Using simple biomechanics, the upper cuspids, lacking space, are treated considering the face first

#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.


  • 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


  • 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!


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


  • Apexes have closed nicely
  • No root resorptions


  • 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


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


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

This face will age better!


  • 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


- Arch development can be very simple and extremely effective with the right tool and the right protocols. - Our treatment choices affect our patients throughout their life and if we could choose to be less invasive maybe we should consider it.