# Orthodontic Treatment Challenges

# Question:

I have a 38yo female patient who is skeletal and dental class 3 with anterior open bite and cusp to cusp intercuspation in the posterior. She is not concerned with the aesthetics and is not having an TMD issues. She said that she wouldn’t mind doing ortho if it would benefit her functionally in the long term but will not consider surgery. With her class 3 she is wondering if it is “worth it”.


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# Answer: 

[https://www.loom.com/share/dfb75f53f2ca4342bfa66ffd5967b746?sid=212b4598-9841-43a3-ba54-d42698dec280](https://www.loom.com/share/dfb75f53f2ca4342bfa66ffd5967b746?sid=212b4598-9841-43a3-ba54-d42698dec280)


In cases like this, where a patient presents with a slightly underdeveloped maxilla and a significantly developed mandible, several complex issues arise. Primarily, there is an anterior-posterior discrepancy, possibly accompanied by a tongue-thrusting habit. These factors contribute to a class III malocclusion with a bilateral posterior open bite and an anterior open bite, indicating that surgical intervention would likely offer the most effective treatment.

Addressing the patient’s dental alignment solely through orthodontic measures, such as sequentially distalizing the lower teeth, may offer limited improvement due to the underlying structural challenges. Although it might be possible to partially resolve the posterior crossbite, the anterior-posterior issues could still lead to an edge-to-edge bite, which would not significantly improve the overall occlusion. If the patient is not considering surgical intervention, the achievable results may be restricted.

Additionally, the patient exhibits signs of gingival recession and enamel wear, particularly in the upper teeth affected by the crossbite. One possible treatment option could involve a lower incisor extraction to create some overjet and improve the occlusal relationship, thereby preventing an edge-to-edge closure in the anterior region. Alternatively, extractions of two lower incisors or premolars could be considered, though this approach would not address the transverse discrepancy. Given the combination of an anterior-posterior misalignment and transverse discrepancy, along with a long vertical dimension, this case is among the more complex types encountered in dental practice.

Surgical correction would facilitate significant improvements by allowing for adjustments in jaw positioning to address these issues comprehensively. In cases where the patient does not wish to undergo surgery, a non-surgical approach may involve maintaining the current occlusal state, particularly if aesthetic concerns are not the primary complaint. Should the patient’s main objective be improving overall occlusal harmony and functional alignment rather than closing the open bite or enhancing anterior function, the benefits of correcting the crossbite or bringing the anterior teeth down may be minimal.

Addressing only the anterior-posterior alignment through tooth extraction and repositioning will likely fall short of solving the mid-arch transverse issues. In conclusion, while orthodontic adjustments could provide some relief, surgical intervention would be the most effective treatment to achieve significant improvement in occlusal function and dental harmony.