Mindy’s Case Study

Video

Inital Exam

Chief Complaints
  • “I have lost my upper face.”
  • Upper lip has collapsed due to 4 bi extraction 25 years ago
  • Lack of upper lip support makes nose appear to be larger
Diagnosis
  • Lack of upper lip support due to 4 bi extraction from prior orthodontic treatment (25 years ago)
  • Collapsed posterior arches
  • Root resorption & bone loss from prior treatment
Treatment Options
  • Surgical option- 2 jaw surgery to restore upper/mid face support
  • Open extracted bicuspid space and place implants
  • Open extracted bicuspid space and use TADs to close molars forward, protecting the upper lip. (Mindy chose this option.)

Torque Selection

Upper
  • Upper 2-2 Low Torque
  • Upper 3s Regular Torque
    • Because we are using coil springs to open up space and push anteriors forward, the teeth are going to want to flare forward.
Lower
  • Lower 2-2 Low Torque
  • Lower 3s High Torque
    • Lower cuspids are very dumped in.

Month 5

Wire Progression

Upper: 19×25 PT NiTi – 20 degrees of lingual crown torque
Lower: 17×25 PT NiTi -20 degrees of lingual crown torque

Comments
  • We started in .014 CuNi for 6 weeks and placed coil springs on the upper & lower 3’s back to the 6’s, activating them by 1/2 bracket’s length
  • Used a light-medium titanium coil spring. only advancing the coil spring by 1/2 a bracket every 6 weeks.
  • .018 for 6 weeks
  • 14×25 rectangular wires for 6 weeks

Month 8

Wire Progression

Upper: 19×25 PT NiTi – 20 degrees of lingual crown torque
Lower: 17×25 PT NiTi -20 degrees of lingual crown torque

Comments:

Same wires. Still advancing the springs by 1/2 a bracket every 6 weeks. Notice the space starting to open up between the 3s and 6s.

When you have a spring over a rectangular archwire, it tends to keep the cheek off of the teeth, and shields the buccinator muscles from confining the arch. This allows the arch to broaden and widen much easier.es.

Month 15

Wire Progression

Upper: 19×25 SS
Lower: 19×25 PT

Comments

At this point she looking the best facially (so far), and I’m still working on opening up space. The change that I’m more excited to see is the change in the palatal vault. She is really starting to gain some width along with better upper lip support (notice the upper lip roll in the profile picture). We are about ready to start with the TADs in the next few months. I’m still increasing the springs by 1/2 a bracket.

Month 18

Wire Progression

Upper: 19×25 SS
Lower: 19×25 PT

Bracket Repo

All 5’s UR1 & UR2

Comments

Now that we have increased the upper lip support through opening up space, it’s time to place 2 6mm Vector TADs to slide the posteriors forward.

I placed the anchors in between the roots of the upper 2s and 3s, tying the anchor to the bracket on the cuspid. This turns the cuspid in to an anchor, allowing us to attach a power chain to it and slide the molars forward.

I also chose to clip the wire distal to the 6s, allowing us to have minimum anchorage in the posterior segment. The 7s will usually follow as the 6s slide forward.

Notice that I chose not to place TADs in the lower arch, even though we will be sliding the lower molars forward. I have found that most of the time it is unnecessary to place TADs on the lower arch because we can support the anchorage with Class II elastics without impacting the arch.

Month 22

Wire Progression

Upper: 19×25 TMA
Lower: 17×25 TMA

Elastics

cl ll at night all w/ Moose

Comments

At this point, the spaces have been fully closed. Notice the width development in the upper arch.

I’ve switched from a 19×25 Stainless Steel wire on top to a 19×25 TMA, and I’ve switched the lower to a 17×25 TMA as well. This will allow me to spend a few months making minor finishing adjustments.

I also wire tied upper and lower 7-7 to make sure the space doesn’t come back.

Month 26 – BeforeĀ  & After

Case Summary

Notice the increase in arch width and the beautiful smile arc. With the increase in arch width, notice that you don’t see as much gum tissue in the posterior!

The day I took her braces off, I handed her a mirror and invited her to look at her new smile. With tears in her eyes, she told me that she “got her smile back”. This is truly why we do what we do. We are here to change peoples’ lives and impact them for the better!

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