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USDI Case Consult Written Plan


Patient name,

Due to the severe crowding, this is an extraction case. Since her upper midline is aligned with her face I think that on the upper you will extract both 1st bicuspids. You can retract the cuspids into the extraction sites, then bring the laterals into the space created by retraction of the cuspids. Very little space closure will be needed on the upper arch. The lower arch is a bit more tricky. The left side will be done conventionally, that is extracting the lower left 1st bicuspid. It will be done this way because the molar relationship is Class I and retracting the lower cuspid into the 1st bicuspid extraction site, then moving the lower left lateral incisor into the created space will solve the crowding problem on that side and at the same time maintain a Class I molar relationship. The lower right side is a bit more tricky. Look at the molar relationship. It is Class II. The strange thing is that even though the molar relationship is Class II on the right side and Class I on the left, the upper and lower midlines are aligned. This is unusual, and it means there is an asymmetry somewhere.

If we simply extracted the lower right 1st bicuspid and close space reciprocally, I think you would be left with a Class II relationship on the right side and a midline discrepancy in the lower arch. So, how do you treat this? Well, looking at the crowding, there is about 8 mm of lower arch crowding on the left side and about 5 mm of lower arch crowding on the right. This is where your asymmetry lies. To finish in a Class I relationship we need to use less of the extraction site on the right side to relieve crowding than we do on the left. Additionally we need to use more of the extraction site on the right side to protract the molar-move it forward-than we do on the left. We can do this by extracting a lower right 2nd bicuspid instead of the more traditional lower right 1st bicuspid. So the bottom line is this: we will extract upper right, upper left, and lower left 1st bicuspids, and the lower right 2nd bicuspid.

This is a rather unusual extraction sequence. However, I think it will also allow us to close space reciprocally-which is easier mechanically than asymmetrical space closure-and still end up with a Class I molar relationship. You will have to pay attention to the molar relationship throughout treatment and add a Class II elastic to the right side if the molars are not cooperating by moving into Class I. Refer to the month to month plan for details.

There is another unusual aspect of this case. Even though she is only 13 years old, she has 4 fully developed wisdom teeth. It appears a couple of them are partially erupted. If she were my patient, I would have the wisdom teeth extracted at the same time that the bicuspids were extracted. I would refer to an oral surgeon to have all 8 teeth taken out. Then I would wait about 3 weeks before starting orthodontics.

A treatment alternative that I might consider would be extraction of the lower right 1st molar instead of the lower right 3rd molar. By protracting (that is moving forward) the lower right 2nd molar, we could create enough space for the 3rd molar to erupt at the same time to help us achieve a Class I molar relationship. The 2nd molar would have to move forward only about 4 or 5 mm to get into Class I. This would solve the problem of having to put a crown on the lower right 1st molar. However, after considering this treatment plan, I have decided to reject it. It is tough to protract the 2nd molar, and there is no guarantee that the 3rd molar will erupt in a reasonable manner. So, if the patient hasn't had any trouble with the root canal, I would save that tooth and just take out the 3rd molars.

I find it hard to believe that this patient is only 13 years old. It is rare to see fully developed 3rd molars can someone so young. But since they are developed I think it is okay to remove them. Most parents and patients would rather have only one surgical procedure rather than spreading it out over more than one procedure. Therefore extracting all 8 teeth at one time makes a lot of sense.

The mechanics may be a little difficult. Good use of anchorage control-that is lacebacks- is essential. A couple of other things are also important from a mechanical standpoint. When you bracket the upper lateral incisors, place the brackets on upside down. You need a lot of labial root torque to put those teeth in the proper position. You just don't get that when the brackets are positioned normally. I would start with the brackets upside down right from the initial bracketing and leave them that way throughout the whole treatment. To manage the space on the lower right side I would probably start by not engaging the lower right 2. Pack coil between the lower right 1 and lower right 3 and combine that with a laceback from the lower right 3 to the lower right 6. Once you have enough space for the lower right 3 stop using a laceback in that quadrant. This will probably happen more quickly than in the other 3 quadrants because you have less crowding to correct. You do not want to over retract the lower right 3 because you want to save as much space as possible to move the lower right 6 forward. So the bottom line is you probably will have lacebacks in the other 3 quadrants for a month or 2 longer than you will in the lower right quadrant.

This case is quite difficult mechanically. But, the results will be fantastic. She has beautifully shaped teeth and a nice smile line. Also her profile looks great and that should not change a bit if the mechanics are handled properly. She and her family will be very happy with the results.

Plan: refer to oral surgeon for extraction of all 4 3rd molars, as well as upper left and right 1st bicuspids, lower left 1st bicuspid, and lower right 2nd bicuspid.

2 weeks later: place spacers. Wait 1 week, then begin treatment.

Month 1. Band 6's and bond 5 3-3 5 on the upper (do not bracket upper 2's yet) and 4 3 1 1 3 5 on the lower. Place anterior brackets on both upper and lower 1 mm incisal to the center, and all other brackets in the center. Bond a 1 mm thickness of composite to the occlusal surface of the lower 6's to open the bite slightly to clear the anterior brackets from the occlusion. On the upper, place lacebacks in both quadrants and pack coil between the 1 and 3 on both sides. The coil spring should be 2 mm longer than the distance between the distal of the bracket on the 1, and the mesial of the bracket on the 3. Do not engage both upper 2's. On the lower left place a lacebacks and pack coil between the lower left 1 and lower left 3. The coil spring should be 2 mm longer than the distance between the distal of the bracket on the 1, and the mesial of the bracket on the 3. On the lower right, place a laceback. The lacebacks will be a little different than the other 3 quadrants because it will engage the 3, 4, and 6. Do not engage the lower right 2 and pack coil between the lower right 1 and the lower right 3. The coil spring should be 2 mm longer than the distance between the distal of the bracket on the 1 and the mesial of the bracket on the 3. Wires used: 016 nitinol/016 nitinol. Remember to place the lacebacks underneath the nitinol wire so when you retie the wire you don't have to remove the lacebacks.

Month 2. Tighten lacebacks and retie 016 nitinol/016 nitinol. Repack coil in all 4 areas. Each coil spring should be 2 mm longer than the spring used in month 1.

Month 3. Tighten lacebacks and retie 016 nitinol/016 nitinol. Repack coil in all 4 areas. Again, the springs are each 2 mm longer than the springs used in month 2.

Month 4. By now, there should be enough space created to engage the lower right 2. Remove the laceback in the lower right quadrant, tighten the lacebacks in the other 3 quadrants, and retie 016 nitinol/016 nitinol, this time bracketing and engaging the lower right 2. There should be 3 coil springs remaining. Repack coil in these 3 areas, using a spring that is 2 mm longer than the spring used in month 3.

Month 5. By now, there should be enough space in the 3 remaining areas where you have coil spring to engage the blocked out lateral incisors. Tighten lacebacks, and bracket the 3 lateral incisors. If the upper lateral incisor brackets interfere with the occlusion, bond more composite to the occlusal surface of the lower molars so the bite is open enough so the lateral incisor brackets no longer interfere with occlusion. Place both upper lateral incisor brackets on upside down. Because these teeth are so far out of the arch form, they will move more efficiently if you can use a lighter arch wire when engaging them. I would use 012 nitinol/012 nitinol. So, at this point you have all the teeth bracketed, lacebacks in 3 quadrants (you have already removed the laceback in the lower right quadrant) and all coil springs removed.

Month 6. Remove all lacebacks and retie 012 nitinol/012 nitinol.

Month 7. By now, the upper lateral incisors and lower left lateral incisor should be in the arch form. Remove the composite from the occlusal surface of the lower molars. At this point, go back to 016 nitinol/016 nitinol.

Month 8. Begin wire progression. Wires: 014 stainless steel/014 stainless steel. Coordinate arch wires so no expansion or constriction of arches occur. Refer to CD for details.

Month 9. 016 stainless steel/016 stainless steel. Coordinate arch wires.

Month 10. 020 stainless steel/020 stainless steel. Coordinate arch wires.

Month 11. 019X025 nitinol/019X025 nitinol.

Month 12. Panorex, reposition, check root resorption. Wires: 016 nitinol/016 nitinol.

Month 13. 019X025 nitinol/019X025 nitinol.

Month 14. 019X025 stainless steel/019X025 stainless steel. Coordinate arch wires. These are your working wires. Leave them in until finishing.

Month 15. Retie working wires. Begin space closure. There probably is not a lot of space to close. I would guess you would have about 2 mm of space on each side on the upper, 2 mm of space on the lower left (in all 3 of these quadrants the space will be distal to the canine) and about 4 mm of space mesial to the lower right 1st molar. Close this remaining space with 6-6 chain, upper and lower. If the right side molar relationship is still Class II, add a Class II elastic on that side. Elastics used-1/4 inch medium. Patient attaches elastic from upper cuspid hook to lower molar hook on right side only. She wears the elastic full time, changing it every 12 hours. Eating with it in place is optional.

Month 16, 17. Retie 6-6 chain, upper and lower. Continue right side Class II elastic until the molar relationship on that side is Class I.

Month 18. By now, all spaces are closed and occlusion is good. Begin finishing. Panorex, reposition, check root resorption, and go over pre-finishing checklist. Evaluate the position of the 7's. If they are out of position, bracket and engage them now. If you keep them engaged throughout the finishing procedure, by the time the braces are removed they will be aligned well. If the 7's are not out of position, there's no need to bracket them. Wires: 016 nitinol/016 nitinol.

Month 19, 20. Finishing wires. 018 stainless steel/018 stainless steel. Coordinate arch wires and use finishing bends and/or finishing elastics if needed.

Month 21. Removal. Retainers: upper Hawley with a bite plane and lower 3-3 lingual bonded retainer. Because her bite is slightly deep and extraction mechanics were used, a bite plane is necessary to retain the occlusion. Refer to CD for fabrication instructions. After 2 years, replace the lower 3-3 with an Essix.




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