Orthotown October 2020 - 35
Decision on extractions
The concern for lower-third facial height in the present and
long term and the narrow arch in the "smile window" were the
two biggest factors that led me to begin treatment with a nonextraction plan. In "borderline" non-extraction plans like this one,
extractions may still be opted for after initial alignment, before
the pano/repo appointment.
Treatment outcome
The non-extraction plan was seen through, and total
treatment time was 20 months. Significant arch expansion was
achieved via self-ligating appliances (Alpine brackets, Rocky
Mountain Orthodontics) used in combination with light-force NiTi
"extra wide" wires. "Extra wide" wires have a shape slightly wider
than that of the Damon or universal shape. In cases like these,
after initial placement of a 0.14 NiTi extra wide, I will advance to
and typically leave the patient in 20x20 extra wide NiTi wires for at
least six to eight months to maximize dental expansion under very
light forces. By the time we advance to finishing wires, most often
18x25 TMA, there is little to no further need for expansion.
Significant interproximal reduction-approximately 0.7mm
per contact point L3-3 and 0.9mm per contact point U3-3-
served the purpose of gaining space for alignment and also was a
microaesthetic benefit to the individual teeth.
Class 2 elastics were used at different times during
treatment, both for occlusal correction and also to benefit mild
tipping of the occlusal plane to benefit maxillary incisor vertical
show and smile arc. "Shorty" Class 2 elastics (U4s to L6s) are
shown in the initial appliance placement photos. Alpine brackets
were also repositioned midway through treatment to benefit
smile arc; upper anteriors were placed more gingival, and lower
anteriors more incisal. No upper incisor brackets were "flipped"
during this treatment.
The severe crowding aligned with a very mild increase in
upper proclination and more significant increase in lower anterior
proclination, which was expected. As seen on the up-close lateral
smiling photo (Fig. 2), the upper anteriors show an aesthetically
acceptable angle of proclination. Additionally, there is no visible
evidence of periodontal thinning or recession at the end of her
treatment, and retention records through 12 months posttreatment have shown the same.
Beautiful upper anterior vertical display and smile arc were
achieved (Figs. 3a-3c, and Figs. 4a, 4b and 5). The dental
expansion truly projects her beautiful teeth within her smile
window. The slightly more rectangular (rather than barrel) shape
of the upper incisors as well as the more linear contact angles
also add to the final aesthetic result, which speaks for itself.
Fig. 2
Fig. 4a
Fig. 4b
Fig. 5
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Orthotown October 2020
Table of Contents for the Digital Edition of Orthotown October 2020
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