Today I would like to break the series of theoretical post with a purely clinical one, sharing my first case with Insignia, the customized vestibular braces system that I chose for my practice – not that many alternatives are on the market as it’s the only one at present =)
As with any new appliance that I use, I selected an easy case to start with. The idea of selecting an easy case, is that I could easily find an alternative solution in case of failure of the new device. It’s a motto that my mentor, Dr Redento Peretta, thought me and I apply in any occasion where I’d like to test a new product (that is pretty often!).
I present the case of this young patient that came to me for some minor crowding and a slightly increased overjet. She was the perfect patient on which to try with confidence this new customized bracket system.
Initial photos and x-rays.
Setup. I planned:
- Correction of the cross-bite on right first molars
- Control of upper proclination by distal crown tipping of upper canines and diminished torque of the lateral and central incisors
- Conversion of the v-shaped arch into u-shaped ones
Treatment progression. In light blue the months of therapy, in red numbers the appointments. The treatment lasted 11 months.
Stock Damon .013 and .016 wires were used in the first 3 months. Thereafter only the customized arches from Insignia were used.
Progression. 3 months of treatment / 3rd appointment. The crossbite is corrected before the .014x.025 CuNiTi wires.
Progression. 5 months of treatment / 4th appointment. With .018x.025 CuNiTi arch coordination starts.
Progression. 8 months of treatment / 6th appointment. Working with CLII elastics
Progression. 11 months of treatment / 9th appointment -> Debonding
Final panoramic x-ray. It would have been better to take it before debonding to assess for the mesial tip of the root of 1.3 before debonding. The crown of the upper right canine did not allow to imagine that the root could have been that mesially tipped.
May this be a limit of the library root that are manually linked to the crowns during the setup?
Or just my first experience?
Final lateral x-ray and superimpositions. I was lucky that some residual growth was there during the period of treatment with braces and some CLII elastics. The overbite and overjet were diminished and matched to the planned values.
Final photos. The unpleasant increased overjet and the profile were corrected due to CLII elastics and residual growth. The smile was improved even if the 1.2 is showing a not ideal correction. A torque bend would have for sure been helpful.
Treatment sequence. The treatment finished into 11 months and 9 appointments.
The first 7 months were spent into levelling and aligning. The .013 and .016 wires were CuNiTi Damon arch form stock wires. Wire customization is negligible during the first light wires. The cross-bite was corrected during the first 3 months with Chipmunk elastics (1/8″ 3,5oz) before to install the .014x.025 CuNiTi. From rectangular wires on, the arch was customized according to the arch form that I approved in the setup.
CLII correction started with stainless steel wire and was accomplished in three months with the help of Impala elastis (3/16″ 6 oz).
Rebracketing was necessary to adjust minor discrepancies before debonding.
Take home message. From my first Insignia case I learned that:
- The customized set of bracket worked well in an easy case, specially…
- … I was very happy with lateral intercuspation. What typically happens in a case were I use standard wires during the leveling and aligning phase, is a lost of control of the occlusion in the premolar and molar area (and thereafter it takes time to get back to a good occlusion after the workng phase). By having a customized set of wires from .014x.025 CuNiTi on, I never lost control of the occlusion. The torque of the premolars and molars were expressed in such a way that, once the patient used elastics, it was only a matter of time to get into a very good intercuspation.
- Orthodontics is the art of seeing, as Dr Davide Mirabella never ceseas to say during his lectures. I did not really saw a lack of torque expression on the 1.2, neither I corrected it appropriately in the setup. A customized system helps approaching to excellent results but even if the finishing phase is higly facilitated, the art of finishing still play an important role.
- A control panoramic x-rays may have been higly beneficial before debonding. The crown of 1.3 looked nice into the occlusion, but the root was too mesially tipped. I couldn’t see this in the setup, probably because the standard set of library roots that the technicians “bond” to the crown, is just an aproximation of reality. If we really need complete root control we should provide a CBCT xray to allow the technicians to bond the true roots to the crown.
- I really liked the straight-forwardness of the treatment. I really felt easy to treat this case and achieve a good control of the occlusion. In an period where the treding topic is how to accelarate treatments (and where I keep a skeptic position with regard to vibrations and photobiomodulation), I think that customization of the appliance plays an important role. I think that to be able to provide a good service in a reasonable short time it’s a value for our patients. I am not obsessed for being fast, but I would like to be as fast as possible providing an high quality service, and a customized set of brackets and wires may be really helpful in this sense. This is a big them to be debated. Stay tuned as we will discuss a lot about this!
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