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A Dental Class II Case with Severe Crowding Treated with Self-Ligating Brackets by Dr. Blair Feldman, DMD, MS

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Have you ever heard a claim from an orthodontic supply rep that sounds like the following? "Doctor, by using our product you will see a 30 percent decrease in treatment times!" Well, silly as that claim can be, it turns out that some products can help significantly with certain scenarios. This case study will highlight one such case.

If you're like me, you've probably bought a few products (or a few dozen) from reps thinking about the amazing benefits you'll acquire with all this free time they promise. Think about it: 30 percent. In a typical treatment plan of 18-24 months you could save 5-7 months!

And, it gets better. Have you ever found yourself fantasizing about the benefits of combining multiple products into your practice that promise to save you a percentage of time?

"Eureka!" you exclaim. "I must be the only one who has figured this out! If I save 30 percent by using this manufacturer's braces and 20 percent by using this manufacturer's device, and another 10 percent by using yet another time-saving product, I will not only be rich in money, I will be rich in time!" It only makes sense, right?

Buy the products the vendors say save time, combine them all and treatment times should be in the range of five months. I even know what I'll call it: 5-month smiles!

Although I have been called (by my wife) a sucker for trying nearly every product that offers a time-saving benefit, I have also learned a great deal about many of the orthodontic products that promote themselves as high technology, more comfortable and time saving. There are certainly some terrific products out there that increase comfort, add precision to treatment and may even save a bit of time.

It could be said that I have a passion for amassing partially used orthodontic product superstars, such that the arsenal is worthy of orthodontic doomsday-prepper status. My true passion lies in finding the best orthodontic experience from start to finish for my patients. It's a quest that will take my entire professional career and I'm okay with that.

I believe a day will come when the perfect orthodontic case will be accomplished. This case will last precisely two visits: the start of treatment and the finish. And, of course, within these two visits all of our goals will be achieved: ideal occlusion, function, and aesthetics. Oh, and it will also be comfortable and we will still give patients reward points for good brushing and flossing.

The following case illustrates the use of some interesting technology. This case was not a supremely difficult case, where surgery was offered and declined and yet I proceeded to miraculously save the patient from surgery and a hospital bill in the Audi A4 price range. This case, like many moderately challenging cases, could have been treated in several different ways.

My therapist tells me I am a peacemaker, so I will say that each of the different treatments that you readers will dream up end with the same wonderful result. My personal and professional goals in this case were to create a plan that would utilize advanced technology to treat this case with comfort and precision.

Case Presentation 1
Diagnosis
A 12-year-old male presented to our office with the chief complaint of crowded teeth. He showed severe crowding on the upper and lower arches. He had an end-on molar relationship on both sides, and a crossbite of the upper right lateral. He also had a deep bite and the midlines off slightly with the lower shifted to the right side by about 1mm. The patient had a great-looking profile but he had a slightly obtuse NLA and thin lips. On his panoramic X-ray there were no significant findings and his cephalometric film showed that upper and lower incisors were upright (Fig. 1).


Treatment Plan
Although he showed severe crowding, his cephalometric film (Fig. 1b) gave evidence that made me optimistic about a non-extraction treatment plan using a passive self-ligation bracket (Damon) and developing the arches. I let the patient and his mother know that I would make a therapeutic diagnosis between 8-12 months on the progress of my non-extraction plan. I informed them that extraction of four bicuspids was not out of my thoughts, rather, I wanted to give him the chance at a non-extraction plan and that I felt his X-rays and facial photos indicated that a non-extraction plan could be beneficial. I also informed the patient that I would be using suresmile to detail and finish his case.



Despite the fact that some marketers and champion doctors claim radical time savings by the mere mention of their product names, I didn't promise this patient a time savings from my use of any particular products. I proposed that treatment of this type, in my office, would take between 18-24 months. I did inform the patient, however, that in my practice, I have seen excellent results with severely crowded cases and the Damon system. I also promised that by using an iTero scanner and suresmile I would be able to better communicate visually with the patient about his progress and my finishing goals.

Case Progression
We bonded this case in a typical fashion using Damon standard-torque brackets on his upper 2-2 and low-torque brackets on his lower 2-2. I did not initially bond the upper 3s, preferring to open spaces for those teeth with open coil springs prior to bonding. This was also for patient comfort as patients in my practice frequently complain about brackets on teeth that are high in the arch. On his LR2 we placed an eyelet and tied it in to an open coil spring on the wire with a ligature tie. We delivered a .014 Niti and sent the patient out for 10 weeks.

When the patient returned we activated his open coil springs, threaded the wire through the eyelet on the LR2 and sent him out for another six weeks.

At 16 weeks I bonded the upper 3s and engaged them with the same .014 wire. We proceeded for six weeks in an .018 niti and then a 14x25 niti for six weeks.

At this point we were seven months into the case and it was time for his suresmile scan. I call this appointment "the scan, pan, plan."

We take a panoramic X-ray and ceph and an iTero 3D scan to send to suresmile. I spend some time while the patient is in the chair taking a good look at our progress. I look at the records on that day and I look at the 3D model on the iTero screen. I also sit face to face with the patient and look at his smile as we have a casual conversation. I make notes for suresmile on reference teeth (teeth that I don't want to move) and goals for the suresmile wires that we will create.



It's at this point that I also let the mom know about the therapeutic diagnosis that I mentioned to her at our initial visit. The photos from the day of our "scan, pan, plan" can be seen in Fig. 2. At this point I felt confident in telling the mom that extraction of four teeth was not necessary. She was impressed with the work we had accomplished in seven months. I let her know that, although he has had some terrific improvements, it is the remainder of the treatment time where I will spend time building in stability, function, and aesthetics. Because I had a 3D image of the patient's teeth, I was able to illustrate the areas of the teeth and bite that still needed improvement.

Suresmile Scan Day

The concepts and technology behind suresmile have had a tremendous effect on my practice. However, like any other orthodontic product, suresmile is just a tool. It's up to the user to interact with this tool and create a finished product. But suresmile is a phenomenal tool the way an Apple MacBook Pro is not the same as a Google Chromebook or a Makita is not the same as a Ryobi, for all of you Home Depot weekend warriors out there.

Suresmile is a tool created by orthodontists for orthodontists. I have used other 3D virtual-treatment systems and none of them come close to the control and information that suresmile offers.

Looking for a way to scare your local general dentist away from doing a complex ortho case? I recommend that you sit them in front of a suresmile screen shot and start talking about different vectors of tooth movement, three different types of tooth reference positions and then show them the root of a tooth virtually moving through the cortical bone in the maxilla.


Suresmile for general dentists is like garlic for vampires. It is even good at scaring away other orthodontists, unfortunately. Fig. 3 shows a screenshot of the proposed movements for this patient. Regular suresmile users read and understand the grid like Neo in the Matrix.

For non-suresmile users, the grid shows magnitude of movements for each tooth in each of the vectors. For example, the patient's final wire will introduce movements into the UR1 as seen in Fig. 4 of 4 degrees of lingual torque, distal 0.2mm, buccal .3mm, 1mm gingival and 3 degrees of distal rotation.

It is such a powerful tool that I use it cautiously. I study the proposed tooth movements and simulations to the point of obsession and paranoia (time to get back to the therapist). It is for that reason alone that it took nearly four months for me to receive and deliver the patient's first suresmile wire. I have met many experienced suresmile users who have the custom wires available for the patient at their next normal appointment (4-6 weeks). So, for those of you counting appointments, I could have saved three months and a couple of appointments if I'd been more deft with my decision making within the software.

Suresmile Finishing

This patient received two suresmile custom wires. The initial wire was a 17x25 Niti which he had placed for four weeks followed by 12 weeks in a 19x25 Niti. These wires are custom-bent Niti wires. Yes, you heard me, bent Niti wires.

"But, I thought you can't bend Niti?" you may be asking. You can bend Niti if you use a robot, and suresmile has that robot. One of my favorite views within suresmile is shown in Figures 5 and 6. They show the bends in the wire relative to the current bracket position before placement of the suresmile wire.

It is at this point where I start to get philosophical about my wire-bending skills. And, like any good philosophy, there is no absolute right answer. When I look at Fig. 6 I first ask myself, "Could I have made similar adjustments in the patient's TMA or stainless steel finishing wires?" My answer is always, "No way, Jose." The next question I ask is, "Can those suresmile bends get me to a result that is extremely close to the virtual finish I see on the screen?" The answer to this question is, "You have to try it to find out for yourself."

The patient wore Class II elastics in the early stages of treatment but he did not wear any elastics during his suresmile wires.

His finish occurred at the 15-month mark with 13 appointments including braces placement and removal. On his removal day, I placed a bonded lower 3-3 permanent retainer and gave him upper and lower clear suck-down retainers with instructions to wear them only while sleeping.

Results
In this case, all of those bends shown in Fig. 3 brought the patient's teeth to the positions shown in Fig. 7. In my humble opinion the results were excellent. It's not a perfect case (have you had one of those lately?) but it hits all of my professional targets for occlusion, function, stability, and aesthetics. The patient and his mom were extremely happy since we were able to meet or exceed our promises regarding results and treatment timing.

Conclusion
This case shows the use of several advanced technologies, namely iTero 3D Scanning, passive self-ligation braces and suresmile. I make a joke to the residents at A.T. Still (where I teach part time) that I won't be satisfied until I spend more on overhead on each case than anyone else. Clearly, that is not my goal in using these technologies, nor is shaving months off of typical treatment time. I choose these technologies because of the advantages they offer to me as the operator. These advantages include control and precision. I also like the advantages they offer to patients: greater comfort, easier communication about results and greater precision.

If you have similar passions I highly recommend you try these technologies! You may not save time in treatment but you may see your cases in ways you haven't seen before.


                   
Dr. Blair Feldman is an orthodontic specialist practicing in Arizona and is an adjunct professor of orthodontics at A.T. Still University in Mesa, Arizona. He's a proud member of the American Association of Orthodontists, the American Dental Association and the Arizona Dental Association. Feldman completed his undergraduate studies at the University of Michigan with a bachelor of arts, after which he received his DMD from the University of Pennsylvania.

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April 2024
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