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Case Presentation: The Next Twelve by Daniel Grob, DDS, MS, Editorial Director

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The practice of orthodontics provides an opportunity to utilize many sophisticated techniques and technologies to solve difficult and rare malocclusions.

However, I am sure everyone would agree that the bread and butter of orthodontic practice consists of hundreds, if not thousands, of 10- to 14-year-olds either in need of room for erupting teeth, or dealing with potentially crooked teeth.

Such is the treatment of the young patient in this case presentation. In practice, and with the Treatment by Twelves philosophy, this patient falls into the category of “The Next 12” permanent teeth, or the stage of treatment when the upper and lower cuspids and bicuspids erupt into the mouth. In other words, complete treatment of the adolescent dentition.

Treatment by Twelves is a trademarked method to describe caring for patients of all ages who have malocclusions, with the express intention of treating to the new aesthetic demands.

Observations
The patient is an 11-year-old boy who has been monitored for many years for potential crowding. The medical and dental history is unremarkable. There is good nasal breathing, and no discernable oral habits were present.

Prior to this visit, four primary cuspid teeth were removed to enhance the appearance of the anterior teeth and create a pleasing smile during childhood.

As with most patients in this situation, the family was reminded that removing four primary cuspids could result in the need to remove four permanent bicuspids. This statement commonly accompanies serial extraction procedures.

Not pleased with this option, the family began to explore other alternatives and searched for something that could be done to eliminate the need to remove permanent teeth.



Figs. 1 & 2: Photos indicated a well-balanced facial appearance with relaxed musculature. The intraoral photos demonstrated a constricted arch form.

Fig. 3: The panoramic X-ray showed teeth definitely crowded and permanent teeth expected to erupt within the next one to two years. The eruption pattern was symmetrical and age-appropriate.

Fig. 4: The cephalometric X-ray once again suggested balanced facial structures with a slight tendency towards skeletal overjet. Using traditional definitions of malocclusions, this patient would be considered a slight Class II with crowding.

The plan
It was mutually agreed to give the patient the benefit of attempting to treat non-extraction with a period of therapeutic re-evaluation within a year or so.

Fig. 5: Treatment began with a fixed 2x4 appliance on the upper arch and a lower lingual arch to preserve space.



The purpose of the 2x4 appliance includes the following anecdotal goals and observations:
  • Aligning and leveling of the incisors and opening the bite
  • Distalization of the molars
The spring holds the cheeks away from the developing buccal segment, exerting a functional or Frankel effect on the erupting teeth. The function of the appliance is dependent on closed lip posture and competence with nasal breathing. If present, the desired buccal expansion and distalization occurs. If not present, the anterior teeth would flare, most probably necessitating removal of permanent teeth or aggressive headgear therapy.

Figs. 6 & 7: At six- to eight-week intervals, the wire was gradually increased to .18 and finished with an 18x25 with added expansion to hold the molars in position.

Fig. 8: Once eruption of all of the permanent teeth occurred, the remainder of the fixed .022 slot appliance was placed and the treatment was finished uneventfully. The result

Figs. 9 & 10: All teeth were utilized in treatment and gradual expansion occurred with growth and maturation.

Figs. 11 & 12: The panoramic and cephalometric X-rays documented the changes and the lack of unfavorable side effects such as posterior crowding or flaring of the anterior teeth.



Comments
Many clinicians would have waited for all of the permanent teeth to erupt. Some clinicians would have removed the four permanent bicuspid teeth.

The philosophy that I have developed over the years—one that many parents, dentists, patients and especially staff understand—is to begin non-extraction and provide a period of therapeutic evaluation where muscle, habit and cooperation are evaluated prior to deciding on the final outcome of care. The goal is to finish within six months of eruption of 12-year molars, which for most females is prior to high school and for most males, during their freshman year.



Conclusion
This was not a difficult treatment to accomplish. However, this demonstration and example have been utilized hundreds of times to explain to potential patients, parents and dentists exactly what we do to derive and complete a treatment plan.

The most important issue in this form of treatment is maintaining favorable lip, tongue and facial muscle balance. In situations such as these, an outstanding treatment result can happen.



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April 2024
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