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Dental Tribune Middle East & Africa Edition | 3/2017 ORTHO TRIBUNE E5 ◊Page E4 CASE STUDY 2 PERIADOLESCENT ALVEOLAR MODELING: Pretreatment Diagnosis An 11.5-year-old female patient pre- sented with a Class I jaw relationship and severe tooth size/arch length discrepancies with 9 mm of crowd- ing in the maxillary arch and 15 mm of crowding in the mandibular arch. Her mandibular incisors were up- right at 89° to the mandibular plane and she exhibited normal circu- moral muscle tonus and competent lips. Her parents wanted to attempt a nonextraction treatment plan. In- formed consent was obtained and a therapeutic diagnosis was initi- ated with a reassessment planned for approximately 6 to 9 months to determine if the nonextraction attempt could continue or if extrac- tion would be required. Treatment Summary Damon protocols were employed with initial .013” Copper Ni-Ti wires and NiTi open-coil springs activated one-half-of-a-bracket width to begin to create space for the unbracketed, blocked-out teeth. Eyelet attach- ments were placed on the lingually blocked-out teeth and lightly ligated to the coil springs with enough force to minimally defl ect the archwire. Since the alignment at the 10-week appointment was deemed insuf- fi cient to engage a larger wire and comfortably close the bracket door, the initial wires were inspected for deformation and replaced. The springs were then reactivated, the blocked teeth religated and the pa- tient reappointed for 8 weeks. Although in signifi cantly crowded cases the transitional wire is typically a .018” Copper Ni-Ti wire engaged in preparation for a .014” x .025” Copper Ni-Ti wire, at the 18th week bracket alignment was again deemed insuffi cient for rectangular wire engagement so a .014” Copper Ni-Ti wire was placed, the springs were reactivated and the blocked-out teeth religated. At subsequent appointments as space was created, initially blocked-out teeth were bracketed and engaged with .014” Copper Ni-Ti wires. At 8.5 months, the decision was made to continue with the nonextraction treatment plan. This severely crowd- ed case did not progress beyond the .018” Copper Ni-Ti wires until 12 months into treatment. Results The fi nal result was obtained after 23 months of treatment. Retention included bonded lingual wire retain- ers and clear, vacuum-formed Essex- style removable retainers to be worn while sleeping. Sizecorrected lower occlusal photographs taken at initial bonding and debonding illustrate the change in the size and shape of the mandibular alveolus induced by passive self-ligation treatment. By the three-year posttreatment follow up appointment, teeth #8 and #9 had been crowned and the bonded maxillary lingual wire had been re- moved. The patient reported infre- quent removable retainer wear and the alveolar modeling obtained had remained remarkably stable. PERIADOLESCENT ALVEOLAR MODELING: Pre-/Posttreatment Comparison Demonstrates Alveolar Modeling PERIADOLESCENT ALVEOLAR MODELING: Results PRETREATMENT POSTTREATMENT 3 YEARS POSTTREATMENT CASE STUDY 3 ADOLESCENT ALVEOLAR MODELING Diagnosis A female patient age 13 years, 5 months presented with a Class I mal- occlusion, crowding and constricted dental arches. Her case illustrates how muscular imbalance can have a constricting impact on the development of den- toalveolar bone. The collapsed buccal segments and retroclined mandibu- lar incisors are indicative of the infl u- ence of hypertonic buccinator and orbicularis oris muscles. Treatment Summary The key element in cases like this are the leveling sequence and the use of turbos for disarticiulation. It is essential to stay in round wires at least 6 months to give the muscles adequate time to rebalance; that is, to change the balance of forces between the overpowered tongue muscle versus the muscles of the lips and cheeks. With passive self-liga- tion, muscles become an ally in treat- ment similar to the way the Frankel assists transverse development. The wire sequence in this case (both arches) was .013”, .016” and .018” (6.5 months) Copper Ni-Ti followed by .014” x .025”and .018” x .025” Cop- per Ni-Ti (8 weeks each). The case was fi nished in .019” x .025” TMA (upper) and .017” x .025” TMA (lower). Results The case result was obtained in 19 months. The light, biomechanical load transmitted to the alveolar bone with a fi xed, PSL appliance combined with small diameter, low-modulus- of-elasticity archwires demonstrates alveolar bone modeling as the teeth uprighted in the transverse dimen- sion similar of the patient’s man- dibular arch. ÿPage E6