# Insights on Patient Treatment Plan 🦷

# Question:

This is a case that I started sequential distalization. I am correcting midcourse as this was definitely a mis step on my part. Glad I caught it before I shifted the upper midline!  
Can I get some opinions on this new clincheck to correct the plan towards a more favorable outcome? Is there a way to better plan this so that she doesn't require so much IPR?  
Thanks in advance!  
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# Answer:

[Insights on Patient Treatment Plan 🦷 - Watch Video](https://www.loom.com/share/e885ff99fdbf466183b3c80c10747ed2)

 ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/9b24cce6-724e-4d5d-b7d3-d1aad33f20b0/e885ff99fdbf466183b3c80c10747ed2-eb39fae82cc0c71a-full-play.gif?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Credential=AKIA4EOUDTOVUICLPZ4P%2F20260920%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20260920T213000Z&X-Amz-Expires=86400&X-Amz-Signature=a0f9949a534e253764cdbebdd452997c52a9b077115c1f3149ef5c3fd9239de6&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject " =640x360")

## Case Analysis and Treatment Considerations

### Introduction

This case involves a patient in a late or mid-growth phase undergoing orthodontic treatment. The treatment initially included sequential distalization, which was halted partway through before midline changes were fully addressed. This analysis will explore the midline alignment, treatment approach, and next steps.

### Midline Assessment

Upon reviewing the patient's facial midline, it is evident that her face is slightly angled in the provided image. A screen capture was taken to further analyze her facial symmetry. Key observations include:

* The philtrum is slightly off to one side.
* The midline of the teeth and chin exhibit some deviation.
* The ears appear even, indicating that this is not solely an angulation issue.

Given these factors, some sequential distalization to adjust the midline is appropriate. The decision between sequential distalization and a bite jump depends on the patient's growth stage and remaining potential for development.

### Sequential Distalization and Bite Jump Analysis

By evaluating the progression from stage one, the following observations were made:

* The first molar was used as a reference point.
* Sequential distalization of 1 to 2.5 mm at the molar.
* A bite jump of 1 mm on the lower arch, resulting in a total correction of 3.5 mm.
* If the patient is still growing, up to 4 mm of AP correction could be achieved using elastics and natural growth.
* Distalization on the opposite side primarily resulted from first molar derotation, followed by a bite jump.
* The lower incisors required significant intrusion, which was effectively implemented in the initial treatment phase.
* Upper teeth leveling was minor, though slight intrusion adjustments might be beneficial.

### Midline Changes and Treatment Direction

While some midline adjustments have occurred, they do not appear to be inappropriate for the patient's facial symmetry. The current plan would result in a slight shift from the left to the right, which is within acceptable limits.

At this refinement stage, the options include:


1. Continuing with sequential distalization as planned.
2. Closing the space as currently outlined.

A recommended approach would be to fully close the space, potentially leaving some space around the canine to minimize friction.

### Recommendations for Further Refinement

* **Button Placement:** A button should be placed on the extruding tooth to help seat it properly in the tray, ensuring consistent movement.
* **Avoid Excessive Intrusion:** Since the patient does not exhibit a gummy smile, excessive intrusion should be avoided.
* **IPR Consideration:** Bolton analysis shows a maxillary excess in the 6-to-6 segment and a slight mandibular excess in the 3-to-3 segment, but neither exceeds 2 mm. It is advisable to complete space closure before determining if interproximal reduction (IPR) is necessary.
* **Class 3 Elastics:** Since there is no significant Class 3 bite jump, elastics may not be essential. It might be beneficial to assess the final positioning before introducing them, though a slight nighttime use could be considered for minor adjustments.
* **Final Adjustments:** The proposed intrusion of a particular tooth may be excessive. A more conservative approach to intrusion will help maintain a balanced curve of Spee.

### Conclusion

Overall, the treatment has been effective, and the current approach is well-aligned with the patient's needs. A minor bite jump appears sufficient, and excessive Class 3 correction should be avoided. Final refinements should focus on controlled space closure and minor intrusion adjustments. This approach will help ensure optimal alignment and functional occlusion.

### Final Thoughts

The proposed refinements should help fine-tune the treatment outcome. These insights aim to guide the next steps, ensuring the best possible results for the patient’s alignment and occlusion.