MODERATE UPPER CROWDING WITH BRIDGE

Question:
This patient has a Maryland bridge that extends from the UL2 to UL4 to replace the missing UL3.  Is it possible to treat this case with the bridge in place or is it better to remove it, move the UL2 and make a new Maryland bridge afterwards?  

Answer:
This is a good case for the Inman Aligner.  You do not have to remove the bridge as the teeth appear well placed.  Ideally, it is best to take it off, but it depends on how the lateral sits in the patient's arch.  It seems to be in a good position.  Without study models, I can't tell if the occlusion will allow the uppers to retract without hitting the lower incisors.  If they collide with the lowers, then you need to treat the lowers first.  If not, it will work fine.  A Spacewize analysis reveals 2.5mm of crowding, which is well within the 3mm recommended for successful treatment.  You can proceed with the IA alone or you could consider adding an Expander to the IA to minimize IPR if you wish.  Also place a composite anchor on the palatal incisal edge of the UR2 and maybe one on the UR1 if the bow skids up.

MODERATE UPPER CROWDING WITH BRIDGE - SLOW PROGRESS

Question:
Progress with this case has been slow.  When the lab made the Aligner, which has an incorporated Expander, they extended it to include the palatal of the UR2 which is part of the bridge and therefore obviously won't move.  I have trimmed the acrylic back from here as much as possible, but if I take more off, the metal wire will touch.  She has been wearing the Aligner for an average of 15 hours a day.  My queries are:
1.  Should there have been some movement by now?
2.  Do I need to have a new Aligner made completely free of the UR2?
3.  Do I need to remove the wing from the UR2 to enable movement here?

Answer: 
From the picture, the upper lateral has moved a bit already.  However, it looks like it is still stuck behind the central.  This is the key tooth.  I would get an anchor on the palato-incisal edge and ensure the palatal bow tucks into it.  Also, it looks like you have been very conservative with your IPR.  I would bet the contacts are fairly tight, thus restricting movement.   I would carry out more IPR to free up the contacts.  How many turns of the midline screw have been performed?  Ideally the patient should be turning it once a week.  How wide is the gap now on the expander?  I would check all these things before removing the wing.

Tags: Moderate Upper Crowding, Suitable Case, Combined Inman and Expander, Composite Anchor, Spacewize Analysis, Bridge, Teeth Not Moving, Problem Solving