- Submitted by Dr. Darrell Schmidt
DEMOGRAPHICS/APPLIANCES
Diagnosis/Plan:
Patient was seen initially on 10/26/09 with a chief complaint of crowding and a poor bite. She had a class 1 and a bilateral posterior cross bite, and significant maxillary crowding . There is an anterior cross bite as well. # 10 and 22 hit in CR and the mandible postures forward into CO. There is a bilateral TMJ crepitus audible and palpable. There was a possibility of orthognathic surgery, TADS, and/or reverse pull headgear and class 3 elastics to improve the anterior cross bite explained to the patient and parent. There was a possibility of removing permanent teeth or at least IPR to gain space explained. The success of the proposed palate split was dubious because was 12 ½ when I started the expander. The objectives were to occlude the teeth without a major CR shift, and correct all cross bites with an initial non-extraction treatment.
Visit (4/7/10)
There was a 20x20 Bio-Force Senalloy left in the lower anteriors since 12/28/09. They are basically aligned except for the bracket placement errors that are visible in the latest film. The next visit will be to re-position the brackets that are in error. We are awaiting the eruption on # 29 and the alignment of the upper teeth which includes an impacted canine. The first wire was placed 11/18/09.
Visit (6/24/10)
- 20x20 Bioforce wire placed in the lower arch and was rescheduled in 6 weeks.
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“Dynamic” Simulation by Dr. Rohit Sachdeva
I have run a dynamic simulation of the correction of the malocclusion based upon mechanics used. Please note that most of the space for the alignment of the canine has been achieved by the advancement of the upper incisors and distal movement of the upper right buccal segment as a result of using the coil spring. My current belief is that little space was gained through expansion of the upper arch. Once we have the therapeutic scan we will superimpose it against the predictive model to assess how valid my assumptions are in the simulation of the dynamic model. Please note that I have not brought the upper right canine to it’s final position since my simulation only accounts for the current state of correction.
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Visit (8/11/10)
There has been endodontics performed on her UR 1 since her last appointment due to devitalization of this tooth. LR 5 was direct bonded and the previously placed 20x20 Bioforce wire was engaged into rotated and partially un-erupted LR 5 Vertical elastics were continued on her right side to assist in the eruption of UR 3and prevent a cant tendency. As soon as LR 5 can be correctly re-bonded she will be scanned, probably after the next appointment in 6 weeks. At that time a new panorex will allow evaluation of all the 7’s positions and eruption potential or lack of it. The patient and her parents are very comfortable with the position of her upper incisors at this point. She does not think they are too procumbent and clinically they appear to me flared, but acceptable for now without any lingual crown torque that I could later add to the SS wires. I also have IPR available on numerous teeth and still an extraction option on the UR E, all of which I could use to reduce the flare of her upper centrals.
I appreciate all the great comments on the blog about this case. Interestingly I am treating her brother simultaneously and he has had one internal- resorbtion caused root canal on UL 2 which was visible and had initiated prior to ortho, and one endo on UR 2 which had an incisal communication to the pulp on an anomalous tooth treated shortly after the start of ortho. Does anyone know if devitalization and/or internal resorbtion have familial origins other than anomalous teeth.?
Therapeutic Scan
Treatment Plan
Visit (10/11/10)
Patient LJ had the first SS wires inserted today. The bracket on the UR E was removed because that tooth is ankylosed and does not appear to be moving. In retrospect I could have checked this on the SS set up as an immovable tooth but at the time I was unsure it was ankylosed. I removed the bracket on it to allow the SS wire to work without any pressure from that bracket. Class 2 elastics were to be worn bilaterally for 2 weeks with a check in 6 weeks to observe the wire progress. The patient is class 1 and the class 2 elastics need are minimal. The patient was appointed in 6 weeks.
Visit (11/22/10)
#1 SS wires were left to work . They have been in 6 weeks and she was re-appointed in 6 weeks. A power chain was placed to close the residual spaces and elastics were not worn at this point. Neither the parent nor patient wanted the ankylosed UR E altered or replaced. Accordingly the dental midlines will be not coincident due to the freeway space on the upper right side being unavailable. The lower 7’s which looked suspect have not erupted and are mesially angulated and appear impacted. The existing 8’s were scheduled for extraction ASAP.
Visit (1/5/11)
Patient was seen 1/5/11 and tooth position errors were noted. An estimated progress model was ordered and the desired correction values from the patient were reversed and transposed to the virtual order form. The progress model was now a replica of the observed discrepancies on the patient. The SS lab will reverse the values and the corrected wire will be placed at the next appointment. The desired correction values taken at chair side were copied on a prescription sheet and included so the viewer can compare my tooth position evaluation and corrective values with their own. # 1 SS wires have been in since 10/11/10 so I assume they are largely passive. The patient was re-appointed in 3 weeks for wire insertion when the revision wire will arrive.
Visit (3/7/11)
Patient was debonded. There was a space left between #10 and 11 due to a tooth mass discrepancy and the dental centerlines being coincident with each other and with the facial midline. A composite is planned to fill in the space mesial to #11.. The UR deciduous retained (at parents request) “A” is larger than the succedaneous tooth so there was a tooth size discrepancy with both an occlusal and anterior-posterior size issue. The devitalized central will be bleached and crowned and the unerupted 7’s are being regularly monitored for eruption progress and will be bonded along with the 6’s and a sectional wire added if they erupt ectopically. Both the patient and her doctor were unwilling to have her wear her appliances until the 7’s erupted. Essix vacuum retainers were made and placed after debonding.
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