#1 Appointment Case Details

A 13 years old boy presents with an esthetic problem. Parents and the young man are looking to avoid extraction treatment if possible.

Diagnostics:

• Class I Dental
• Major crowding with almost complete lack of space for 13 and only about half the space available for 23.
• Midface deficiency with lacking support for the upper lip

Face Treatment Plan

• Improve midface support
• Improve lip support in the lateral thirds
• Improve lip step
• Maintain upper incisor inclination

Intraoral Treatment Plan

• Rezolve crowding
• Fix the class II
• Develop upper arch
• Fix the midline discrepancy

Observations

• Do not “open” the face
• Many apexes are widely open
   - High forces can lead to root resorption

General Treatment Plan

• No Extractions
• No Stripping
• No RPE
• No TADS
• No Corticotomy
• No Flaring
• No Inclination of the lateral groups
• Damon Q2 Bracket
• Light Forces 
• Bone Reshaping

#2 Appointment: Bonding Day

Treatment Protocol

• Torque Selection
  - 12-22 Low Torque / Retrocline
  - 13,23 High Torque / Procline
  - 33-43 Normal Torque
     - Today I would choose:
        - 32-42 Low Torque / Retrocline
        - 33,43 High Torque / Procline
• Light Elastics
  - Today
     - I would start with Quail on the right side as well
     - I would start with 14-47 and not touch the cuspid until there is more space -> Month 4 in this case.
• Coil Spring 
  - Today I would activate only 1-2 spirals every 6 weeks
• Bite Turbos on lower 6s

#3 Appointment

• Better choice for the right side elastic

#4 Appointment

• 13 is engaged with the 013 CuNiTi wire

#5 Appointment

• 8 months due to pandemics that should have been 3 or 4 the most
• 014x025 CuNiTi wire is in. This is also known as the bionator wire.
• Bite Turbos Removed
• Otter (3/16’’ 3oz) elastics only at night 

#6 Appointment

• After 2 months
• 018x025 CuNiTi wire in the upper arch to allow for an easy insertion of the 019x025 SS

#7 Appointment

• 019x025 SS wire in the upper and 016x025 SS wire in the lower for finishing
• Stainless Steel wires were adapted to the shape of the lower arch

#8 Appointment

• Finishing bends

#9 Appointment

• Removal of braces

Total treatment time: 1 Year, 10 Months

• On total duration please consider:
  - About 3-4 months were lost due to pandemics.
  - My personal primary retention protocol implies keeping the patient with the final archwires for 3 months before debonding.

That would mean about 16 Months of actual treatment!

Observations

• Very nice Class I
• Healthy gum aspect throughout the treatment
• Midline centred
• To monitor
  - Space between 43 and 44
  - Occlusion settling

Observations

• Apexes have closed nicely
• No root resorptions

Observations

• Very nice transversal development of the upper arch
  - I would argue that there is less vestibulo-inclination at the end than at the start
• Reduced Wilson curve on the lower arch

Observations

• Better midface support
• Better upper lip expression in the lateral thirds
• Better lip volume overall 
  - including considering growth

Observations

• Better facial esthetics!
• Improved Lip proportion & exposure
• Improved Lip step
• Improved Mentolabial crease

This face will age better!

Observations

• Space between 43-44 has closed
• Occlusion is better but still needs to settle some more

Setup used

• Damon Q2 bracket 5-5
• Snaplink all 6s
• Titanium all 7s
• Archwires
  - CuNiTi: 013 x2; 014x025 x2; 018x025 x1
  - SS: 016x025 x1; 019x025 x1
• Elastics Quail [3/16’’ 2oz] and Otter [3/16’’ 3oz]
• NiTi Open Coil Spring Medium
• BlueGlue for Bite Turbos
• GreenGlue for bonding