Evaluating Orthodontic Progress and Compliance
Question:
I have a 12yo female pt. Interesting case... congenitally missing 25, severe over crowding, have had the initial set up and the mid course correction helped through the clearly portal for this case but I'm struggling getting progress with some of the suggestions that have been made for her... she did have a wicked posterior crossbite occuring on her right side so we have been trying to sling crossbite elastics on her right side from the 14/15 palatal to the buccal of the 45/46. Then we were slinging class III elastics from the palatal of the 16 and the buccal of the 44...
Issue is that her 15/16 palatal buttons keep falling off (i believe because she predominantly chews on the right side due to the large gaps on the left) and the short clinical crowns of the 15/16 do not allow for adequate bonding surface....
My other issue is the 13 is just NOT coming down... we have tried buccal and palatal attachments, previously had elastics too but im wondering if we need to use a heavy gauge elastic to physically pull the 13 down into the arch... she is overcrowded on this upper righr anterior region so that doesnt help either as I'm sure she is probably binding with the neighbouring teeth as well....
It's just a bit of a struggle and I feel like we are seeing her back every few months because buttons are falling off or that 13 is going off track again etc....
For the record her compliance is good.... just got a very tricky mouth with teeth that dont seem to move well considering how young she is.... any insights would be helpful
Orthodontic Case Discussion: Upper Right Canine and Patient Compliance
Overview
This case discussion centers on challenges related to button debonding, potential ankylosis of the upper right canine, frictional resistance between teeth, and issues of patient compliance affecting tooth movement and treatment progress.
Button Debonding and Recommended Materials
In cases where buttons repeatedly detach, it is recommended to use precision buttons available from precisionbuttons.com (as referenced in the treatment handouts).
The metal mini button is typically large enough to be placed on a premolar. In addition, there are clear buttons designed specifically for premolars, also available through Dynaflex. These buttons are known for their superior strength and durability and are considered the most reliable option when buttons continue to come off.
Evaluation of the Upper Right Canine
When assessing the upper right canine, there is always the possibility that the tooth could be ankylosed. To evaluate this, the clinician should percuss the tooth and listen for a dull thud, which may indicate ankylosis.
The next step is to determine whether there is friction between the canine and adjacent teeth. Although in this case it does not appear that friction is present, the clinician can still reapply a button to the tooth and use a vertical elastic to assist in pulling it down into alignment.
The key priority is to verify the absence of interproximal friction, as friction can impede movement. Given that the tooth already has double attachments, there is no need for significant biomechanical changes. The main focus should be ensuring that there is no friction and confirming whether ankylosis is present.
Assessment of Tooth Movement
Upon reviewing the overall progress of tooth movement, it is evident that some degree of change has occurred; however, this raises questions about the patient’s compliance level.
When examining how the lateral incisors have moved buccally into the arch, the movement achieved so far is moderate. Although there has been definite improvement compared to the initial positioning—where the laterals were more severely blocked out—there remains substantial movement to complete.
Thus, while the teeth have moved, the rate of progress appears slower than expected. This suggests that compliance may be acceptable, but not optimal. It remains uncertain whether the patient’s aligner wear and elastic use have been consistent enough to achieve the desired level of progress.
Canine Progress Evaluation
In reviewing the position of the upper right canine compared to earlier stages, the tooth has not demonstrated significant progress. When compared to adjacent teeth—such as the laterals and premolars—the canine remains relatively high and has not descended as much as anticipated.
Given the tooth’s initial location and the mechanical setup in place, this lack of progress further supports concerns regarding patient compliance. There is no apparent biomechanical reason that would prevent the tooth from moving as planned, suggesting insufficient or inconsistent aligner wear or elastic use.
Retention and Biomechanics
The patient currently has multiple attachments on the T-zone, which should contribute to good tray retention, arch development, and expansion. The elastics are correctly set up, and while failure to wear elastics will naturally cause delays, it should not significantly affect the fit of the aligners themselves.
The treatment plan includes:
Bringing the upper right canine down,
Ensuring no friction between adjacent teeth, and
Expanding to correct any crossbite.
However, these goals are dependent on consistent patient compliance.
Conclusion
In summary, the clinician’s main observations are:
The patient’s buttons should be replaced with precision buttons (preferably the metal mini or clear Dynaflex options) to prevent further detachment.
The upper right canine should be evaluated for ankylosis through percussion testing and assessment of potential friction.
The tooth movement progress suggests that while mechanical setup is adequate, patient compliance may not be at the desired level.
The presence of appropriate attachments and elastic setups should be sufficient to achieve the intended movements, provided that the patient adheres closely to prescribed wear times.
Ultimately, this case highlights the importance of differentiating between biomechanical limitations and compliance-related factors when evaluating slower-than-expected orthodontic progress.