Inital Exam
Chief Complaints
- Benson can’t close his lips.
- He has a hard time chewing his food.
- He doesn’t like to smile because he is embarrassed of his teeth.
- Judging by looks, it seems like Benson might have developmental problems. This is not the case. He is a very sharp kid who is smart and articulate.
Diagnosis
- Mandibular Asymmetry
- Bi-lateral Crossbite
- Severe Class III
- Tongue Thrust Issues
- Anterior Open Bite
Treatment Options
- 2 jaw surgery- The issue here is we would have to wait until Benson is done growing before getting the surgery done. This didn’t resonate because of how long he would go without any treatment, especially with the brutal bullying culture we have in schools these days.
- We could do an RPE and Facemask, but that seemed like an outdated option due to the technology we now have with PSL.
- Thanks to Chris Chang’s example, I learned we could also place Buccal Shelf TADs and retract the lower arch while rotating the occlusal plane. This option would impact Benson’s life the fastest, so that’s what we chose to do!
Treatment Plan
- Variable Torque Bracket Selection
- Use Tongue Tamers to influence a normal swallowing pattern, keeping it from pushing on the teeth.
- Once we place SS wires, have the 8’s extracted and place two Buccal Shelf TADs to retract the lower arch
Initial Setup
- I’ve placed tongue tamers Upper and Lower 2-2.
- Initial wires are .014 CuNi
- Notice I placed a stop in between the upper 1s to keep the wire from traveling too far and poking the patient.
- I’ve clipped the lower wire distal to the 5s and placed a little composite to keep the wire from sliding out of the slot. (It would have also been fine to place a stop in between the lower 1s like we did on the upper.
- I chose to hold off on any type of elastics and just let the wires do the work.
Inital Bonding
Torque Selection
Upper
- High Torque Upper 3’s
- They look pretty dumped in.
- Low Torque upper 2-2
- Because we are using class III mechanics, we want to avoid causing the upper teeth to flare forward
Lower
As we retract the lower arch, the lower anteriors are going to want to dump in lingually.
- Lower 2-2- Low Torque bracket reversed
- This will keep the roots upright and the crowns upright and not just dump the crowns back or stick the roots out through the bone.
- Lower 3s-High Torque
Treatment Progression
Month 2
Wire Progression
Upper: .018 CuNi
Lower: .018 CuNi
Month 3
Wire Progression
Upper: 16×25 CuNi
Lower: 16×25 CuNi
Auxiliaries:
We added steel ties upper and lower 3-3.
Comments
Month 5.5
Wire Progression
Upper: 19×25 SS
Lower: 16×25 SS
Auxiliaries:
Bracket Hooks
– Add Bracket Hook at U&L 3’s
Tie-Backs
– Add Tie-Back at U&L 3-3
Comments
We placed CS2000 springs (10mm) for class III correction
Month 8.5
Wire Progression
Upper: 19×25 SS
Lower: 16×25 SS
Comments
- Placed sling back UL7-UL hook
- Placed sling back from lower 7 to the lower hooks on both sides
- Placed hook distal to CS200 spring on lowers
- Moved L hooks distal to L2’s
Month 12
Wire Progression
Upper: 19×25 SS
Lower: 16×25 SS
Bracket Repo:
Brackets
– Reposition MolarTube Bracket at LL6,LR6
Buttons:
– Added a button at UL7 for crossbite elastics
Elastics:
– Add Ram at LingButton(27)-LL7-LL6 (Fulltime)
– Update Ram at LR3-UR6,LL3-UL6 (Fulltime)
– Add Moose at LR3-UR6,LL3-UL6 (Fulltime)
Month 13
Wire Progression
Upper: 19×25 SS
Lower: 18×25 CuNi
Bracket Repo:
Brackets
– Reposition High Torque Metal Bracket at LL3
– Reposition MolarTube Bracket at LL7
Comments
Removed band on LL7 and bonded a LL6 bracket to tooth. LL7 is out too far and needs to be torqued in. also repo’d LL3
Auxiliaries
C-Chains
– Add C-Chain at LR6-LL6-LR6 (Closed, Over)
Steel Ties
– Remove Steel Ties
Month 14
Wire Progression
Upper: 19×25 SS
Lower: 18×25 CuNi
Bracket Repo:
– Reposition Regular Torque Metal Bracket at LR2,LL2
– Reposition MolarTube Bracket at LR6
Comments
- Performed 0.1mm of Inter Proximal Reduction at:
- UR2-UR1
- UL1-UL2
- UL2-UL3
- UR3-UR2
- UL1-UR1
- Removed bite turbos.
- LR6 is a snap link
- Dr Frost adjusted bite with at diamond flame burr
Comments
Bracket Hooks
– Add Bracket Hook at LL4
Elastic Bands
– Remove All Elastic Band
– Add 6-4-3 Moose (Fulltime, Left)
C-Chains
– Remove All C-Chain
– Add C-Chain at UR3-UL3-UR3 (Open, Under)
Month 15
Wire Progression
Upper: 19×25 SS
Lower: 16×25 SS
Bends:
Add Bend at UL2 (Upper, Mesial In)
Add Bend at LL1,LR1 (Lower, Extrusion Step)
Comments
I explained to Eldon that everything is exactly where I want it, except the upper right 6 (which is a crown). I explained that the upper arch should be slightly more broad than the lower. Unfortunately, Eldon’s upper right 6 crown does not stick out farther than the lower arch and is still in crossbite (which is where he started.)Â I informed him that if he ever has the crown redone, he can have them build it to not be in crossbite anymore.
Comments
Elastics
– Remove Ram at LL3-UL7,LR3-UR6
C-Chains
– Remove C-Chain at LL6-LR6-LL6 (Closed, Over)
– Remove C-Chain at UR3-UL3-UR3 (Open, Under)
Steel Ties
– Add Steel Tie at UR3-UL3,LR3-LL3 (Braided, Over)
Before & After
Case Summary
This was a tough case! I am still amazed at how we were able to impact Benson’s life through orthodontic treatment. As you look at the comparison photos, he looks like a completely different person. He no longer looks like he has developmental problems and finally has learned how to smile!
This is truly why we do what we do. We are here to change peoples’ lives and impact them for the better! Be sure to watch the video walkthrough for this case. I am able to go more in depth about the story behind Benson’s case. It’s worth the watch.