Personalised Learning

Patient case study: utilising elastics to address lateral open bites

Pre-treatment IO photographs

Case introduction

" I was very conscious of my teeth prior to meeting my dentist, I would try to cover my mouth during conversation, avoid pictures and smiling "

The patient was a young sports and fitness model who had always been self conscious about his smile and particularly his UL2. It was having an impact on his work and in his day to day life. He was an ideal patient who was highly motivated and compliant throughout. It was a challenging case because the patient didn't just want cosmetic alignment- he wanted a complete smile makeover, but no fixed appliances.

After working through the case with a specialist and discussing treatment options we felt it was appropriate to proceed with clear aligners.

Service: PRO
Initial stages: 21
Wear schedule: 10 days
Extra aligners: 12
Material: single layer PETG
Duration: 12 months

Initial Approach

Treatment considerations

Case Complexity: Complex

We knew from the outset that more than one series of aligners might be needed and made sure the patient was consented for this.

At presentation there was crowding, a narrow upper arch and a class III skeletal pattern with evidence of poor oral hygiene. Stabilising his oral health with patient education and a hygienist appointment was required prior to commencing orthodontic treatment.

The focus of the treatment plan was to align teeth (especially instanding UL2) and expand upper arch to reduce buccal corridors with an attempt to correct buccal segment relationships.

Before & afters from the treatment simulation

During treatment

How did you monitor?

With this case it was especially important to monitor compliance and progress regularly. This was easy using the remote treatment check-in tool. It provided an excellent series of photographs as clinical records so I could track progress between visits which I found useful. As a bonus, it also was a good source of content that I could use for my clinical portfolio. The patient engaged well with this feature and I got positive feedback that he liked the convenience of virtual reviews and the support of regular monitoring. I kept a close eye on things with fortnightly (remote) treatment check-ins punctuated with 6 weekly in-person reviews.


After completion of the initial 21 stages there were bilateral posterior open bites >2mm with contacts on 1s, lower 8s to upper 7s / 8s.

We were aware that lateral open bites were more common in clear aligners (due to intrusion of the posterior teeth with a thin layer of plastic), but I was quite worried about whether we'd be able to fix this!

I was reassured by the specialist that we'd work together to settle the open bites with elastics with refinement aligners. In-person appointments were increased and regular photo updates shared to check on progress.

Lateral open bites after completion of initial 21 stages of treatment

Approaching the lateral open bites

Considerations from one of our specialists

A challenging case due to the bilateral buccal crossbites and a reduced overbite.

A combination of posterior occlusal interferences and the Class III skeletal base have resulted in the bite being propped open. Correcting the crossbites in this case requires controlling the buccal root in the posterior segments to prevent the overbite from reducing further. 

Key Considerations: Ensuring adequate attachments to control root torque and good compliance with elastics. 
Possible risks during Tx: Worsening of overbite causing an anterior open bite if not planned correctly. 
Comment on the final result: An excellent outcome. Complete correction of the crossbite with good interdigitation which will help with stability. 

Aims of refinements

1) Improve the incisal relationship by using IPR in the lower labial segment and retroclining the lower incisors - this will help improve the OB/OJ. 

2) Improving the lateral open bites through the use of multiple button cut-outs and elastics (as detailed below)

Refinement Clear Aligners fitted with button cutouts to accommodate elastics on the 3-6s

Completing treatment

How did you achieve the final result?

I started the whitening during treatment which helped to keep the patient motivated and saved having to create additional whitening trays. The look was with composite bonding, particularly over the upper 2s.

Lessons Learnt

What lessons did you learn which would be useful for a colleague?

It is thoroughly reassuring to be able to work through complex cases as part of a team that includes an orthodontist. I was a bit worried about the lateral open bites when they initially appeared, but through discussions with the Specialist I felt confident in managing this with support.

Elastics were something I had only used a couple of times previously, and never in this arrangement, but I found them to be an exceptionally effective tool that achieved a great result.

Patients are willing to stick with you through long courses of treatment and really appreciate the work you put in to get the results they want. It was really rewarding to get to the end and this patient was so pleased with the outcome!

" Honestly could not recommend the service enough. One of the best investments I have made. I was very conscious of my teeth prior to starting treatment, I would try to cover my mouth during conversation, avoid pictures and smiling. The level of attention and commitment to gaining me the best result possible is what differentiated 32 stories and my dentist in particular, they went above and beyond and I am very grateful. ”



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