Severe Adult Orthodontic Malocclusion & Airway issues Part 1

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Posted on By Maurice Salama In Orthodontics

Thoughts on treatment for this Adult Male with Severe Skeletal and Dental Malocclusion. Has medical issues as well and sleep apnea/airway concerns. Missing maxillary central incisor, severe crowding, maxillary constriction, V-shaped arch form, etc. etc. Thoughts? Treatment plans? Dr. Salama

pre op frontal image
preop max occlusal view

preop crowding
preop smile image


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13 Comments

Good periodontal condition and stable teeth.

Panorex preop


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or just take out a lower single central incisor?


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Patient looks skeletally open on the ceph. Advanced crowding present may need all 4 bicuspids extracted to prevent over proclination of the anterior teeth. surgically assisted expansion of the upper arch to gain space; use broad arch wires also to close dark buccal corridors. Lateral may have to be converted to a central incisor. What you think?


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Creative thinking....definitely. Airway patients often do NOT do well with 4 bicuspid extraction though? Dr. Salama


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Interesting, I learnt something new today thanks Dr. Salama! :)


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Extracting is out of question.
It would ruin the facial profile.
Chin neck distance doesn’t allow extractions.
Neither the nasolabial angle.

Mandatory to create space for the missing central incisor.

Damon will make it much simpler, because of the bone remodeling you’ll get, crowding means availability of dento-alveolar remodeling units, powerful in posterior transverse adaptation of the arch. Airway will improve, but if not enough orthognatic surgery might have to be considered.


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Hard hard case !!!

On the Upper, I would recreate space for other central by Surgically assisted expansion plus Roman arch form given by wires.
On the bottom, one incisor might have to go.
The most important issue is airway. Bimaxillary advancement would be the cure for his apnea and related medical issues, and helping you with stability of the arch widening. If patient doesn`t have to keep mouth open anymore to breathe, tongue would then be up on the palate and keep arch form.
Vivera type retainers to keep arch form and not take any needed tongue room in the mouth.
Also make sure no deviated septum or other blockage to proper nasal breathing and labial seal.


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Laurent; Good thoughts here as well. For sure all these comments are very good. Will post Part 2 shortly. regards Dr. Salama


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At first glance it appears to be an expansion case and a good candidate for PAOO.


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Chuck; when SARPE (Surgically Assisted Rapid Palatal Expansion) is performed, I typically wait on any further corticotomies. regards Mo


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Just posted the case treatment as Part 2.


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I be leave that if the medical problem is present: sleep/apnea, the diagnosis if the gravity of the problem must be make before. The Rx lateral-lateral of the cranio show that the airway space is most reduced.
In a similar clinical case the extractions of the bicuspids in a big mistake, this therapy reduce the functional space for the tongue and so the posterior reduction of the airway.
How is the AHI index?? The index gives us the gravity of the sleep/apnea that must be linked to the medical History
(cardiologic-et all) to evaluate the quality life of the patient.
The residual years of the life are strongly linked to gravity of AHI.
In Any case the RPE for this patient is the first election therapy.
If the patient is young-adult is most probably. that the Maxillary-mandibolar advanced is the best Terapy after Orthodontic therapy. Sometimes the surgery must be performed before the orthodontic treatment but the surgery is little more complicate.
So, Before the diagnosi of sleep/apnea and the evaluation of the scale index of the pathology.
Dr Carmelo Lotta -Italy


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dr Carmelo Lotta is right.The extractions are big mistake. Myofunctional othodontics (Myobrace)+ ALF + Osteopat or cranio-sacral therapist for me are the best treatment option.
dr.G.Lukanova


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