (1998) showed comparable results to RPE group.
Mandibular Rotation
Posterior rotation observed
Posterior rotation observed
Consistent with previous studies (Merwin et al., 1997; Kapust et al., 1998).
Anterior Face Height Increase
Observed
Observed
Findings align with previous studies.
Maxillary Plane Angle
Decrease of 1.53 degrees (T3)
Decrease observed
A/D-RPE showed significant decrease, consistent with previous studies.
SNA Angle Increase
Significant difference (greater in A/D-RPE)
Observed
A/D-RPE resulted in more significant SNA angle increase compared to RPE group.
ANB Angle Increase
Significant difference (greater in A/D-RPE)
Observed
A/D-RPE showed more significant increase in ANB angle.
Overjet Correction
Greater correction in A/D-RPE
92.5% skeletal, 7.5% incisor tipping
A/D-RPE showed a higher skeletal contribution (93%) vs. RPE (92.5%).
Skeletal vs. Dental Contribution to Overjet
93% skeletal, 7% dental
92.5% skeletal, 7.5% dental
A/D-RPE showed a higher skeletal contribution (57.9% maxillary, 35.1% mandibular).
Soft Tissue Profile Changes
More pronounced in A/D-RPE (upper lip anterior, lower lip posterior)
Observed (less pronounced)
Profile improvement observed in both groups; A/D-RPE showed more pronounced soft tissue changes.
Clinical view of the patient’s palate. Burning Mouth Syndrome or Something More? A Case of Dual Diagnosis
An 80-year-old patient presents to the office with a chief complaint of a continuous burning feeling on his palate. Upon examination you find that the patient is extremely sensitive.When you finish your examination, the patient complains of sudden chest pain. He starts to sweat and has labored breathing.
Q: What is your diagnosis of the patient?
Medical: There are a number of possibilities for the patient to have chest pain and labored breathing. The patient might be experiencing an acute myocardial infarction, hyperventilation, or angina pectoris.
Dental: The patient has a Candida species infection, which is a gingival disease of fungal origin. It is also known as atrophic (erythematous) candidiasis.
Q: How will you manage the patient if he is having a myo-cardial infarction?
Stop the dental procedure
Administer oxygen to the patient at 4 to 6 liters per minute
Call emergency medical services (EMS) immediately.
Administer nitroglycerin from the emergency kit (if pain continues, most likely not angina)
Administer aspirin (fibrinolytic properties): Give the patient 325 mg of non-enteric-coated aspirin to chew if they have no contraindications (e.g., allergies or bleeding disorders)
Monitor vital signs
Keep the patient in a comfortable seated position to minimize strain on the heart.
Manage the patient’s pain with opioids (morphine) or nitrous oxide
Q: What is your approach to treating the dental condition of this patient?
First treat the condition with a topical antifungal (eg, nystatin or clotrimazole troches) applied to the tissue side of the denture four to six times a day for 2 to 3 weeks. If the fungal infection persists,treat the patient with 100 mg fluconazole daily.
@dr.mehnaz
REFERENCES: PERIODONTAL REVIEW : A STUDY GUIDE / DEBORAH TERMEIE.
When Bad Breath Signals Trouble: A Case of Mandibular Molar Abscess
The patient is a 65-year-old man complaining of oral malodor. His dentist referred him to you to access the mandibular right second molar because of swelling, pus, and soreness. When he sits in your chair, he seems disoriented and irritable.When you look in his mouth, you find generalized inflammation of the gingiva and an abscess on the buccal aspect of the mandibular right second molar with suppuration. Charting demonstrates an 8-mm facial pocket and 6-mm palatal and interproximal pockets.
Q: What is your diagnosis of the patient?
Medical:
There are a number of reasons for the patient to appear dazed and irritable:
Hypoglycemia or hyperglycemia
Alcohol or drug overdose
Hyperthyroidism or hypothyroidism
Cerebrovascular incident
Dental:
The patient may have diabetes mellitus–associated gingivitis related to the endocrine system, under the heading of gingival diseases modified by systemic diseases, which is a subcategory of dental plaque–induced gingival diseases.
The patient has a periodontal abscess, which is a subclassification of abscesses of the periodontium.
Q: What could have led to the abscess formation?
Diabetes: According to Bjelland et al,18 multiple periodontal abscesses may result from uncontrolled hyperglycemia. Rees19 listed multiple or recurrent periodontal abscesses among the possible indications of undiagnosed or poorly controlled diabetes mellitus.
The abscess may also be caused by a preexisting periodontal pocket in association with bacteria at the depth of the pocket.
A foreign body can also cause a periodontal abscess.
Q: How will you treat the periodontal abscess?
I would ask the patient if he has seen his physician recently and whether he knows his hemoglobin A1c levels to determine if the abscess may be associated with diabetes (only his medical doctor can make that diagnosis).
An incision at a 90-degree angle to the long axis of the tooth will drain the exudate.Without removal of the cause (foreign body, bacteria, or calculus), the abscess will recur. If this is not possible, extraction might be necessary.
Antibiotics and analgesics should be prescribed. A follow-up with a dentist is also needed.
Saline Rinse: Advise warm saline rinses to reduce discomfort and promote healing.
Dentowesome | @dr.mehnaz
References: Periodontal review : a study guide / Deborah Termeie.
So you’ve got the braces thing going on, huh? A journey to a stellar smile, no doubt! But let’s face it, chomping down on everything from apples to samosas can be a real drag with those metal friends attached. Fear not, fellow food enthusiasts, for this guide will turn you into a braces-wearing, balanced-diet boss!
Carbs: Your Chapatti and Rice BFFs
Lucky you! Most grains are soft and chew-friendly. Pile on the fluffy rice, indulge in those melt-in-your-mouth rotis (dunk ’em in dal for extra protein power!), and enjoy that breakfast bread (just maybe avoid the rock-hard baguettes for now). Discomfort? Mash those chapattis into a delightful curry and rice symphony – your taste buds and braces will thank you.
Dairy: Your Calcium Cavalry
Milk, yogurt, cheese – the holy trinity of strong teeth and happy braces! They’re soft, delicious, and pack a calcium punch. Bonus points for milkshakes (because, hello, who doesn’t love a good milkshake?), but go easy on the sugar. Think of yourself as a calcium crusader, venturing forth with every spoonful of yogurt!
Veggies: Your Mashed Marvels
Ah, vegetables – the dietary champions! Most Indian meals involve cooked veggies, which are a breeze for braces. Feeling a bit adventurous? Mash them up for extra comfort. Need a raw veggie fix? Grate those carrots or chop your salad into bite-sized pieces. Just remember, you’re not a superhero (yet!), so skip the superhero-sized bites.
Fruits: Your Juicy Jewels (with a Few Caveats)
Fruits – the colorful crew that adds sweetness to life! But with braces, things can get a little tricky. Apples? Unless you’re feeling like a dental daredevil, cut them up. Unripe pears and peaches? Give them a side-eye. Feeling extra tender after a wire change? Citrus fruits and berries are your new best friends. Remember, if all else fails, fruit juice is always a healthy option. Just a heads-up, though, chomping on icy-cold fruits might not be the most pleasant experience with all that metal in your mouth. Let your food warm up a bit for a friendlier feast.
Nuts & Seeds: Your Sneaky Saboteurs (But We Can Work With Them)
Okay, nuts and seeds – they’re delicious, nutritious, but a real challenge for braces. Here’s the deal: during your orthodontic adventure, swap those whole nuts for nut butters (think creamy peanut butter heaven!) or coarsely grind your favorite seeds. This way, you get the goodness without the potential for a braces breakdown.
Meat: Your Tender and Chopped Champs
Meat – the protein powerhouse! Unfortunately, it can be a bit fibrous and tough on braces. Here’s the golden rule: avoid gnawing on meat straight off the bone (think of your teeth, not your inner caveman). Tofu and cottage cheese are great protein alternatives, but if you must have meat, choose lean, tender cuts and chop them into bite-sized pieces.
The Absolute No-Nos: Your Braces’ Nightmares
Now, let’s talk about the foods that would make your braces weep. Gum (both sugary and sugarless) is a big no-no. Sticky candies? Forget about it. Hard foods like whole nuts (unless grinded), popcorn, corn on the cob, pizza crusts (sorry!), ice, and cookies are strictly off-limits. Think of them as villains in your quest for a perfect smile.
Remember: Consistency is key! Stick to this guide, embrace some creativity in the kitchen, and you’ll be a braces-wearing, balanced-diet pro in no time. Now go forth and conquer that delicious, nutritious world, one bite at a time (and maybe cut that bite in half)!
Dentowesome 