Case S Rosser

Hmm...
I d go for upper and lower fixed with some class 2 elastics and IPR in lower
Bond 7-7 upper and lower

As for TMJ... her occlusion will be better but we can not guarantee her tmj will be

her teeth will look better...... thats the reason for doing it

her upper centrals - may need some composite due to the shape of them ... necks touch but not further down....

Hi Ian,
I'd appreciate your opinion on this case.
HPC: No previous ortho. Saw a dentist in Cardiff for consult and was told "'side bite' on left and suitable for Invisalign or fixed braces" (I'M NOT CONVINCED INVISALIGN WOULD WORK!!). Jaw problems on and off and often 2 weeks of discomfort and can't bite properly and then it settles. Has been diagnosed with hypermobility of joints at age 16 and thinks this has started to affect the TMJ. Her chiropractor told her having straightening of teeth may help jaw (CHIROPRACTOR DOING ORTHO NOW?!)
She doesn't like the colour of the teeth, the spaces at the top and the crowding of the lowers.
MH none

OE:
E/O skeletal class 1, slightly concave E line. slight asymmetry of nose. centreline upper to L of midline by 1-2 mm
FMPA normal/borderline increased
IO:
class 1 molars, canines and incisors although x bite LHS canine and molars
lower mod crowding, upper mild spacing and well aligned
LHS posterior crossbite UL4-6
I suspect a Bolton issue: discrepancy of anterior tooth size between arches (uppers too narrow)
upper centreline shift 1- 2 mm to left
dental health good
gingival health good
thin biotype
ref: LR1 seems to be in good contact and position related to uppers
OJ and OB normal, although uppers are a little retroclined

Problem list:
- xbite
- crowded lowers
- spaced uppers
- size discrepancy between anterior teeth
- centreline shift
- TMJ history

Thoughts:
if uppers expand then will have spaces which would need composite or porcelain to close
if lowers retracted then retroclining lowers will compromise OB OJ, if extracting in lowers then may be too much space for closure and maintaining ob oj

possible opts:
upper arch expansion and accept mild crowding lower (align as best as possible non extraction, keeping LR1 as anchor point in class 1 inc position), upper arch composite diastema closures post ortho which would improve smile and proportions of uppers - ideally with correction of LHS crossbite?

or XLA lower premolar R/L for space but may compromise molar or incisor relationship - 5s more ideal to maintain incisor relationship and facial aesthetics and bring molars to class 2 full unit?

Photos of pt and study models here: https://www.dropbox.com/sh/jwy4zoawdlsb7d0/AADJqnMeaShmW7JVstaUE0DJa?dl=0

Is it worth me sending models to you for a digital set up?
Is correction of xbite going to improve her TMJ at all - I know evidence is sparse and conflicting for TMJ relationship to Ortho tx...
How bad would the spaces on the upper be if trying to correct that xbite by widening the upper arch?

Your thoughts would be much appreciated!!

Cheers

Josh