Pacific Coast Society of Orthodontists Bulletin Spring 2022 - 45

Case Report
How would you treat this malocclusion?
Posttreatment
B.L., 14 years, 9 months
Treatment Objectives
Because the major skeletal discrepancy was
successfully corrected during phase I, the
treatment objectives of phase II were to resolve
the mandibular crowding while maintaining a
Class I molar relationship, attain ideal overbite
and overjet, coordinate the upper and lower
archforms, and improve the smile arc.
Treatment Alternatives
Three options were provided to the patient and
his parents. Each treatment option presented
involved extraction of the L4s to resolve the
mandibular crowding and establish positive
overbite and overjet but varied in appliance
selection and treatment mechanics.
□ Option 1: Comprehensive orthodontic
treatment with traditional braces with
straight-wire and sliding mechanics,
extraction of L4s, reciprocal space closure
using sliding mechanics with power chains,
Class III elastics as needed.
□ Option 2: Comprehensive orthodontic
treatment with InBrace appliance with programmed
nonsliding mechanics, extraction
of L4s, reciprocal space closure using power
chains on power arms as an auxiliary, Class III
elastics as needed.
□ Option 3: Comprehensive orthodontic
treatment with Invisalign with clear aligner
mechanics, extraction of L4s, reciprocal
space closure using the clear aligners, use
of power arms or sectional buccal fixed appliances
if needed to support space closure,
Class III elastics as needed.
Treatment Plan
The patient and his parents chose option 2 to
be treated with InBrace because the patient
did not want to have traditional braces and
would accept only an esthetic treatment option.
The patient's parents chose the InBrace
appliance system over clear aligners because
Figure 6. Pretreatment malocclusion (top row) and InBrace Smile Design with overcorrections
(bottom row)
they were concerned about noncompliance
with clear aligners. This system uses InBrace
Smartwires, which are all programmed 0.014in.
(Smartwire 1) or 0.016-in. (Smartwire 2
and 2A) round NiTi wires with a multiloop
configuration and the special shape-setting
processes. These designs and fabrication
processes make the Smartwire behave very
differently from conventional 0.014-in. or
0.016-in. archwires.
Treatment Progress
The patient's intraoral digital scan and other
records were submitted to the InBrace Smile
Design Studio, and an InBrace Smile Design
was generated (Figure 6). In the patient-specific
InBrace Smile Design, the mandibular crowding
was resolved by extraction of the L4s, and overcorrection
was added in the mandibular arch
to counteract the expected bowing side effect
from premolar space closure; for the maxillary
arch, the U6s mesial out-rotation was put in
place to widen the upper premolar and canine
areas to coordinate with the mandibular arch
and broaden the smile. All InBrace Smartwires
were custom fabricated from the doctor-approved
InBrace Smile Design. The three-dimensional-printed
indirect bonding trays were also
custom fabricated for this patient.
Prior to treatment, the patient was referred
to a general dentist for routine maintenance
and dental clearance to verify that no caries
or periodontal issues were present. Treatment
began with indirect bonding of InBrace brackets
on L7-7. Sectional Smartwire 1 was engaged in
the mandibular arch from L5-7 on both sides
and L3-3, and the patient was referred to have
the L4s extracted (Figure 7A). The maxillary arch
was bonded indirectly later when the patient
had been in treatment for 5 months, because
significantly less treatment time is required for
the maxillary arch than the mandibular arch.
At 2 months in treatment, the L4s had been
extracted, and power arms were bonded to start
space closure with power chains (Figures 7B and
8B). Initial leveling and alignment of L3-3 was
already completed after 2 months, so Smartwire
2A was placed, which has a mandibular anterior
straight-wire segment to keep L3-3 together and
to increase the rigidity and control during retracSpring
2022 PCSO Bulletin
45

Pacific Coast Society of Orthodontists Bulletin Spring 2022

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Spring 2022