Case of the Month

  • January 2019
    January 2019 by Dr. John Bunkers Please Note:This website is best viewed with the latest versions of all browsers. If you are having issues viewing this, or…
  1. Carol
  2. Uncategorized
  3. Wednesday, 21 June 2017
hi,

I have this young lady coming for a treatment presentation and I have my doubts about clear aligners being the best treatment in this case. I have limited experience with braces but from what I understand you can move posterior teeth forward with better predictability than aligners. This patient already has retruded lips, so not sure that 4-5mm of retraction is going to help her. She's going to look 70! So my questions are:
Would you recommend aligner therapy
Would you leave spaces (ie behind canines)
Do you think closing all the spaces will leave the patient with less lip support or do you think it will be negligible?
I'd love to hear your thoughts
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Carol wrote:
hi,

I have this young lady coming for a treatment presentation and I have my doubts about clear aligners being the best treatment in this case. I have limited experience with braces but from what I understand you can move posterior teeth forward with better predictability than aligners. This patient already has retruded lips, so not sure that 4-5mm of retraction is going to help her. She's going to look 70! So my questions are:
Would you recommend aligner therapy
Would you leave spaces (ie behind canines)
Do you think closing all the spaces will leave the patient with less lip support or do you think it will be negligible?
I'd love to hear your thoughts
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  1. more than a month ago
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Some more pictures
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Dr Perry E. Jones Accepted Answer Pending Moderation
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Carol,
The case has a tooth size discrepancy (TSD). The mesial-distal tooth mass of the upper arch compared to the M-D tooth mass of the lower arch has a defined ideal proportion of about 92%. Bolton's published data places this phenomena as occurring in about 1/3 of population. Higher incidence of TSD has been published in various studies often with a small sample of cases.
There are three modalities used to resolve TSD: 1. Opposing arch IPR, 2. Redistribution of space, 3.Combination of both.
Let's assume you like the labial angle of inclination and labial angles of inclination. If you add lingual crown tipping movements to "retract" the teeth you will alter these angles. The interincisal angle becomes more "obtuse" and the labial angle of inclination more "retroclined".
IPR or excess space may be closed with lingual crown tipping. The above "angle" concerns may mean it is best to use "redistribution" of space. There are many choices for redistribution of space. Space can be left distal to the canine, distal to the lateral incisors (Align's default), equitable around the laterals, for example. Smile design is a consideration as well. The M-D width proportion can often be optimized using space redistribution to help optimize Smile Design, for example using the Rule of Golden Proportion.
The "decision" tree for your case is to assess the labial angle of inclination and inter-incisal angle. Assess the M-D width proportion starting with the Maxillary central incisor width to I-G height proportion. You may wish to use space redistribution with space proportioned to allow post tooth movement restoration. As a restoring dentist, a very nice solution can be maintain an optimal inter-incisal angle, maintain an optimal labial angle of inclination, redistribute the M-D width and use bonded composite resin to close excess space. Many of us have published very nice finished cases using redistribution of space with post tooth movement composite bonding!
Perry
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Hi Perry,

Thank you for your response. Yes I agree that she has a tooth size discrepancy. I did not mention it because the patient is not interested in restoring any teeth. I also did not mention the class II malocclusion since at this point, I do not think we can correct it. I wish this patient came to me when she was younger so we could have possibly caught things a bit earlier and maybe used growth to help correct her bite. I think we can improve her esthetics by creating a more ideal inter-incisal angle without doing too much retraction (leave spaces distal to canines). I am just worried that the residual spaces will be very large. Maybe I can get my partner to place a few implants in there!
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Dr Perry E. Jones Accepted Answer Pending Moderation
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Carol,
I would hate to see the "retroclined" look! If the redistribution space creates a large enough M-D space, if you can create enough proximal root space for implants and if the quality/quantity of bone is sufficient for implants that might be an option. Its a slow process but you can add "Smart Force" feature to help create lingual root torque to compensate for the crown tipping effect and help maintain the interincisal angle and labial angle of inclination.
The intercuspation will be a best compromise, but you should be able to work that out to a reasonable occlusal scheme.

Perry
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