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Townie Treatment Case: Non-Extraction Treatment Plan by Dr. Zvi Kennet

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xxxxxxTownie Treatment Case: Non-Extraction Treatment Plan 

This patient—like 96% of this orthodontist’s cases—was treated without bicuspid extractions, rapid palatal expanders, facemasks or headgear

by Dr. Zvi Kennet

A few months ago, I spoke in front of a group of orthodontic residents and young orthodontists about systemizing clinical treatment to achieve efficiency and profitability. I began by describing my path of growth as an orthodontist and finding my way of providing care to my patients.

During my orthodontic residency, molar distalization was not reliable and arch development was mainly done using rapid palatal expanders. As a result, extraction of permanent teeth was prescribed to a significant number of patients. We were taught that a crowded lower arch dictated extraction of two bicuspids, matched by two upper bicuspids, and Class II and III malocclusions were often treated by bicuspid extraction.

My assumption was that these days, residents were taught differently and extractions were rarely used. To my surprise, the audience in my lecture revealed that extractions are still taught as the main option for these situations. I also noticed that younger orthodontists practicing with me tend to prescribe extractions in many cases I would not.

In the beginning of my career, I followed what I was taught in my residency; gradually, I found new devices and treatment methods that expanded my ability to treat various situations and improve clinical results and patient experience. I learned that if I listened to my patients and treated their faces, the dentition would fall into place from an aesthetic and functional perspective.

Today, my practice does not use traditional rapid palatal expanders or any external headgears or facemasks. Instead, our toolbelt contains a wide variety of smart devices that can be combined in different ways to address each patient’s unique situation, and in almost all cases without bicuspid extractions. The case presented here is a good example of this philosophy, even though it did not achieve an ideal finish.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 1

Case presentation and appliance selection
The patient seen in Fig. 1 is a 12-year-old male with a severely crowded Class I malocclusion. His profile and molar relations are Class I, but the severe dental crowding resulted in a partial anterior crossbite and Class III canine relations. He also exhibits poor oral hygiene, gingival inflammation and some gingival recession. Treatment plan and appliance selection were affected by the following:
  • The flat upper lip and narrow smile were detrimental in making the decision to treat non-extraction. Our treatment methods should overcome the dogmatic assumption that severe mandibular crowding dictates four-bicuspid extraction by developing the arches.
  • The position of the canines also dictates that arch development should be done cautiously to avoid any buccal forces that may increase the gingival recession (which would occur if braces were placed first). Arch development should include buccal expansion combined with some distalization.
  • The patient’s poor oral hygiene also affects the treatment methodology:
    • Oral hygiene often gets worse when braces and wires are in place. This might be a situation where our treatment becomes a race against time, trying to achieve good treatment results before poor oral hygiene forces us to terminate treatment. One option to decrease oral hygiene challenges is to start with smart appliances that develop the arches, thus minimizing the time braces are used.
    • Poor oral hygiene is often an indicator of future poor compliance. For that reason, using noncompliance methods to develop the arches would improve the predictability of achieving good results.
We selected the DMAX-2000 appliance for the maxillary arch and the MSX-2000 appliance for the mandibular arch. Both appliances, developed by Dr. Michael Williams more than 20 years ago, are made exclusively by DynaFlex and incorporate nickel titanium springs that expand the arch and distalize the molars. This combination has become popular in our practice for both Phase 1 treatment in the mixed dentition and comprehensive treatment in adolescent adult dentition. Both appliances are self-propelled and highly systemized, and require no patient or parental compliance and essentially zero doctor time, improving efficiency and profitability.

When combining these two appliances, our protocol is to place the maxillary appliance first and deliver the mandibular appliance after the first maxillary appliance check, eight weeks later.

Because this case started in 2016, both appliances used traditional bands fitted by the lab on the molars and first bicuspids. Today, these would be made with DynaFlex’s 3D-printed bands. These custom-fitted frameworks are bonded to the existing dentition, often providing better adaptation than prefabricated bands. Using 3D-printed bands eliminates the patient’s discomfort associated with separators and improves efficiency by eliminating the two separators’ appointments.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 2
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 3


Treatment progress
Arch development phase
After the maxillary DMAX-2000 was cemented (Fig. 4), the patient was seen every eight weeks. At the first appliance-check appointment, expansion was sufficient and was stopped by placing Band Lok cement (Reliance Orthodontics) on the expansion springs. At subsequent visits, when the first molars had distalized sufficiently, the cement was also placed on the distalizing springs to lock the molars in their new position. At that time, a segment wire was placed from the first molar to the first bicuspid, and the second bicuspid was distalized with an elastic thread. The mandibular arch progressed in a very similar fashion. The MSX-2000 appliance (Fig. 5) was inserted two months after the maxillary device was cemented; expansion of the buccal segments and distalization of the molars and second bicuspids took six months.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 4: Insertion day.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 5: Insertion day.


After eight months in treatment, both appliances were ready to be removed (Figs. 6 and 7). At this point, both arches were expanded and the molars and second premolars were distalized, creating an “extraction space” distal to the first bicuspids.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 6: Removal day.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 7: Removal day.


After the appliances were removed, the first bicuspids were bonded and a new segment wire was placed from the first molar to the first bicuspid. The first bicuspids were then distalized with an elastic thread, while the molars and second bicuspids served as anchorage.


Braces phase
Once the first bicuspids had fully distalized, twin brackets were placed on the remaining dentition. Progress photos taken after three months with braces show the V-shaped arches beginning to form a healthy ovoid shape, and the crowding was replaced with mild spacing (Figs. 8–10). After 14 months of treatment, only three of those with braces, we transformed this Class III canine, severely crowded, narrow arches situation into a Class I spacing. The rest is basic orthodontics. One surprising thing was that this teenager’s oral hygiene, with braces, was actually better than when he started (although still far from ideal).
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 8: Month 14 in treatment.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 9: Month 14 in treatment.

Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 10a
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 10b
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 10c
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 10d
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 10e
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 10f
Figs. 10a-f: Before treatment and at 14 months—Class I spacing and improved oral health.

A comparison of panoramic radiographs before treatment (Fig. 11a) and while braces are already on (Fig. 11b) shows the bodily distalization of the molars and lack of blocking of the second molars, as some suspect would be the case.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 11a
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 11b
Figs. 11a-b: Pure distalization evident in panoramic view.


Final results
Occlusal views of both arches (Figs. 12 and 13) show the remarkable resolution of the crowded arches by merely using two noncompliance devices. The persistent oral hygiene and other personal matters forced an early termination of treatment without achieving ideal results. However, aesthetic smile, healthy functional bite and improved facial symmetry were achieved (Fig. 14). More importantly, resolution of the crowding (Fig. 15) provides for an oral and dental environment that promotes the preservation of teeth and gingiva, even with less-than-ideal oral hygiene.
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 12a
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 12b
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 13a
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 13b
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 14a
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 14b
Townie Treatment Case: Non-Extraction Treatment Plan
Fig. 15


Treatment took 10 months of arch development, which is typical for this appliance combination, followed by 16 months with braces. The two appliances featured in this case are typical of our definition of smart appliances:
  • Effective: Predictable results.
  • Versatile: Works in a variety of situation and can be combined with other devices.
  • Reliable: Low breakage or emergency visits.
  • Decreased doctor time: Systematic and highly delegateable.
  • Decreased chair time: Fewer or shorter visits.
  • Improved patient experience. Using a wide variety of such appliances enables us to provide non-extraction treatment to most of our patients and eliminate painful expanders and embarrassing headgears.

Author Bio
Dr. Zvi Kennet Dr. Zvi Kennet, who has practiced in Michigan since 1998, now has four namesake practices in the Detroit metro area. Kennet was an early adopter of Invisalign (1999) and is an Invisalign Diamond provider. His practice is often a test site for new technology, including intraoral scanners, aligner systems, dental lasers and digital X-rays. In addition to clinical practice, Kennet is the vice president of orthodontics for Smile Partners USA.



 
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