Okay, I apologize in for the slightly click-bait title to this weeks blog.
Just before I get some arsy emails – lets be clear – I cannot treat big skeletal discrepancies with ortho, complex or simple. I can’t even treat with surgery – Ill leave that to the specialists!
Here is a case walkthrough of a patient who I treated, and finished treatment about 6 months ago. Here are the pre-ops:
If you actually want to learn a little about ortho, you need to look at these photos, and do your analysis. At least look at the canine classes, overjet, overbite and count the teeth!
If I just give you my analysis, you won’t learn anything – trust me, you only learn by doing, not just by listening.
The Salient Features
So, the most obvious issues here are:
- Class 3 Skeletal relationship
- Full unit class 3 on the left, and almost 1.5 units on the right (canines)
- Overjet is negative, and overbite is normal
- Upper arch spacing, lower arch mild crowding
- Some dento – alveolar compensation for the SK3 base
- Upper midline is about 3mm to the right of the facial midline
- There is a supernumerary left lateral incisor
The thing you can’t see from the photos is that there is a 5+mm pocket between the UL1/2
Because of this, I recommended he see the periodontist for treatment before we started braces. This is important, because he had seen a specialist ortho before coming to me, and one factor for him taking up treatment with me was that I told him about this pocket, and advised that he sees the periodontist!
What does the patient care about?
Now, from a dental point of view, the most obvious thing here is the SK3 relationship, and the best option is surgery. All the patient cares about is how crooked the teeth are!
So we discussed surgery, we discussed extraction ortho, and compensation, and talked about just straightening them.
It turned out that all the patient wanted was to have them straight. He has lived with the reverse overjet all his life, and its not a concern for him!
We also told him about the supernumerary, and that it is an extra tooth (with a funny kink to the root), so we may not be able to get it perfectly straight, and he was happy with that.
To be honest, the supernumerary was a bit of a gift because it helps to reduce the reverse overjet, and its not massively obvious that its there, the shape and the colour of the tooth is pretty good!
So thats our treatment plan sorted, we stuck on the brace, normal labial brace with 3M Gemini brackets:
These photos are straight away after a perio session – but wait – what is that massive growth you can see on the lower occlusal??!
According to the periodontist who was treating him, this is an epulis, or pyogenic granuloma. It can be safely removed surgically, so this is what I did at the end of ortho.
Okay, now we are happy with that, and more importantly, the patient is no longer concerned with it, we can finish the ortho.
Normal wire sequence, probably something like 14niti, 18niti, 20-20niti.
The End Result
So you can see that I got happy with a scalpel, to remove the overgrowth. Apparently this is the best way to remove it. Its the first time I have had to do this, so lets see how this works!
The upper retainer is from 3-3, but because of the supernumerary, this looks really long!
The reverse overjet is also increased, this is because the lower arch has ’rounded out’ and are much more upright.
The most important thing is that the patient is happy.
Could it have been improved?
Clearly surgery would give the best result here. It is possible to tip the lower back with extractions, possibly two premolars or an incisor (personally I would be inclined to take the premolars).
If you noticed, that granuloma didn’t completely go after the initial surgery. I probably didn’t remove it enough the first time around. After the last review, I haven’t seen the patient, but I am sure he will call if this is bothering him. If he does, I will reattempt to remove it surgically.
Any questions/ comments please get in touch as normal!