Case 3 - Class 1: Spacing, crossbite, bi-maxillary proclination. Fixed Appliance Plan: Non-Extraction

Hi. So welcome back to the ortho playbook. Let's get into this case. Okay. So this is a class one case with spacing and a crossbite, and we've got one plan for this that I'm gonna go through. So for this patient, the main complaint is they didn't like the spacing, and they didn't like the proclination of their teeth. They had bio maxillary proclination. They felt that both their teeth were just pointing forwards too much. Patient was about fourteen years old, fitting well, no history of habits or trauma. Skeletally, they were class one but with bimaxillary proclination. Everything else was average. The nasal label angle was reduced, which is quite common in Afro Caribbeans, and the smile line was high. So intraorally, oral hygiene, you can see, is quite poor. Definitely need to work on that before we even start. In the upper arch, we've got upper seven to seven present with spacing, and the same in the lower, seven to seven present with spacing. So the incisor classification is class one bimax with the lower incisal edge resting on the cingulum plateau of the upper incisor teeth. The overjet was average. The overbite was average, ever so slightly reduced though. The upper centreline was correct to the mid face and it was the lower centreline that was to the right by about three millimeters. The canine relationship on the right hand side is about quarter class two and the molars were half class two and then on the left the canines were quarter class two and the molars were class one. Now in terms of crossbite, there was a crossbite affecting the upper right two and three and they had a displacement to the right of three millimeters. That's what caused the centreline discrepancy. So when the patient opens up wide, their midlines matched, centrelines matched. It's only when they closed that they displaced or deviated to the right by three millimeters. So the incisor relationship inclination was they were bimaxillary proclined compared to their maxillary and mandibular bases. And the occlusal plane was relatively flat, a very normal furthest spay there. The main thing is the large diastema that was present and they did have a blanching frenum. So when you pulled on the frenum, pulled the lip forward, the frenum attachment blanched palatally to show that the tissue connected all the way across. So my problem list, this is my standard template that I use to make sure I don't miss anything in my diagnosis. These are all the features of the malocclusion that I would pick out. Just anything that varies from an ideal occlusion. And so for this patient they had bimaaxillary proclamation extraorally with a high smile line. The incisors were class one and there was a cross by affecting upper right two and three with a displacement of about three millimeters to the right. So there was upper and lower spacing. The overbite was slightly reduced. The centerline was displaced to the right in the lower arch by three millimeters. The canines were quarter class two and the molar on the right was a half class two. And there was bimaxillary proclination and a blanching frenum. So that's the orthodontic diagnosis for this patient. OPT showed no pathology, normal bone height, and root lengths, and all the wisdom teeth were present. So no concerns there. So my treatment aims for this patient. This is my standard treatment aim template for an ideal occlusion. So personalizing for this patient, they need to, first of all, achieve excellent oral hygiene and be able to maintain it before we start anything. And then I don't need to relieve any crowding because I've got spacing. And I wanna level and align the arches. I just basically make sure all the contact points are all lined up. And I wanna achieve an average overbite, so just correct this ever so slightly. Wanna maintain class one canines, and I wanna achieve full unit molars left and right, get the canines molars to class one. Achieve my class one canines, maintain full unit molars, and I wanna maintain class one incisors with an average overjet and ideally correct their inclination. I want to achieve coincident centerlines, get my centerlines to match up, and I wanna coordinate the arches. I wanna correct the crossbite, basically correct all that crossbite. I wanna leave no residual spaces. I wanna close all the spaces, then I'll finish in detail, I'll finally retain all of these changes. So next is the ortho gearbox. This is my simple hack for orthodontic decision making. And it is these basic the questions I ask to find the mechanics that I need to build a plan that I can trust in the order that I usually treat cases. So for this patient, I ask myself, how am I gonna relieve the crowding? We don't need to. It's non extraction. How am I gonna level and align the arch wires? I'm going to do, standard aligning arch wires. I don't think I'll actually need lace backs in any of these quadrants to align them, so I don't think we'll need any lace backs for this case. And for the overbite, I'm gonna do my anterior open bite mechanics. Now we've got a reduced overbite. I don't think it's major, so I don't need to use all of these, and probably just a small combination of them. So the main thing is that I would stay in a lower round wire, and that's an o one eight steel is what I would work up to. So I'm not gonna do rectangular wires in the lower arch. And I would have an anterior vertical elastic component. So whether that's a class three or class two elastics with a vertical component or an anterior box elastic or an anterior v elastic, like from the upper four to the lower four to the upper three, or an inverted v goes from the lower four to the upper three to the lower three. Any combination just to have an anterior vertical force because I feel as this flattens out even more, then you can develop an anterior open bite. And that's why I wanna stay in a round arch wire. I wanna maintain this curve of spine, and I'll use anterior elastics to keep this down. And I'd reassess for extractions, and you consider the fives for, an anterior open bite if this got worse. In this case, I really don't think we need any extraction, so I would like to avoid it at all possible because we've already got space. So I really don't wanna take anything else at all. And then in terms of the canines, so ideally, I wanna achieve class one. Sometimes we can accept slight class two. The main reason we want class one is it helps us get our incisors to class one. But if we are prioritizing the overjet, sometimes I'll accept a slight class two. So I'll use my standard class two canine mechanics. So that would be power chain from the upper six to the upper threes and power chain lower three to three. And what that's gonna do is just retract these upper canines back, bring the lower canines forward, help correct this to a class one canine relationship. I would also do some class two elastics from the lower six to the upper three, but I would add that vertical component. So I'll go down to the lower three as well. So it would look like this. Just one elastic goes up and down, and I'll get them to wear that full time, but stop if they start biting edge to edge. That means they've overdone it. So just tell the patient, wear it all the time. And if you start biting on the tips of your teeth, stop your elastics, and that will drop back down. And then for my molars, how am I gonna achieve class one molars? I would use my class two molar mechanics. So that's just gonna be my elastics, my class two elastics to help correct this out here. Again, time, but stop it fighting edge to edge. And then for my incisors, so I'm gonna expect a class one finish. I might do a little bit of work to make sure we achieve that, but I would expect a class one finish. So I would work to upper nineteen twenty five stainless steel arch wires. Normally, it'd be upper and lower, but I am staying in an o one eight stainless steel, a round arch wire because of the risk of an anterior open bite. So these are gonna be my working arch wires. And I'll do power chain six to six to retract the incisors, close all the spaces, and reassess for IPR, which we're just not gonna need in this case. And I would monitor the overjet, and I'd use class two or class three elastics if required. Especially when you've got a lot of spacing and you've got class one, when you close the spaces, sometimes they can close at slightly different speeds or rates, and so you might end up a bit class two or class three. And so you would just do the class two or class three elastics if required. And then for the centerline, I would do an anterior cross elastic if required, but I would, wait until I've corrected the crossbite first before doing that because I feel that this sense line discrepancy is mainly due to the crossbite. And once that's corrected, I expect it to be normal. So I don't think we would need much. And so for the crossbite, I would do buccal crossbite mechanics. So in the upper arch, I'm going to expand the upper arch wire and contract the lower arch wire to try and correct this crossbite, and I would stay in a lower o one eight in in a lower round wire. So I'd work to an o one eight stainless steel arch wire because that's gonna let all of these teeth roll inwards, especially with the power chain. Whereas this rectangular arch wire, it just kind of broadens everything out. So I would work to a nineteen twenty five steel in the upper and an o one eight steel in the lower, and that's just gonna help correct this crossbite relationship there. Then finishing would just be my standard finishing. So do any repositioning or finishing bends as required. I like to finish on upper and lower o one eight stainless steels, especially if there's any lateral open bites. And I'll do power chain six to six to close the spaces if there's any left and just my zig zag elastics as required. And again, an anterior cross elastic if I needed teeth for the centerline, but hopefully we wouldn't need that. And then I'd finish with upper and lower Essex retainers, vacuum form retainers, plus a bonded retainer if the oral hygiene has been good. I really want a bonded retainer in this case because the relapse rate is really high, and so it would be like belt and braces to have the bonded retainer plus the vacuum reform retainer. And I would consider a frenectomy for this patient if they would be, willing to do so just because the renal tissue runs all the way through, and so that increases the risk of relapse. So I would do that, and that can be before treatment. It can be at the end of treatment. It doesn't really matter. Treatment options. I would, number one, is always leave a monitor. Number two for this case is non extraction, open low fixed appliances, and retain. The main risks are an AOB and the centerline discrepancy that are additional to the normal standard risks. So I'd use my AOB mechanics. I'd use my crossbite mechanics and the centerline mechanics as we discussed previously. So let's look at it step by step in the ortho plan. So I would start off with upper and lower o one four night eyes. My standard aligning arch wires are on all the teeth. I don't think we would need any lace backs in this case. If we did if the patient was biting on the brackets, then I would do posterior bite blocks, just like little bits of GIC or composite on the upper sixes just to pop them open as small as possible. And I would just retie until it was passive. I don't think I would need an intermediary wire, so I'd go straight onto the next arch wires, which would be an upper eighteen twenty five night tie and a lower o one eight steel. I would do power chain up to two to two as there would be space there, and I'll do anterior vertical elastics. So if this did open up, then I'll do some anterior vertical elastic like a box elastic just to help correct this here. Having the rectangular arch wire is gonna help with this, to expand this upper arch wire and staying in a round is gonna help, to contract the lower arch wire as well. And then I'd work up to a nineteen twenty five steel in the upper and an o one eight steel in the lower, and I would expand the nineteen twenty five steel. So I'll make the arch wire really big when it's outside the mouth and then tie it in, and it's gonna help expand the arch wire, the arches. And I would do power chain upper six to three to retract these canines back. I'm trying to get them to class one. Keep the power chain up at two to two, replace it, and do power chain lower three to three. Bring these canines forwards in the lower, canines back in the upper, get a class one canine relationship. And I would do or alternatively, I would do asymmetric power chain in the lower. Now I really feel that this centerline is due to the centerline shift. But if you've got a case where it's not due to the centerline shift, you correct this center this crossbite, and they've still got this centerline shift. When you've got space, you wanna kinda compound it and utilize it best time to get this centerline matching before all the space is gone. So what I would do then is do the power chain from the lower left six to the lower right two, and that's just gonna bring close the spaces and bring the center line back to the middle. And I would do my class two elastics to help get the canine to class one with a vertical component. So you do quite lot when you're in the working arch wires. This is why they call them the working arch wires. You're correcting your overbite. You're getting your canine to class one, and you can address the centerline as well if it's significantly off. And I would reassess for IPR or extraction when the crossbite is corrected. In this case, I know I'm not gonna need it. But if you've got a similar case, you correct your crossbite first, and then you reassess for IPR or extraction and how you're gonna manage everything else. And then you consider your anterior cross elastic if you needed to once that crossbite is corrected. And so the next stage is very similar, same arch wires, but we've basically once our canines are class one, overbite is corrected, now we wanna correct the incisors, most enclose the spaces. So we're just doing power chain six to six. Close all the residual spaces now, and we will keep the class two elastics with the vertical component if required. So it's at full time or nighttime only. So when you're trying to make a change, I would wear elastics full time. And if you are just trying to maintain the changes that you've already achieved, then I would wear the elastics night times only. But always tell the patient to stop class two elastics if they're painting edge to edge because they've overdone it, and it should relapse back down. And then I'll finish in my upper and lower o one eight stainless steel arch wires, do any finishing bends or repositioning, definitely keep the power chain six to six, and do any settling zigzag elastics or an anterior cross elastic if required. And then I would debond with vacuum foam retainers plus or minus the bonded retainer. Would really want it, but it would depend on the patient's oral hygiene. If it was poor throughout treatment, I wouldn't. It's not worth the risk. But if it has been good, then I would definitely give that and put the vacuum foam retainer on top, and then plus or minus the frenectomy if the patient's willing. And that's how I would manage this case.

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