20 y.o. Female with An OpenBite and Posterior Crossbite
SUBJECTIVE: She presented with her mother with concerns of an open bite. They had previously had a consult with the orthodontist who originally treated her, but were told there wasn’t anything he could, “sorry, we can’t help you”.
OBJECTIVE: She had bonded retainers from #7-10 and #22-27 with no other removable retainers. She demonstrated a slight Class II right, and Class I left malocclusion with associated lower midline deviation to the right. Her upper arch was tapered and exhibited a cross bite involving #4, 5, 28, 29. Her open bite extended from canine to canine, with a reverse smile arc, proclining upper centrals and constricting laterals. #22-27 demonstrated intrusion relative to the premolars. Her tongue sat low and forward at rest with spontaneous anterior tongue thrust on closing, swallowing, and smiling. Her mandibular plane angle was normodivergent, with proclined and protrusive lower incisors.
ASSESSMENT: Treatment goals were to:
- Encourage improved tongue posture to allow spontaneous and orthodontic bite closure.
- Remove the bonded retainers.
- Broaden the upper arch to address the cross bite and allow autorotation of the mandible, thereby aiding in bite closure.
- Extrude the upper and lower anteriors to aid in bite closure.
- Option 1: Upper clear/lower metal brackets.
- Option 2: Upper and lower Invisalign.
- The option to restore #7 was presented as well.
- Estimated tx time: 18-20mo.
PLAN: Patient elected to proceed with Invisalign and esthetic restoration on #7.
Treatment
Following discussions of proper tongue placement at the consult, She saw some spontaneous closure of the open bite prior to Invisalign delivery, this gave her increased motivation to continue with proper tongue posture and treatment to correct the cross bite. Initial Invisalign aligners were delivered September 2022 with instructions to wear 22+ hours per day and change trays every 14 days.
In December 2022 I elected to have her begin changing trays every 10 days as her teeth demonstrated excellent tracking, the cross bite was correcting, and the open bite closing. We continued to follow she and in June of 2023 we scanned her for additional trays, which were delivered in July of 2023. As the open bite was nearly closed, and the cross bite corrected, I had her begin changing trays every week. Things progressed well and she expressed satisfaction along with a desire to conclude treatment, receive retainers, and coordinate with her dentist for an esthetic restoration of #7 to appropriate size. We removed attachments and took final records on April 8th, 2024. She received a temporary in-house clear retainer while she worked with her dentist to restore #7, after which she returned for a scan for final upper and lower Vivera retainers. She was instructed to wear them full time for 1 month, then at home and night for an additional month to maintain the position of her teeth. I anticipate instructing her to wear the retainers at night only, presuming they fit passively at her retention check in June.
Treatment Review
She was visibly thrilled with the outcome. We fixed her crossbite, closed the open bite. I was thrilled too seeing clear aligners ability to correct posterior cross bites (non-skeletal), and close open bites in the hands (or mouth, pun intended) of a compliant patient.
Critically reviewing my final records, I could have improved the torque on #11 (more buccal root/lingual crown torque) to better lock in canine guidance. #12 could have also benefitted from being placed more lingually, and lingual crown torque for a better occlusion. The lower midline was slightly off and likely could have been corrected with the use of Class II elastics on the right side. However, considering her initial presentation, and general outcome, I am extremely proud of this case and excited to use it as a showcase for future patients and presentations.