Customization of any orthodontic treatment (not only aligners and lingual appliances) will very likely become the standard of care in a few years.
When I lecture on this topic, one of the main criticisms is that it’s not needed for simpler cases. I personally think that the costs are still relatively high, but obtaining arch coordination from the very first set of archwires is a big plus even for simple cases.
Nevertheless, there is no doubt that a setup for complex cases helps you in visualizing results and in figuring out the most appropriate mechanics to achieve your treatment goal.
When I first met Ilaria, she had already visitedmany other colleagues, and most of them proposed a classic four premolar extraction treatment, which I could fully understand.
Seeing her for the first time when she was 17 years old, I didn’t think that a four premolar extraction treatment was ideal. In fact, being at the end of her growth, I couldn’t count on any contribution from the mandible and I was pretty sure that it would have been extremely difficult to get a full molar CLI relationship. That’s why I immediately accepted mandible retrusion and tried to solve the case working mainly in the upper arch. Upper first premolar extractions could have been a good classic option, but she had a large restoration on the 2.6 and her wisdom teeth were present.
I therefore decided it would be a better idea to extract both 1st molars rather than the healthy first premolars. That said, I was conscious that I could not count on only second molar anchorage to retract the upper arch.
I thus planned an indirect anchorage approach to avoid second molar mesialization, in order to obtain the anterior retraction that I needed and planned through the setup.
By showing Ilaria and her mother the planned setup, it was much easier to explain to them the reasons why extractions were needed (this was their main reason for refusing the previous proposals). Seeing how the extractions space would have been used to serve the interest of the patient, and how no spaces are left at the end, was extremely helpful to obtain their consents to the treatment. They were also positively impressed with how much care was involved in planning a customized solution for Ilaria.
I started leveling and alignment, having the first upper molars extracted only after bonding was performed, in order to avoid any tooth drift that could have impeded indirect bonding.
I then waited until the 4th appointment to bond an indirect anchorage TPA. I typically insert an 8mm paramedian screw and then ask the technician to bend a TPA. I then bond the TPA feet with some flowable composite on the lingual side of the molars. This allowed me toplace a customized tube on the vestibular surface, avoiding the need for bands.
I placed the TPA in a super CLI molar configuration as I know that the TPA is quite flexible and would experience minor anchorage loss.
Once on .019x.025 SS I started to retract the upper premolars.
Interestingly enough the left Brodie self-corrected just by archwire coordination provided by the customized wires without the need of special criss-cross elastic mechanics.
After some months of premolar and anterior group retraction I was stuck. I thus decided to abandon the original wire sequence that I ordered, and I built a “shoe-horn” on a .020 SS to allow easier sliding on the lateral sides.
I was thus able to properly finish the retraction and space closure of the upper arch.
The upper second molars, that served as indirect anchorage for the duration of the treatment, ended in a sound CLI, as planned in the setup.
Repositioning and/or detailing bends are often needed before debonding. I did a progress panoramic radiograph and repositioned as needed. I went back to .018x.025 CuNiTi customized upper and lower archwires before debonding.
The final result was very similar to what was initially planned in the setup.
Retraction was possible thanks to a large intrusive component on the upper incisors, which can be visualized from superimpositions on SN.
Total treatment time was 22 months. Most of this time (10 months) was spent on the working phase, both on .019x.025 SS and .020 SS wires. Any kind of customized treatment needs a keen understanding of active mechanics in order to be successful, whether it is space closure, CLII or CLIII sagittal correction, or open or deep-bite correction. I feel that customization of torque helped me greatly to smoothly manage this case. Furthermore, the initial setup was extremely helpful in showing the outcomes of a complex case, and it can be used as an additional tool when presenting a treatment plan to patients.
We do it for aligners, why not to do it for braces or complex cases treated with any tool?
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