Video
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- We could do an RPE and Facemask, but that seemed like an outdated option due to the technology we now have with PSL.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
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
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.
Treatment Progression
Month 3
Wire Progression
Upper: .018 CuNi
Lower:Â .018 CuNi
Comments
Took the new wires all the way back to the 7’s. Taking them all the way back, we start to correct the discrepancy in height on the molars.
We are still staying away from elastics while progressing through the sequence.
Month 10
Wire Progression
Upper: 19×25 Stainless Steel
Lower: 19×25 Stainless Steel
Spring
150 gram 10mm nickel titanium spring and activated it about a half a bracket of coil. (very light forces!)
Wire Tie
We have used a tie back that goes from the post on the wire to the 6s to keep any space from opening up in the posterior.
We have also continued to wire tie both the upper and lower anteriors to keep the spaces closed as well.
TADs
At 9 months in treatment, Benson is ready to have his wisdom teeth removed. Because the oral surgeon is my brother-in-law, I went in with him to place the Buccal Shelf TADs while he was already under anesthesia.
Month 15
Wire Progression
Upper: 19×25 Stainless Steel
Lower: 19×25 Stainless Steel
Wire Tie
Lower 3-3
Comments
Space was opening up so we wire tied the lower 3-3.
As we have been retracting the lower arch, for some reason the lower 7’s were starting to super-erupt, so I took the opportunity to reposition the 7’s at this point.
Month 18
Bracket Repo
Lower 7’s (again), UR4, UL5
Comments
At this point in treatment, he has overlap of his upper and lower teeth and he almost has his lower midlines on. This is the point in the case that I felt like that I finally knew deep in my heart that I was going to finish this case, and finish well. I’ve decided to wait until we have a little more overlap and to let things settle a little more before repositioning more brackets.
We have also placed some Caplin Hooks on the upper 6’s and 7’s so we can start some cross bite elastics.
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.