Orthotown March 2022 - 32

Much has changed for me as a clinician
since just a few months after graduating,
but if there's one thing that has not, it's
that I'm willing to push the boundaries
of what we've been told is possible while
setting realistic, albeit sometimes very
diffi cult, goals and expectations. I think
this is the world we should all live in. It's
OK to use the knowledge you already have
to cautiously and intelligently move away
from the limits the existing evidence has set
for you. That's an important point: existing
evidence. Sometimes what you're doing is
going to be the evidence, and you can and
should pursue that path. We all have an
opportunity to change lives in this fi eld,
and this case an example of that.
Diagnosis
As previously mentioned, the list of
problems for this 18-year-old patient is
lengthy, including:
* Narrow maxilla.
* Irregular mandibular arch.
* Severe crowding.
* Severe anterior open bite.
* Severe overjet.
* Bimaxillary protrusion.
* Lip incompetence.
* Improper tongue posture secondary
to malocclusion.
* Posterior cross bite.
* Severe reverse curve of Spee.
* Excess posterior gingival display.
* Reverse smile arc.
* Impacting 8s.
* Excessive lower third of the face.
* Steep mandibular plane angle.
The patient's main concern was correcting
the crowding and open bite but he was
wholly unwilling to pursue surgery, despite
a long discussion with someone who has
been through orthographic surgery himself
(me). He mentioned that he was open to
removing teeth, but that was the extent of
his tolerance to orthodontic care.
Treatment goals
This is where the outside-the-box
thinking comes in, and I want to take a
32 MARCH 2022 // orthotown.com
moment to highlight the " why " behind
my thought process before I focus on the
" what " and " how. "
In the orthodontic profession, for reasons
I fi nd diffi cult to explain, most of us are very
focused on obtaining perfection. It's silly,
really, when you think about that because
perfection is nearly unattainable. So why
are we so hell-bent on getting there all the
time? And do we really think when we
fi nish treatment that our results are actually
perfect? I know some amazing orthodontists
and I don't even think they would agree to
the latter statement; there's always room for
improvement and some situations are just
not set up for perfection.
However, we can do one of two things
to get the results both we and our patients
desire. One option is to redefi ne perfection.
Is perfection an ideal Class I malocclusion,
with a beautifully broad smile, narrow buccal
corridors and 2mm of gingival display? For
many it is, but for others maybe perfection
is being able to chew again, simply being
able to close their lips without struggle, or
looking in the mirror and loving what they
see even if they have a crossbite.
My point is this: The perfect result looks
different for everyone in every situation. The
second option is to simply understand that
even if your goals are lofty and you did not
arrive at all of them, improving someone's
life is a great thing that we should be happy
about. Let me be abundantly clear: I am not
saying we should compromise our results;
I'm simply saying that if we look at things
differently, we can create situations where
everybody wins.
Treatment progression
When I started this case, I was going to
attempt to correct all of the aforementioned
issues without extracting any teeth. (This
was young and naive Dr. Mike! I would not
even consider that today.)
I started by bonding all teeth except for
blocked-out U2s and L3s. We use Damon
Q2 brackets in the practice, and I chose
standard torque U2-2, low torque L2-2,
and high torque 3s. (Today, I would use
standard torque on the L2-2, to prevent
the lower incisor roots from moving too
far facially and knowing that extractions
are in the future.)
I placed 0.014-inch copper nickeltitanium
(CN) wires and used nickel-titanium
(NiTi) open-coil springs to make space for
blocked-out teeth and 3/16-inch, 3.5-ounce
triangle elastics (Fig. 3) to start closing down
the bite. In hindsight, I should have run
these from U3s to L3-4s, and not L2-4s
the whole time. I think that made it more
diffi cult to develop the arch and make space
for blocked-out L3s.
Thankfully, I realized about fi ve months
in, which was only a few appointments, that
there was no way this could be corrected
without removing teeth. I believe this is the
most critical decision I made in this case. I
discussed extraction of all 6s with him, and
Fig. 3
http://www.orthotown.com
Orthotown March 2022

Table of Contents for the Digital Edition of Orthotown March 2022
