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to jump in there and start. I have another case more crowded than this one where I have just sent
a referral to exo the 5s. ■
1/17/2015

Ivyortho
Member Since: 11/17/08
Post: 5 of 34

Just like Ryan, I would look at the angulation of the anterior teeth first and design my mechanics
around that. In this particular case I would not extract (unless the ceph shows significantly flared
U/L incisors). Upper 6s and 5s are rotated and the lower 5s are huge. I would derotate upper 6s
and 5s, and hold the upper 6s with TPA and IPR the crap out of those lower 5s! ■
1/17/2015

NY sent
Here is the ceph. Angulation of the upper
and lower incisors looks good. I'd be afraid of
proclining them more without extractions. I love
picking up a handpiece to reshape wide lower 5s.
Yeah I think this is one of those borderline "do I
extract or not" cases but I'm thinking extraction
would be a more efficient treatment plan. ■

Member Since: 10/10/05
Post: 6 of 34

1/17/2015

charlestonbraces
Member Since: 06/05/09
Post: 7 of 34

I agree with you here. U/L5s and get the incisor inclination where you want it first. Then to
help blow anchorage at that point, I would place a 21/25 SS (if 22 slot) to help control torque loss.
You could supplement with a protraction face mask with elastics from the mask to the U/L 6s. I
closed an entire e-space (huge!) in all four quadrants once doing this (21/25 SS and face mask)
without any appreciable torque loss (in a case that was minimally crowded). I am sure it is just
positioning error on the ceph, but just check for any facial asymmetry. ■
1/17/2015

tom525
Member Since: 06/18/08
Post: 8 of 34

In this case, I want to retract the 4s. I would custom bend .016 steel to the malocclusion, and
then retract the 4s to get the 3s some space. ■
1/17/2015

Fenrisúlfr
Member Since: 02/25/09
Post: 9 of 34

I agree with you. Definitely an extraction case (in my hands), given the degree of crowding
and the near-optimal existing inclination of the incisors. With the upper ML appearing to be off
to the R, I'd consider extraction of three 5s and UL4 (to help correct the midline). The lower 5s
look super funky, so it'd be great to lose them.
However, given the size differential between the upper and lower 5s, anchorage control would
be a bit challenging (relative to maintaining the molar relationship).
With regard to the drift, you can preserve the maxillary extraction space (which usually is
the problem) with tubing during the leveling and alignment phases (so you don't lose space).
On the mandibular, I'd bypass/step around the 2-2 and retract the 3,4 either with a stiff
continuous arch (like case #1 below), or retraction springs. This will help "burn" some anchorage
as well as unravel the lower crowding.
To minimize tipping/rotation of the 6s during retraction, V-bends in the 1s and 2nd order
(toe-in and tip-back) will help. By the time the crowding is unraveled, if the 7s are in, you could
get on the 7s and control anchorage as required. ■

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