By Jason Tam
We just saw a nearly 18-year-old new patient as a 4th opinion. Usually I am a bit wary of these, especially if they have traveled some distance to see me, but hey, I had time. She had been to two other orthodontists in the city as well as to the clinic at the ortho school. This patient had some overjet, severe crowding in the mandible and mild crowding in the maxilla. Her lips were not at all full and, if anything, the upper lip is thin. Overall, I’d say most laypeople would say she looks pretty good. The previous treatment plans included a range – removal of two upper premolars, four premolars and jaw surgery.
As I alluded to in my post in Ortho101 about angle classification, my treatment philosophy is to treat to the upper lip. Due to the position of the upper lip, I did not want to remove upper teeth on this patient. I don’t care if I can get to Class I canine if it means a bad facial profile. In the lower arch, it was a borderline extraction case, so I discussed the option of IPR or a lower incisor if needed. I discussed the possibility of some residual overjet, with full correction requiring surgery.
Mom then asked the question, “Why do orthodontists think it is so important for the top teeth to touch the bottom in the front? I want my daughter to have straight teeth and I can’t even believe someone would suggest surgery.”
At that point I discussed with her that some people don’t like to have their top teeth sticking out from the bottom, and how the teeth fit together, but as her daughter is not growing anymore, the only way to move her bottom teeth/jaw forward would be surgery, because we don’t want to move the upper to the lower. I showed her my own teeth and how my upper is forward of my lower, how I was told to take out two upper premolars or do jaw surgery, but decided to straighten my teeth.
Mom said she couldn’t believe it took until her fourth consultation and required her to travel out of the city for a doctor to understand what she wanted. As I write this post, her daughter is getting braces and mom is having records taken as a walk-in consultation.
Thanks for sharing this case and your insights with everyone Jason. I understand what mom wanted and you were willing to do matched but here’s the question – when the crowding is corrected – will she have periodontal issues long term? I Know a few periodontists who have shown me cases where the teeth were aligned without extractions or surgery and they have resulted in recession of the gingiva in the canine and premolars area due to the tipping of teeth. I am not saying that it will happen in this case but I just wonder if long term perio health factored in these cases of crowding
Great question! As mentioned in the post, we discussed the possibility of IPR or a lower incisor. The reasoning here is not simply for unravelling crowding but also with considerations of the periodontium.
You may consider POPA in this case.