The Melina Project – July, 2015

14-SPEC-012, Melina's TreatmFB DAuthor: Ryan K. Tamburrino, DMD

Predictability. Consistency. These two words are hallmarks for the CCO System and keystones for orthodontic treatment. While the definitions of each are unique, their meanings have to be intertwined in a successful orthodontic practice.

Predictability means that the doctor can have a reasonable idea of the expected outcome prior to even beginning treatment. Consistency means this predictable result happens over and over, patient after patient. One of the biggest treatment planning difficulties I see orthodontic residents and experienced practitioners alike struggle with is planning a difficult case, mainly because they do not understand where a case will finish and what variables can be eliminated from the equation. Without this clear vision in place, it becomes a daunting task to figure out a sensible treatment plan, understand potential limitations to treatment, and properly set expectations to the patient and parent.

“Beginning with the end in mind…” is something I was always told in my training, but, with many of the current diagnostic methods and different treatment systems available, defining the “end” could be highly variable depending on treatment goals and the criteria used to measure them. So, while two different practitioners may have sensible treatment plans for the same patient, they may disagree on how to get there since the frame of reference for defining the finish is different. Even though we are all orthodontists by training, we often find ourselves essentially speaking in different languages!

A hallmark of the In-Ovation bracket and its active clip is the ability to fully express the bracket prescription on 19×25 wire. Since there will little “slop” or “play” in the system, the practitioner can realize the final tooth position on a patient (virtually) before ever placing a bracket on the tooth. Additionally, this position will be repeatable patient after patient. This predictable and consistent information is critical to helping orthodontist know where to “start” with treatment planning.

Using the maxillary incisor, for example, the CCO prescription of 12˚ of torque with a 19×25 wire, will result in a tooth inclination of 57˚ to the maxillary occlusal plane – every time – provided the anatomy of the alveolus can accommodate this position. For the mandibular incisor, the prescription of -6˚ corresponds to an inclination of 70˚ to the maxillary occlusal plane. This predictability of the inclinations, as well as the consistency of achieving them, is what allows realism and confidence with treatment planning.

15-SPEC-001 AAF Edit Ryan's Melina Images-ideal inclination

For Melina’s case, her initial maxillary incisor inclination was 50˚ to the maxillary occlusal plane. Also, for her mandibular incisor, the pre-treatment inclination was 68˚. Knowing that the ideal inclinations of the maxillary/mandibular incisor should be 57˚/70˚, respectively, and that these correspond to the outcome of usual CCO treatment mechanics, we were able to set these tooth positions on our Treatment Design simulations as a starting point. This visualized our goal for her final tooth position and allowed us to see how these movements will affect (positively, negatively, or neutrally) the soft tissue and smiling esthetics for us to make further decisions on her treatment, should they be indicated.

15-SPEC-001 AAF Edit Ryan's Melina Images-Comparison-CO CR Conversion

15-SPEC-001 AAF Edit Ryan's Melina Images-Comparison-Superimpositions

With this quick exercise, we now have extremely powerful information. For one, this shows us what will happen to Melina’s case should we just “place brackets” and do nothing else. Secondly, we have a realistic view of what will happen if we just “place brackets” and, if the result is not acceptable, we can better plan adjunctive modalities to then get the acceptable result versus just “guessing” or doing them “on the fly”. Thirdly, we can have a much more honest and realistic discussion with Melina’s parents if adjunctive modalities beyond braces would be indicated for her treatment, and show, visually, why they are being recommended.

As Melina’s case indicates on the Treatment Design, idealizing her incisors to 57˚/70˚ has them centered in their respective alveoli, coupled at the ideal overbite/overjet, and does not detract from her esthetics. This tells us that she has sagittal and vertical skeletal harmony, the skeletal positions coincide with acceptable esthetics, and allowing the brackets to express their prescription fully will let the case work out nicely.

We have shown previously that Melina has been taken through transverse normalization and the wire sequence for leveling/aligning. At her last visit, maxillary and mandibular 19×25 SS wires, coordinated to her archform, were placed along with chain elastics to consolidate the residual space. This was backed up with short Cl. II elastics to ensure the posterior occlusion remained solid.

15-SPEC-001 AAF Edit Ryan's Melina Images-Pictures 2015 07 06At her next visit (in 12 weeks) we will take a progress image to evaluate for any bracket repositions and we will also be able to visualize the expression of the bracket prescription. We anticipate that, due to the active clip on the 19×25 SS wire size, the incisor inclinations will be very close to the optimal of 57˚/70˚ even with the chain elastics for space consolidation, and the anterior teeth should be coupled at the proper overbite/overjet.

Until next time…keep brushing and keep smiling!

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