Orthotown October 2020 - 37

Fig. 7b

Fig. 7a

A non-extraction plan is more questionable here in regard to if
it would be capable of providing enough upper incisor retraction.
In this non-extraction scenario, retraction of the upper
incisors would rely mostly on significant dental expansion,
significant IPR and negative-torque upper anterior brackets. In her
case, the lingual inclination of the maxillary posteriors (particularly
the bicuspids) poses an opportunity for such expansion, the large
incisor crowns are favorable for IPR, and "flipping" maxillary incisor
brackets could provide the needed negative torque.
Considerations of how potential treatment options could
affect the lower-third facial height are very similar to the first
case. Referencing my original facial observations, any further
decrease to the lower-third would be detrimental to overall facial
aesthetics. My preference in this case, more so even than in
Case #1, would actually be to slightly increase her lower-third
facial height, because it would seem to have potential to improve
overall facial balance. There is no doubt retraction of maxillary
anteriors would improve upper lip eversion, but a slight increase
in vertical here would also aid in establishing better lip balance as
well. A non-extraction plan, in my opinion, gives a better likelihood
of resulting in this increased vertical, if that is what is desired.
The long-term lower-third facial height concerns as they relate
to a four-bicuspid extraction plan are very similar to Case #1. Just
as in that case, she displays a short lower third, a round face, well

Fig. 7c

developed masseters and absent third molars. My opinion on how
aging would tend to further decrease lower-third facial height as a
detriment to facial aesthetics would be the same in this case.

Miniaesthetic considerations in treatment planning
As previously mentioned, the height of her "smile window"
is short and I would evaluate this as at least partially secondary
to soft tissue (lip) redundancy in this case. This lip redundancy is
shown not only in the facial photos but also in the cephalometric
radiograph. If a non-extraction plan would have a better ability to
slightly increase vertical and reduce this redundancy, there could
possibly be some improvement in "smile window" height.
Retraction of her very proclined upper anteriors has the
potential to both increase the vertical show of her upper incisors
(which do not show enough) and also bring better smile arc
form to her currently flat anterior occlusal plane. I would be very
confident that extraction of bicuspids would be more than enough
to satisfy the retraction needed to achieve these goals. The
retraction potential in a non-extraction plan would be less, and
possibly not enough.
While the transverse tooth display within her smile window
does not demand the expansion that was needed in Case #1,
some mild expansion would still benefit miniaesthetics. In this
case, I would say that the buccal torque needed in the bicuspid

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Orthotown October 2020

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