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Case Presentation: Interesting Cases with Teeth in the Wrong Places by Alan A. Curtis, DDS, MS, Editorial Director, Orthotown Magazine

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There’s nothing more rewarding than creatively coming up with a treatment plan that achieves the goals your patient has. For various reasons, a tooth grows into the mouth out of the normal position, ectopic, transposed or missing altogether. While the finished case will never look 100 percent ideal, making the best of a bad situation is the task at hand! To quote one of my favorite clinical faculty members (insert your best Texas accent)… “You can’t make a silk purse out of a sow’s ear!” The following cases show how creative treatment planning can help minimize or eliminate the need for costly implants, bridges and fixed prosthodontics.

Patient 1
Diagnosis
Class I Posterior crossbite Ectopic UR3 missing upper laterals with two anomalous mesiodens. The dentist recommended removing the mesiodens consolidating the large central incisors and placing two lateral implants. Removing the two mesiodens only to place two implants seemed to be a little crazy. Our treatment plan included orthopedic expansion and alignment of the four incisors. (Figs. 1a-j).

Patient 1 Result
Six to eight veneers were discussed at the start of treatment, following orthodontics, patient declined further restorative treatment. (Figs. 1k-w).



Patient 2
Diagnosis
Class I Transposed UR3, UR4 macrodont central incisors. While possible to resolve the transposition, periodontial and root damage together with prolonged treatment time encouraged us to align the transposed teeth in their current locations (Figs. 2a-k).

Patient 2 Result
(Figs. 2l-v).



Patient 3
Diagnosis
Mild Class II div 2 occlusion, missing maxillary laterals and transposedUL3, retained primary teeth. Objectives were to close spaces, resolve transposition, level and align teeth, Class II molar occlusion and canine substitution. The treatment plan was to remove primary teeth together with UL3, remove lower incisor and place one implant at UL2. (Figs. 3a-l).



Patient 3 Result
(Figs. 3m-x).



Patient 4
Diagnosis
Class I malocclusion, severe crowding, ectopic UR3, history of trauma UL1 (failing endo). Objectives were to resolve crowding and resolve trauma UL1. The treatment plan was to extract lower 1st premolars UR1st premolar and extract UL1 (canine and lateral substitution). Patient will need future buildup for UL2 turning it into UL1. (Figs. 4a-k).

Patient 4 Progress
Six months into treatment. (Figs. 4l-s).

Patient 5
Diagnosis
Missing UR1, failing endo UL1, provisionalized bridge (denture tooth with jet acrylic) and procumbent anterior teeth. Objectives were to resolve failing endo and resolve lower anterior crowding. The treatment plan was to extract UL1 and remove UR1 pontic. Have dentist buildup upper laterals to MD width of central incisors, remove lower incisor to allow resolution of lower incisor crowding. Enameloplasty of upper cuspids to improve aesthetics of canine substitution. (Figs. 5a-l).



Patient 5 Progress
Eight months in treatment.
(Figs. 5m-x).



Conclusion
While the above cases do not represent the most idealized occlusion they seek to resolve the patients’ chief concern with the most natural dentition in the shortest amount of time. Truly, every clinical diagnosis could receive a handful of treatment plans. Fun treatment plans come when the clinician starts the treatment planning process with clearly identified treatment objectives. Once those objectives are stated succinctly the resultant treatment plan may surprise you how simple and efficiently you can get from point A to B. The problem with these cases is the fact that we don’t share them with each other and with the dental community at large for fear that our finish is not board quality or that we did not perfectly achieve the VTO (visualized treatment objective). While all of these cases could be treated differently and we can talk about the pros and cons of each result, it’s important for us to share similar creative, non-ideal cases with each other! I invite you to go online today and share your most creatively treated case! See you online at Orthotown.com!
Dr. Alan Curtis is a native of Tempe, Arizona. Dr. Curtis graduated from Brigham Young University with a Bachelor of Science degree. He completed his dental degree at the UCLA School of Dentistry. He then completed two additional years of specialty training in orthodontics at Baylor College of Dentistry, Texas A&M University, where he earned a Certificate in Orthodontics and a Master of Science degree in Oral Biology. Dr. Curtis is an active member of the American Association of Orthodontists, Arizona Orthodontic Study Group, the Pacific Coast Society of Orthodontists, American Dental Association and Arizona Dental Association. Dr. Curtis is an adjunct faculty member at A.T. Still University Post Graduate Orthodontic Residency program. Dr. Curtis and his wife, Christie, have four boys, Alex, Will, Jake and Nate.

Orthotown Magazine
September 2025
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