A Case Study by Dr. Noel Ananthan
Patient’s Chief Complaint: A straighter smile without IPR
Hi fellow Smilers. This is Elvia, a case that I presented during the last Advanced Level Webinar and which I want to share with you. Elvia is a 28 year old executive assistant whose CC was that she wanted a straighter smile. The key elements in the initial assessment were the impacted UL canine and the UL lateral incisor in cross-bite. Because we had determined through an oral surgery consultation that the canine was favorably situated for exposure and alignment, the treatment plan appeared to be a textbook 6MS approach: space creation and alignment through IPR and rounding with the addition of bringing the canine down.
However during the consultation/work-up process, Elvia decided that she wanted absolutely no IPR performed as a part of her treatment. Despite my best efforts to educate her (putting on my best ‘co-discovery’ face) that it was safe and extremely conservative, Elvia remained adamant that we carry out treatment without IPR. Even after I told her that the only alternative was an extraction in each arch, she still did not want IPR to be performed.
I chose a staged approach to deal with this case. The first stage was overall alignment and space closure, which took about 3 months. This consisted of:
- extracting the UL first bicuspid and LR central incisor at the braces on appointment;
- placement of second molar biteguards to open the bite to allow the UL lateral incisor to clear the cross-bite;
- lower arch powerchain to close the extraction space; and
- simply ensuring proper wire engagement to correct rotations and allow the brackets and wires to align the teeth.
This first stage allowed me to stabilize the arches, and most importantly the teeth adjacent to the impacted canine, with long ties for anchorage before moving on to stage two which was exposing and engaging the UL canine. Stage 2 involved engaging the arch wire, powerchain and interarch elastics to guide and help movement. Anchorage is a key fundamental concept in orthodontics and learning to both respect and use it makes treatment much more efficient.
Because of the pre-treatment rotations in Elvia’s right anterior area, a further potential problem that we faced (and had warned the patient of) was the shifting of the upper midline as alignment progressed. Unfortunately, there was no easy solution for this so we did see the midline shift slightly to the left, although Elvia was perfectly happy with the end result. I addressed a small black triangle between the LL central and LR lateral incisors which remained from the space closure (and also a potential problem with ‘crossed’ upper incisors) through simple bonding. Elvia was ecstatic with her new smile. She now feels that it better represents how not only she sees herself, but also how she would like others to see her.
I hope that this case has illustrated that 6MS uses sound orthodontic principles to achieve great results, even with complications such as impacted teeth. In hindsight, if I could change anything with this case, I would have taken greater care to manage the presentation of information to Elvia to have made IPR acceptable to her. But that is my dentists’ bias coming through. We always have to respect that there is a real person attached to the teeth that we treat which makes the Chief Complaint nature of 6MS an even greater service and value to our patients.