Orthotown March 2020 - 25

Patients with this type of malocclusion always, always have very large tongues. I'll bet she
has a speech problem as well? Unless she's willing to have a tongue reduction (a far worse surgery
IMO than orthognathics), then you have to work around the tongue.
Really cannot advise extractions. You'll have a devil of a time closing the spaces, and an even
worse time keeping them closed.
If she wants the occlusion fi xed, she's going to have to have surgery. You need to undo what
was done in the first ortho go-round, reopen the anterior open bite, and get the surgery done.
But do not make any promises that this will help her TMJ issues. Because it may have nothing
to do with it.
P.S.: What were the separators for in the first photos? ■

dhmjdds
Member Since: 11/16/04
Post: 3 of 22

1/6/2020

The case was treated without surgery to begin with. I don't see the postortho records, so I
can't comment on how well IA corrected the open bite. Unless you plan on extracting (which
I am not a fan of), I don't know how you will get better results by treating it non-extraction
and nonsurgically. Even with surgery, you can't promise the open bite will stay closed. This is a
retention problem, not a treatment problem.
I have treated some adult open bite cases with extractions, and it works very well, but as
Diane said, the spaces are hard to keep closed. I have done fi xed retention on several to keep
extraction spaces closed. This means you will have to keep up with the case for many years, and
that can be challenging. Personally, I would pass on re-treating this case, especially if the patient's
expectations are high. ■

emac
Member Since: 11/21/11
Post: 4 of 22

1/6/2020

Just a couple of thoughts. Clearly a difficult case. What is the patient's CC? Is it her TMJ issues?
If so, before thinking ortho I'd have a DDS make an orthotic that did not increase vertical and
fill in the open bite areas. If that resolves her issues, at least you know that it is occlusally related.
The first ortho treated with Invisalign, but there are separators in the initial photos: Was
something done before the IA? I would want to see the immediate postortho photos to see how
the case changed. If this patient walked into my office and I didn't know her past history, I am
not sure I would be thinking surgery. Also, the anterior occlusal contact is present, so that part
has been amazingly stable. Clearly you are also fighting myofunctional issues and, as Diane
suggested, possibly a true macroglossia. There has been nothing done that has placed the anterior
teeth in such a poor position: no excessive proclination or retraction, no excessive incisor stomium/
gummy smile. Vertical closed accentuating the Class III. Any further closure will cause more
expression of the Class III. ■

davidharnick
Member Since: 08/28/02
Post: 5 of 22

1/7/2020

Thanks for your input, everyone. CC is TMD pain. She obviously knows her teeth don't
touch on the sides, but the main reason for seeking treatment is the chronic discomfort. I found
it curious that she says she developed the open bite in college. She showed me high school pictures
and it's true, you can see her bite was not as open as it was before Invisalign was started. Although
I suspect her bite was always open, but just got worse with late mandibular growth?
I like the idea of creating a splint that fills in the open areas. Would you send her to an orofacial
pain specialist for this or do it yourself? Would you prescribe full-time wear? Nighttime wear?
As far as the separators in the initial photos, she never had braces but was considering them
before changing her mind and going with Invisalign. She still wears her retainers from her
original orthodontic treatment. They fit and neither her bite nor teeth have shifted since she
finished mid-2018.

NyceBiteR
Member Since: 10/21/08
Post: 6 of 22

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