Townie Treatment Case: Changing a Smile (And a Life) by Dr. Bryan Nakfoor

Townie Treatment Case: Changing a Smile (And a Life) 

by Dr. Bryan Nakfoor

Smiles Change Lives (SCL) referred this patient to our practice when she was 14. At her initial consultation, full records were taken, including a panoramic X-ray, cephlometric, photos and scan (Fig. 1).
Townie Treatment Case: Changing a Smile (And a Life)
Fig. 1

The clinical exam presented late mixed dentition; the patient was Class III skeletal, her upper incisors were flared, the lower midline was right 2 mm, the upper left canine was buccally impacted and the right was ectopic. The lower right and left second molars were impacted because of severe crowding. The patient had begun puberty about two years before treatment.

The following treatment plans and objectives were recommended based on the clinical exam.

Option 1:
  • Refer to extract the remaining primary teeth.
  • Rapid palatal expander.
  • Upper and lower orthodontic bonding.
  • Refer for exposure of the impacted canines (if needed).
The advantages of this option included avoiding extraction of permanent teeth. The disadvantage of this option was the unpredictability of using the expander, given the patient age of 14.

Option 2:
  • Refer to extract the remaining primary teeth and all first premolars.
  • Upper and lower orthodontic bonding.
  • Refer for exposure of the impacted canines (if needed).
The advantage of this option was the predictability of the outcome.

The patient’s parents ultimately chose Option 1, because of an overall concern about having permanent teeth removed. The treatment objectives for this patient were:
  • Correct the bite discrepancy.
  • Dental camouflage, given skeletal relationship.
  • Guide the impacted teeth into the correct position in the mouth.
  • Straighten and align teeth.
  • Avoid jaw surgery.

Alexis Barclay, director of provider services at Smiles Change Lives, left, and Dr. Bryan Nakfoor at NAK4 Orthodontics.  Smiles Change Lives

Thousands of children across the United States have something to smile about because of the generosity of Virginia Brown. As a child, Brown endured years of teasing and ridicule from her peers because of her crooked teeth. She hated to have her picture taken and rarely smiled. This experience affected her so deeply she vowed that someday she would take action to help children in need.

In 1983, The Virginia and Maurice Brown Foundation, with donor-advised funds at the Greater Kansas City Community Foundation, was formed. In 1997 it was changed to The Virginia Brown Community Orthodontic Partnership and has since evolved into Smiles Change Lives (SCL), a nonprofit organization that serves children nationwide. The partnership between SCL and orthodontists around the country has given more than 16,000 children new smiles, renewed hope and restored self-esteem.

The Brown family continues to pave the way in creating access to orthodontic care with a cadre of staff, volunteers and more than 750 orthodontists nationwide. This partnership enlists SCL to do the upfront work, which includes an in-depth selection process as well as matching children in need with area orthodontists. This also allows the orthodontists to do what they do best—creating beautiful and functional smiles.

To learn more about how to join this partnership, head to
Progress through treatment
A decision was made with the patient’s parents to attempt expansion and removal of primary teeth. A Hyrex expander was fabricated and cemented; as instructed, the patient completed 21 turns.

At the next appointment, dental tipping was seen and a posteroanterior (PA) ceph was taken (Fig. 2) to confirm there was no evidence of sutural expansion. At that time, the expander was removed.
Townie Treatment Case: Changing a Smile (And a Life)
Fig. 2

Extraction of all first premolars (#5, #12, #21 and #28) was decided, along with exposure of #11 with gold chain and bracket bonding. The upper arch was bonded, except #10—the goal was to allow #10 to float freely, because #11 was extruded and distalized in hopes of limiting potential damage to #10.

Sixteen weeks later, the lower arch was bonded, and there was continued distalization and extrusion of #11 (Fig. 3). The bracket was bonded to #10 one month later. Vertical elastics were initiated on left canines and second premolars to level arches.
Townie Treatment Case: Changing a Smile (And a Life)
Fig. 3

In January 2020, a progress Panorex (Fig. 4) was taken to check #10’s root structure. At this point, COVID-19 medical professional protocol was put in place and treatment was delayed for six months.
Townie Treatment Case: Changing a Smile (And a Life)
Fig. 4

Orthodontic treatment resumed in July 2020, including a standardizing archwire sequence and alignment (Fig. 5).
Townie Treatment Case: Changing a Smile (And a Life)
Fig. 5

In September 2021, a progress Panorex (Fig. 6) revealed that while there was mild root resorption on #10, it is our belief that if we had bonded during extrusion of #11, there was a strong possibility the tooth may have been lost. Because of the decision to delay bonding, the long-term prognosis of #10 at this point was excellent. Bite correction and space closure was obtained. The patient completed treatment and was debonded in April 2022 (Fig. 7).
Townie Treatment Case: Changing a Smile (And a Life)
Fig. 6

Townie Treatment Case: Changing a Smile (And a Life)
Fig. 7

I was proud to work with Smiles Change Lives to complete this patient’s treatment, along with many others. I would also like to express our appreciation to the Smiles Change Lives partners—particularly American Orthodontics for its generous donation of supplies used in this case.

Author Bio
Dr. Bryan Nakfoor Dr. Bryan Nakfoor is the owner orthodontist of NAK4 Orthodontics (, a practice with three locations in the northwest suburbs of Chicago. Nakfoor earned an engineering degree at the University of Michigan, and later returned to the same university’s dental school to earn his dental and orthodontic degrees.

After working as an associate orthodontist in the Chicago area for years, Nakfoor purchased his first practice in 2009. As it grew, his core values became the driving force behind an overall vision he calls the “Journey to 10,000 Smiles,” which included partnering with Smiles Change Lives to help children in need.

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