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A Smiling Future by Dr. Cory Costanzo

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A Smiling Future 

Three key strategies for practice improvement

by Dr. Cory Costanzo

Introduction
Irene was kind, personable and incredibly intelligent, but unfortunately didn’t have the smile to match until a concerned teacher stepped into her life.

In the seventh and eighth grades, Irene learned math and science in Mrs. Stacie Johnson’s class. Irene’s remarkable intellect and exceptional work ethic set her apart from the other students.

Near the end of eighth grade, though, Johnson noticed a change in Irene. She became solemn and withdrawn, a stark contrast to the vibrant student that she knew. Johnson noticed that Irene avoided showing her teeth and often smiled with her mouth closed.

One day, Johnson asked Irene to stay after class to talk. She confirmed Irene’s insecurities about her smile and found out that Irene did not have access to orthodontic treatment. Irene’s family had tried to seek out care, but she was denied approval for state-sponsored treatment. Her family could not afford treatment on their own. It would likely be years before she could afford treatment. Johnson, refusing to accept this, felt compelled to act. She found our office through Smiles Change Lives, a nonprofit organization with the mission of connecting patients in need with providers willing to provide pro bono treatment.


Case presentation
Clinically, Irene presented at the age of 14 with a Class I molar relationship bilaterally (Fig. 1). She had moderate upper crowding and mild lower crowding. Her profile was slightly convex with slightly full lips and an acute nasolabial angle. Overjet and overbite, measured at the left central incisors, were measured at 4 mm and 2.5 mm, respectively. Tooth #10 and tooth #11 were transposed. The pre-treatment Panorex (Fig. 2) showed that #6 and #8 were impacted. The root of #7 was slightly transposed relative to the crown of #11. Although a CBCT evaluation would have been ideal in this situation, we did not have a CBCT machine in our office at the time and, because of financial limitations, we were not able to arrange for CBCT from an imaging lab.
Smiles Change Lives Case
Fig. 1
Smiles Change Lives Case
Fig. 2

Because of the severity of the transposition of #10 and #11, any attempt to normalize the position of these teeth was deemed too risky and we decided to maintain the transposition. Because of the aesthetic and functional compromises of maintaining this transposition, we considered setting these teeth up for future restorations and focusing on gingival heights when positioning them. This would have involved extrusion of the canine, requiring significant enameloplasty of the canine’s cusp tip, as well as significant intrusion of the lateral, which would have left the lateral out of occlusion.

Ultimately, we decided not to proceed with a pre-restorative plan, primarily because of financial limitations. This meant our goal was to position the cuspid and lateral for optimal function while maintaining their current size and shape.

The decision on whether to erupt #6 into a transposed position with #7 was a little more difficult and hinged on a consideration of the prognosis of #7.

The long-term prognosis of #7 was questionable for several reasons. It was unclear as to whether any root damage had occurred as a result from contact with the impacted central and canine crowns. Any attempt at forced eruption of the impacted teeth would come with significant risk of further root damage to #7.

Also, the impacted teeth had enlarged eruption follicles which appeared to be limiting the amount of bone surrounding the lateral root. This lack of bone support was confirmed by the oral surgeon at the time of surgical exposure of #6 and #8.

After careful consideration, we decided to move #7 into its normal position and to forcibly erupt #6 into its normal position.

The primary factor in making this decision was the realization that if #7 was eventually lost, Irene would be better off with an implant in the lateral incisor position than with an implant in the canine position. From a functional standpoint, we felt that having a natural tooth in the canine position was more important than having a natural tooth in the lateral position. Also, because of the relative frequency of missing lateral incisors, lateral incisor implants are more common than canine implants. We recognized the advantage for both the implant surgeon and restorative dentist in placing and restoring an implant in a site that they are more familiar with.

Although we realized that maintaining the transposition on the left side and normalizing tooth position on the right side would result in an asymmetry, we felt that this plan was in the patient’s best interest. We decided to proceed and attempt to camouflage the asymmetry as much as possible.

Self-ligating brackets were bonded to the upper and lower arches using digital indirect bonding. A canine bracket with 00 torque was used for the transposed upper left lateral incisor. A bracket was not initially bonded to tooth #11 because of lack of space. Instead, we started with an open coil spring on a 16 NiTi wire to work on gaining the necessary space. We also did not bond a bracket to tooth #7 out of concern that doing so could force the root of the lateral into the crowns of #6 and #8, potentially damaging the lateral root.


Progression
After five months of alignment, the impacted teeth were surgically exposed and bonded with gold chains using a “closed exposure” technique. Initial traction involved a 17x25 NiTi continuous archwire with a 14 NiTi piggyback wire fed through crimpable double-tubes that were crimped on to the continuous wire between #4 and #5 and between #10 and #12. The piggyback wire was threaded through both gold chains and engaged in a lateral incisor bracket that was bonded to #11.

After three months of traction in this manner, a bracket was bonded to #7 and a 14 NiTi continuous archwire was placed, threading through both gold chains and engaging the upper right lateral bracket between the two chains.

Two months later, a progress Panorex was taken (Fig. 3), at which point we started applying mesially-directed traction to #8 by wire-lacing all the teeth in the upper left quadrant and tying elastic thread from the gold chain to #9. We applied distally directed traction to #6 in a similar fashion by lacing #3 through #5 and tying elastic thread from the gold chain to #5.
Smiles Change Lives Case
Fig. 3

From the time of surgical exposure to the time of tooth emergence, it took a total of 12 months to erupt #6 and 20 months to erupt #8. Once erupted, brackets were bonded and alignment was completed (Fig. 4).
Smiles Change Lives Case
Fig. 4

Total treatment time was 41 months. Enameloplasty was performed on upper anterior teeth to improve aesthetics. Active thermoformed retainers, produced using in-house aligner software, were delivered as a final detailing step. Retainers were worn full time for three months and then nighttime thereafter.

The post-treatment Panorex (Fig. 5) shows a significant bony defect around #7. At the time of debond, the tooth was asymptomatic and had Class I mobility. The patient was last seen in the office 10 months after debond at which time #7 remained stable and asymptomatic. Although we haven’t seen Irene in the office since 2021, she reports that the lateral incisor is currently present and solid.
Smiles Change Lives Case
Fig. 5


Conclusion
Soon after having her braces removed, Irene began college. She reports that every day she thinks about how different she would feel with her old smile. Her new smile has given her the confidence to meet new friends, network with professors and give presentations in a lecture hall filled with hundreds of students. In June 2024, Irene earned her bachelor’s degree.

Johnson explains that recommending Irene for pro bono orthodontic treatment was not just about dental work but advocating for a promising young student’s full potential.

We are grateful to Smiles Change Lives for their aid in making this transformation possible. While we could have deemed this case too complicated for pro bono care, we were thrilled to donate 41 months of our time and resources to making a difference in Irene’s life.

Thanks to Dr. Allen Chien for providing surgical exposure of the impacted teeth pro bono. We are also incredibly grateful for Irene’s amazing teacher for choosing to go above and beyond in changing the life of her student.
Smiles Change Lives Case
Before
Smiles Change Lives Case
After

Author Bio
Dr. Cory Costanzo Dr. Cory Costanzo completed his dental and orthodontic training at the University of the Pacific where he also received a Master of Science in Dentistry. Costanzo is a member of the American Association of Orthodontists, Pacific Coast Society of Orthodontists, American Dental Association and he is a past president of the Fresno-Madera Dental Society. He is a clinical assistant professor in the Orthodontic Department at the University of the Pacific Dugoni School of Dentistry. Costanzo is also a Diplomate of the American Board of Orthodontics and owns a private practice in Fresno, California. Costanzo lectures on a variety of topics, including digital indirect bonding, optimized retention and clear aligner therapy.


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