12y 8m male
SUBJECTIVE: A 12y 8m male presented with his mom for an exam, concerned about his crowding and wanting teeth to come in correctly.
OBJECTIVE: He presented with Class I molars, mild upper and lower crowding, and a deep bite. Radiographically his lower incisors were upright relative to the mandibular plane, and his upper incisors were retroclined, leading to an obtuse nasolabial angle. #6, 11, 22, and 27 were all mesioangularly impacted with enlarged follicles present on at least the 11, 22, and 27.
ASSESSMENT & PLAN: Treatment goals were to:
- Remove #c, h and I, m and r. Observe and panoramic radiograph in 6 months to evaluate for self-correction of upper canines.
- Bond lower arch and create space for lower permanent canine eruption.
- As lower primary first molars were not present to extract and aid in immediate space creation, orthodontic intervention was warranted.
- Evaluate in 6 months for exposure and bonding (E&B) of canines as needed.
- Estimated tx time: 12mo.
- Lower Damon Braces (addition of upper brackets as needed for E&B) and Hawley Retainers
- Potential to keep braces on and continue directly into Phase II
Treatment
Lower brackets were bonded August 2022 with an 0.014” NiTi wire for initial alignment. A month later we placed 0.018” NiTi wires and added light open coil spring for both canines. October we engaged a 14x25 NiTi wire, however when he returned the following visit he had a broken bracket and we needed to return to a 0.014” NiTi to effectively engage and re-align #25. By February 2023 we were back on track, increasing open coil spring to increase space for the canines, and March we advanced to an 18x25 NiTi wire.
April we took a progress panoramic and observed excellent self correction of #6, 11, and 22. #27 was improved but not excellent. Options were given to mom to expose and bond the tooth, or give it another 6 months. I propositioned that with the excellent self correction of the other 3 canines, I had high hopes for #27 and would increase space further to improve its chances. While I explained this may add treatment time, Mom elected to wait another 4-6 months before going for an expose and bond, and I agreed wholeheartedly.
We saw him back every 6-8 weeks to allow sufficient time for the tooth to correct and took a progress panoramic again in October of 2023 at which point we determined the tooth was in a prime position and due to the eruption of the remaining dentition, we would remove braces to allow him to have a break between treatment phases. We removed the braces November 2023 and delivered upper and lower retainers.
In 2025 we anticipate his second round to close any space and align the upper teeth.
Treatment Review
My goal is to keep orthodontics as pleasant as possible and avoid unnecessary intervention. As such, I will often propose to the patient/parent that we work with nature as much as possible before jumping to a surgical procedure. In this scenario, it worked out extremely well and mom was overjoyed that we didn’t need to go for surgery (and the added expense it brings).
A critical analysis of the radiographs demonstrates I could have added more distal root tip to the lower first premolars and intruded #23-26 to level the lower occlusal plane more.
Overall, this was a massive success. We avoided invasive procedures and created a situation where teeth could naturally erupt, all while protecting the roots of adjacent teeth with light forces throughout treatment. While it did take 3 months longer, avoiding surgical costs made it worthwhile.