Personalised Learning

Sometimes a deeper look is worth it!

Below is a case example that proves how the patient’s main concern can turn a visually simple looking case into a more than what meets the eye!

Patient Motivations

Jada presented to the clinic motivated by correcting her upper front teeth. In particular, Jada felt her upper teeth are set back and she doesn't like the look of them from the side.

Orthodontic Diagnosis

  • CL 2 Division 2
  • Undersized laterals (Bolton Discrepancy)
  • Spacing lower (5mm)
  • Retroclined upper anterior incisors
  • Skeletal asymmetry with chin point to the R
  • Convex profile with high lower lip
  • Deep bite
  • 1mm overjet

Dental/Social History

  • Previous orthodontic treatment
  • Extraction of upper premolars
  • Calculus bridge

Initial records:

Case Overview

From an initial glance, you could think that this case is relatively straight forward and easily treated with aligners. That is true if the patient specifically wanted alignment and lower spaces closed (while maintaining the deep bite and inclination of teeth); however, in this scenario Jada wished for a more full smile and proclination of her upper teeth. These wishes are not realistically possible with aligners alone— why?

Upper arch: Jada had previous orthodontic treatment and appears as upper premolars were extracted. This should alert you that she must of had even more of a CL 2 profile/tendency when she was younger and the treatment plan at that time called for camouflage treatment by extracting upper premolars. Further besides just missing two teeth on top, given Jada’s laterals are undersized, there is a further discrepancy in tooth structure on the upper compared to the lower. Therefore, in order to maintain complete space closure on top the arch appears ‘constricted’ and that is what Jada is seeing with her upper front teeth being retroclined.

Lower arch: Jada’s lower arch is also tricky. She presents with spacing, which when you already have a deep bite is unfavorable in terms of mechanics. Reason being, as you close spaces, the arch constricts which contributes to deepening of the bite. As a result, closing the spaces on the lower would not only increase the overjet but also increase the overbite.

Caveats to consider from the specialist:

Proclining the upper anterior teeth to meet Jada’s wishes would result in (1) spaces forming on the upper (2) and an increased overjet (ie. a class II div 1 occlusion) Further, due to the pre existing spacing of the lower arch, the lower incisors may need excessive proclination in order to mask the overjet. With Jada’s thin biotype this is risky and could result in an unstable occlusion with a high chance of relapse, minimal improvement from her existing arrangement and gingival recession.

Additionally, 8s appear over-erupted with no lower contact it may be wise to extract these non functional teeth before Ortho, should a specialist take this on with fixed appliances

Overall Recommendation: Referral to specialist for eval with fixed appliances and/or surgery.

If you were to treat this case with aligners without looking deeper into the details, yes you’d have good alignment and spaces closed but you’d most likely have one unhappy patient as her main concerns would not be addressed! We are here to help so that doesn’t happen 🙂

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