Orthotown June 2021 - 29

Should have been surgery from the start. Three-piece maxilla due to the step in the occlusion
from U3-3 and U4-7 bilaterally.
While I think Dr. Ruff is excellent, I disagree with the notion of doing surgery only on patients
who look like they need surgery. Either you can safely fi t the teeth together without surgery or
you cannot. In this case, nonsurgical treatment should not have been attempted in the fi rst place,
that was a huge anterior open bite. ■
1/6/2020
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 fi rst 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. Cause it may have nothing
to do with it. P.S. What were the separators for in the fi rst photos? ■
The case was treated without surgery to begin with. I don't see the postortho records, so I can't
1/6/2020
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 nonexo 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 exos and it works very good, but as Diane said,
the spaces are hard to keep closed. I have done fi xed retention on several to keep exo spaces closed.
Which means you will have to keep up with the case for many years and that can be challenging.
I would pass on re-treating this case. Especially if the patient's expectations are high. ■
1/6/2020
Just a couple of thoughts. Clearly a diffi cult case. What is the pt's CC? Is it her TMJ issues?
If so, prior to thinking ortho I would have a DDS make an orthotic that did not increase vertical
and fi ll in the open bite areas. If that resolves her issues, at least you know that it is occlusally
related. The fi rst ortho treated with Invisalign but there are separators in the initial photos? Was
something done prior to the IA? I would want to see the immediate postortho photos to see
how the case changed. If this patient walked into my offi ce 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 fi ghting 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
stomion/gummy smile. Vertical closed accentuating the CL III. Any further closure will cause
more expression of the CL III. ■
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
orthotown.com \\ JUNE 2021 29
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