Orthotown January/February 2018 - 28

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incisors and mildly upright lowers. The transverse needs to be addressed with RPE, which will
also help resolve some of the crowding.

I have shared this case before, but it illustrates the need for lower extractions in such cases.
Between resolution of anterior and posterior crowding, leveling the COS and diff. growth, one
can easily run of out OJ and not be able to close upper spaces, or end up with end on Class II
molars, Class III canines.

That depends on the magnitude of the movement and the duration that the force system is
in play. The crown moves facially much faster than the amount of time it takes for the root to
resorb bone and move palatally.
In your case, I would consider advancing the 2s only after RPE, extractions and OCS (U4s
to 1s.) On several occasions, I have seen the 2s begin to move mesially due to transseptal pull.
The 3s can still correct, IMO, since root development is not complete, so I would hold off on the
expose and bond. The other and easier option might be to consider extraction of the upper 4s
instead of 5s, and still use the same approach (RPE + OCS). The 3s would likely correct much
sooner. That might actually be a much more efficient option. ■
12/8/2017

JohnnySS
Member Since: 10/18/13
Post: 17 of 24

28

Tough case, no doubt about it. I would not consider any extractions at this point. I would be
gently expanding that upper arch and would stay off the upper laterals until you have a lot more
space. I am a Pitts protocol guy (Tom Pitts, who I believe is a genius) but these views are my own.
I would be gently expanding with coil springs on light wire while limiting the anterior movement
of the upper incisors with very light rainbow elastics. These are 5/16 or 6/16 2-oz. elastics that
run from the lower 3s up and around the upper centrals-from one lower cuspid to the other
and up and over the centrals like a rainbow-to act as lips to limit the anterior movement of the
incisors. This also drives more lateral expansion with the coils.
I was a Damon user but found that the non-extraction expansion often led to proclined upper
incisors. The rainbow elastics from Day 1 limits this. I would also flip the upper incisors brackets
for negative torque. Again, Pitts protocol; I use his prescription. H4 brackets from OrthoClassic.
Passive self-ligation. I use light elastics on light wire right from Day 1 to guide the development
and limit proclination of upper incisors. Once you have lost that torque control it is very hard to
recover, but those upper incisors are very upright and can afford to come forward lots.
I have many cases of severe crowding like this that look so good at the end of treatment that
I cannot imagine extractions. If this case already had proclined upper incisors, then extractions
would certainly make sense. I am much happier with this protocol than using an RPE, which I
used extensively in the past. You could certainly use an RPE.

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