# Complicated adult with many missing teeth

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# Question 1


1. I have a case below where the patient has a cantilever bridge in quad 2 and crowns on 15 14 and 24 and I am wondering if I should exclude them and not place any attachments and how to compensate? 

# 

[https://www.loom.com/share/27fa62ee1d794cf38bf94ed223ad984e?sid=842bed4a-f172-4800-b3f8-cde5d111a64c](https://www.loom.com/share/27fa62ee1d794cf38bf94ed223ad984e?sid=842bed4a-f172-4800-b3f8-cde5d111a64c)

In the situation where a patient who has a cantilever bridge, the question arises whether to place attachments on the involved teeth. Since the occlusion appears stable and there's no significant super-eruption into the edentulous space, attachments are not necessary. If no significant movement, like anterior intrusion, requires attachments, it's generally advisable to avoid placing them on the posterior teeth, including those with the cantilever bridge.


# Question 2


2. Also, since there is space in quad 1 i thought i could distalize the premolars with elastics to make more room for the incisor to derotate.

[https://www.loom.com/share/088e64383ce2448eaf3603e362697069?sid=f06d2ab8-1d08-434b-8092-5412bbcae455](https://www.loom.com/share/088e64383ce2448eaf3603e362697069?sid=f06d2ab8-1d08-434b-8092-5412bbcae455)

In this case involving missing teeth in quadrant 1, the focus is on whether to move the teeth distally, considering the patient's smile aesthetics. A slight midline shift to the right could be aesthetically beneficial, aligning with the patient's nose. Using class II elastics to achieve this is possible, but care should be taken not to disrupt the existing class I occlusion. However, using elastics from a slit in the aligner may pull the aligner off the over-erupted canine, complicating the intrusion of the canine. Adjustments like switching to a button-to-button setup might help, as the aligner can overcome the force of an elastic, but the main issue is ensuring the aligner stays in place.


# Question 3


3. She is getting planned for implants after but i see the 35 is going to be very difficult to derotate. What is a realistic timeline for this and will it need a TAD? 

[https://www.loom.com/share/591973c488154de59886b7d8851cbede?sid=70b8e80d-9b10-4913-90ee-2bdbcbc8fd10](https://www.loom.com/share/591973c488154de59886b7d8851cbede?sid=70b8e80d-9b10-4913-90ee-2bdbcbc8fd10)

Rotating a highly rotated lower premolar is challenging due to its round shape, which makes it difficult for aligners to grip. While using a TAD isn't helpful in this scenario, the process can be aided by placing vertical attachments on the buccal and lingual sides of the tooth. If this doesn't work, using buttons and C-chain is another option. The C-chain, attached to neighboring teeth, helps gradually spin the tooth into position. Once the tooth is straight, an attachment should be placed immediately to hold it in place and prevent it from rotating back. It's crucial not to remove the buttons or C-chain until the new aligners with attachments are ready to avoid relapse.