Orthotown September 2023 - 54

After identifying the patient's
negative attributes, we proceeded to
use digital smile design templates
that demonstrated ideal positioning
of the upper incisors during her smile,
relative to the smile arc target. Based
on the desired tooth movements in
relation to the face and smile, orthodontic
biomechanics were planned
that would enable us to attain this
desired position effectively (Fig. 4).
To achieve the ideal aesthetic
position for the upper incisors, it
would be necessary to orthodontically
extrude them to a significant extent,
with the open-bite gap being closed
by downward movement of the upper
incisors. The conventional approach
for treating an anterior open bite with
inadequate upper incisor exposure
involves using anterior elastics and
was not ideal because it would result
in both upper and lower incisor
extrusion. Mild extrusion of the lower
incisors to refine the occlusion would
be acceptable after ideal positioning
of the upper incisors was attained.
The decision was to insert two intraradicular
miniscrews (8-by-1.5 mm,
BioRay) distal to Teeth #32 and #42
to facilitate maximal extrusion of the
upper incisors without any unwanted
extrusion of the lower incisors.
Desired upper and lower incisor
position was supported by SAP++
bracket position, and would be
adjusted by repositioning the incisor
brackets as required. Posterior bite
turbos placed on the upper second
molars and PT exercises supported
the mechanics by preventing counterclockwise
rotation of the upper
occlusal plane. Squeezing exercises are
part of the Pitts protocol, in which the
patient clenches on the posterior bite
turbos 60 times, six times a day to prevent
extrusion of the posterior teeth.
We also used tongue tamers on the
lingual surface of the lower incisors to
encourage proper tongue posture and
facilitate effective bite closure.
Treatment was initiated with upper
and lower 0.14-inch nickel-titanium
Pitts Broad archwire. Rainbow 2.5ounce,
5/16-inch elastics were worn
from the two lower miniscrews to the
upper incisors to promote extrusion
of those teeth. Lingual buttons on the
palatal surface of the right premolar
allowed wear of a 3.5-ounce, 3/16-inch
crossbite elastic.
Case progress
After four months (Fig. 5), we progressed
to a 0.18-by-0.18-inch Pitts
Broad Ultra soft NiTi archwire, performed
some interproximal reduction
(IPR) and applied a detorquing power
chain. Additionally, the patient was
asked to wear triangular elastics from
the lower left miniscrew to the upper
left canine and premolar to aid in bite
closure and correct the midline shift.
After six months of treatment
(Fig. 6), we conducted two additional
interproximal reduction (IPR) procedures
and continued use of the
detorquing power chain. The patient
was instructed to maintain the same
elastic wear regimen as before. As we
evaluated the treatment outcome
progress, we could confidently state
that the patient was exhibiting a
satisfactory level of incisor exposure
(Fig. 7), a transformation that
noticeably enhanced her smile and
overall appearance.
After analyzing the pre- and
intratreatment extraoral photos,
we decided to readjust our biomechanics
to achieve further aesthetic
gains based on digital smile design
templates (Fig. 8). It became evident
that our patient would benefit from
increased exposure of the upper
incisors, which necessitated further
SEPTEMBER 2023 | 54 | ORTHOTOWN.COM
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