# Insights on Patient Case Management

# Question:

Hi all, this patient has severe bone loss around lower anteriors as well as severe crowding. She hates the way it looks, but I am unsure if it's safe to do a single incisor ext/align or whether we should try for ext of the two teeth with the worst bone loss and do some sort of replacement. She has moderate crowding on the upper arch as well. Scan is from opposing to a crown we're doing. Pt is on American military insurance but is willing to pay out of pocket for ortho, but would prefer not to section the LR bridge if possible, thus my considering doing a single incisor ext to avoid moving those LR abutment teeth.


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# Answer:

[Insights on Patient Case Management - Watch Video](https://www.loom.com/share/bb4e1b8d23824b36b1a7ea26344cc8fb)

 ![](https://outline-production-attachments.s3-accelerate.amazonaws.com/uploads/5e251020-0250-40df-b185-994531667ed4/21820785-df69-4fbd-878a-f61e2ade3c87/bb4e1b8d23824b36b1a7ea26344cc8fb-ecaec28df38b60ec-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=7e509a33e55f9bf1f73ff97c6f2c2fd3eb73135169c7ec94fab787dc799fc21f&X-Amz-SignedHeaders=host&x-amz-checksum-mode=ENABLED&x-id=GetObject " =640x360")

**Dental Case Analysis**

This case presents a patient with extensive periodontal disease, posing a high risk of tooth loss. Patient expectations must be managed accordingly. The primary concern is maintaining periodontal health; any inflammation will compromise the success of the treatment and inevitably lead to tooth loss.

### Treatment Considerations

The worst-case scenario involves the patient losing one or more teeth, ultimately requiring implants or a bridge. If the patient understands and accepts this risk, proceeding with treatment is reasonable.

Hubert's analysis highlights the potential risks associated with the treatment approach. A key question remains: should a single lower incisor extraction (XO) be attempted, or should an alternative approach be considered? The decision depends on the upper arch and the patient's bite.

Due to the degree of bone loss, extracting a lower incisor necessitates shifting the roots of neighboring teeth. While the minimal root structure can be advantageous, it also increases the risk of bone level reduction, which could impact adjacent teeth. Given these factors, a non-extraction approach may be preferable.

### Alternative Approach

Arch development and minor expansion in the premolar and canine regions could provide a viable solution without requiring extraction. This approach remains compatible with a bridge treatment plan.

Interproximal Reduction (IPR) is a key technique in this case. By strategically applying IPR between the bridge and the canine, as well as between the lower right second incisor, canine, first premolar, and first incisor, sufficient space may be created to align the teeth.

The current level of crowding suggests that IPR could be performed without breaking through the contact of teeth positioned more lingually. Initial considerations include evaluating how much IPR is necessary. Assuming no further buccal movement beyond the current alignment of the most buccally positioned teeth (including the canines), an estimate of required space might include:

* Approximately 1 mm in one region
* 0.5 mm in another
* 2 mm in a more crowded area
* An additional estimated 1 mm elsewhere

These estimates suggest a total required space of approximately 4.5 mm. Since lower incisors are typically around 6 mm in width, proper IPR could create sufficient space to resolve the crowding.

### Execution of IPR

The recommended approach involves starting with conservative reductions of 0.4-0.5 mm per tooth. Additional rounds of IPR may be required to achieve the desired alignment, particularly in laterals and canines. Canines, in particular, can tolerate reductions beyond 0.5 mm if necessary, depending on the upper arch configuration.

### Conclusion

If extractions are avoided and controlled proclination is implemented while maintaining periodontal stability, the likelihood of successfully aligning the teeth is approximately 80%. However, there remains a 20% risk of treatment failure leading to tooth loss. Given this risk, securing a signed consent form is essential if the patient opts for this approach.