13 y.o. Male with a Thumb Habit, Apexificated 8 & 9, Class I, Severe Overjet & Brody Crossbite on the Right
SUBJECTIVE: He was presented with his mother. They reported he continued to suck his thumb throughout the day and less than stelar oral hygiene. His molars were Class I bilaterally, but his midlines were off. He had severely proclined and protrusive upper incisors leading to a severe overjet, moderate upper spacing, and his #4 & 5 were in Brody (buccal) crossbite. #8 & 9 had been traumatized at a young age and had apexification performed at that time, however they had recurrent infection that was to be treated in the coming month. He had mild lower spacing, a mild Curve of Spee, but a deep and impinging overbite. His upper lip was thick, and lower lip was everted, leading to a deep labiodental sulcus.
OBJECTIVE: Their previous consult elsewhere had recommended a growth modification appliance to advance the mandible and expand the palate. I took the time to explain differences in treatment approaches but undoubtably favorable outcomes no matter which direction they chose to pursue. I sharedmy opinion that the maxilla and mandible were well positioned, as evidenced by the Class I molars bilaterally. The thumb habit however, was likely causing the upper spacing, along with proclined and protrusive upper incisors that then resulted in a Class II type overjet, protrusive upper lip, and an everted lower lip from the lip trap. I opined that his Brody bite indicated a sufficiently wide maxilla and thus negated expansion. His mother explained the endodontist was requesting no movement on his #8 & 9 for 3 months following the apicoectomy, however they were anxious to get started.
ASSESSMENT: Treatment goals were to:
- Eliminate thumb habit and improve oral hygiene.
- Not move #8 & 9 for 3 months but decrease the overjet and overbite.
- Correct the Brody bite and close all spacing.
- Improve facial esthetics by eliminating protrusive upper incisors and thus the lip trap.
- Option 1: Upper & lower metal brackets.
- Not engaging #8 & 9 for the first 3mo, then use of elastomeric thread to retract the centrals as gently as possible.
- Option 2: Upper and lower Invisalign.
- No movement on #8 & 9 in trays 1-10. Trays worn 10 days/ea (100 days prior to #8 & 9 moving).
- Estimated tx time: 18-20mo.
PLAN: Patient/parents chose Invisalign & restorations on #7-10 in future (high level hockey player).
Treatment
Initial Invisalign aligners were delivered November 28th, 2022 with instructions to wear 22+ hours per day, change trays every 10 days, and encouraged conscious effort for cessation of thumb habit.
In January 2022 appliances were fitting well, #8 & 9 were healing well per the endodontist, and patient/mom reported decreased, but continued, thumb habit. Subsequent visits they reported elimination of his thumb habit and continued excellent tray wear.
November 2023 we scanned for additional trays, and delivered them December 2023. We began weekly tray changes as the Brody bite was corrected, upper incisors retracted, and minor spacing remained. His follow ups were all exceptional.
We confirmed patient and parent satisfaction and removed attachments on April 29th, 2024. He was instructed to wear upper and lower Vivera retainers at home and night for 2 months. I anticipate his June visit to demonstrate excellent retention due to his compliance with Invisalign.
Treatment Review
I’m absolutely stoked that we were able to protect his incisors long term. He has wonderful canine and premolar torque, especially considering the crossbite. I lost anchorage on the right and could have used elastics to maintain the Class I better (he’s slight Class II, leading to mild midline discrepancy, and slight gap at the left canines). Considering what we started with, I’m very pleased.