Outside-the-Box Smile Design by Dr. Mike DePascale

Categories: Orthodontics;
Outside-the-Box Smile Design 

The author shares a complex case from early in practice—plus what he’d do differently today

by Dr. Mike DePascale

Every challenge is an opportunity to become better. My goal is that by the end of this article, you’ll have learned or been reminded of the following three things:

  1. There is always a solution.

  2. If we live inside our comfort zone, we miss many amazing opportunities.

  3. Perfection is not attainable. “Excellent,” “great” and “better” are all reasonable goals.
The patient in this case came to me very early in my career—this is an important fact—with a list of problems that at first glance may appear beyond orthodontic help (Figs. 1 and 2).
Outside-the-Box Smile Design
Fig. 1

Outside-the-Box Smile Design
Fig. 2

Before I continue, I want to mention that three months into my career, the office I was working in did not have 3D digital imaging or a ceph, and I did not send him for one. Now, every patient in our office gets a 3D iCat at the consultation (provided radiographs are appropriate), and if they did not, I would have sent him for one.

As I’m sure many of you are thinking, my first choice was surgical correction. This is as severe and difficult an occlusal discrepancy as I’ve seen in practice, even 4½ years later. Interestingly, at the time, I thought it might be possible to correct without extractions.

Much has changed for me as a clinician since just a few months after graduating, but if there’s one thing that has not, it’s that I’m willing to push the boundaries of what we’ve been told is possible while setting realistic, albeit sometimes very difficult, goals and expectations. I think this is the world we should all live in. It’s OK to use the knowledge you already have to cautiously and intelligently move away from the limits the existing evidence has set for you. That’s an important point: existing evidence. Sometimes what you’re doing is going to be the evidence, and you can and should pursue that path. We all have an opportunity to change lives in this field, and this case an example of that.


As previously mentioned, the list of problems for this 18-year-old patient is lengthy, including:

  • Narrow maxilla.
  • Irregular mandibular arch.
  • Severe crowding.
  • Severe anterior open bite.
  • Severe overjet.
  • Bimaxillary protrusion.
  • Lip incompetence.
  • Improper tongue posture secondary to malocclusion.
  • Posterior cross bite.
  • Severe reverse curve of Spee.
  • Excess posterior gingival display.
  • Reverse smile arc.
  • Impacting 8s.
  • Excessive lower third of the face.
  • Steep mandibular plane angle.
The patient’s main concern was correcting the crowding and open bite but he was wholly unwilling to pursue surgery, despite a long discussion with someone who has been through orthographic surgery himself (me). He mentioned that he was open to removing teeth, but that was the extent of his tolerance to orthodontic care.

Treatment goals

This is where the outside-the-box thinking comes in, and I want to take a moment to highlight the “why” behind my thought process before I focus on the “what” and “how.”

In the orthodontic profession, for reasons I find difficult to explain, most of us are very focused on obtaining perfection. It’s silly, really, when you think about that because perfection is nearly unattainable. So why are we so hell-bent on getting there all the time? And do we really think when we finish treatment that our results are actually perfect? I know some amazing orthodontists and I don’t even think they would agree to the latter statement; there’s always room for improvement and some situations are just not set up for perfection.

However, we can do one of two things to get the results both we and our patients desire. One option is to redefine perfection. Is perfection an ideal Class I malocclusion, with a beautifully broad smile, narrow buccal corridors and 2mm of gingival display? For many it is, but for others maybe perfection is being able to chew again, simply being able to close their lips without struggle, or looking in the mirror and loving what they see even if they have a crossbite.

My point is this: The perfect result looks different for everyone in every situation. The second option is to simply understand that even if your goals are lofty and you did not arrive at all of them, improving someone’s life is a great thing that we should be happy about. Let me be abundantly clear: I am not saying we should compromise our results; I’m simply saying that if we look at things differently, we can create situations where everybody wins.

Treatment progression

When I started this case, I was going to attempt to correct all of the aforementioned issues without extracting any teeth. (This was young and naive Dr. Mike! I would not even consider that today.)

I started by bonding all teeth except for blocked-out U2s and L3s. We use Damon Q2 brackets in the practice, and I chose standard torque U2–2, low torque L2–2, and high torque 3s. (Today, I would use standard torque on the L2–2, to prevent the lower incisor roots from moving too far facially and knowing that extractions are in the future.)

I placed 0.014-inch copper nickel-titanium (CN) wires and used nickel-titanium (NiTi) open-coil springs to make space for blocked-out teeth and 3/16-inch, 3.5-ounce triangle elastics (Fig. 3) to start closing down the bite. In hindsight, I should have run these from U3s to L3–4s, and not L2–4s the whole time. I think that made it more difficult to develop the arch and make space for blocked-out L3s.
Outside-the-Box Smile Design
Fig. 3

Thankfully, I realized about five months in, which was only a few appointments, that there was no way this could be corrected without removing teeth. I believe this is the most critical decision I made in this case. I discussed extraction of all 6s with him, and he agreed. The visit after extraction of 6s, I placed 0.018-inch CN wires (Fig. 4). The reason behind the 6s is twofold: Firstly, the size of them alone warranted consideration because of how much crowding existed. Secondly, I knew it would help with bite closure.
Outside-the-Box Smile Design
Fig. 4

Some have asked me if I regret that decision and should have taken out 7s, especially with the impacted LR8. I do not; I think the result we obtained is excellent given the circumstances, and I made the best decision I could at the time, which is all one can ask for. Stop beating yourself up over your past decisions! But I digress: Removing 7s might have helped more with bite closure, but I believe the mesiodistal width of the 6s was more helpful overall in this case, and it worked out well.

Shortly after the upper and lower 6s were extracted (Fig. 5), approximately nine months into treatment, you can see that I had created a significant amount of room for the rest of the crowding to unravel, and things were more under control. At this time, I had the patient wearing a 3/16-inch, 3½-ounce crossbite elastic on the right side. This is something I would not do again. Given his skeletal discrepancy and the amount of crowding and planned movement, today I would make a pretreatment decision not to correct the crossbite. It’s a reasonable and beneficial compromise in this case because of the decreased risk of dehiscence, fenestration and undesirable bite opening from buccal flaring of the posterior teeth (which did happen and was something I needed to correct later).
Outside-the-Box Smile Design
Fig. 5

The patient continued to wear crossbite and triangle elastics up until the scan and repo appointment, 16 months into treatment (Fig. 6). At this time I repositioned the following brackets: L3–5s, UR2, UL1–2s and U7s, bonded the LL8 and placed 1825 CN/0.018-inch CN wires.
Outside-the-Box Smile Design
Fig. 6

Although I had spoken to the patient several times about this and it took much convincing before, about 22 months into treatment he allowed me to place TADs for posterior intrusion (Fig. 7). By this time, he was in 1925 SS/1625 SS wires. I placed two 6 mm VectorTAS miniscrews between U7–8s and attached them to the upper wire bilaterally with elastic thread to intrude the posterior teeth. Treating this patient again today, I would be much more adamant about the important of placing them to avoid surgery. I believe if I had been able to make that decision sooner, this case could have been finished at least six months earlier.
Outside-the-Box Smile Design
Fig. 7

We start early, light elastics in nearly all of our cases using Damon brackets, and I believe that’s a big part of why things work out so well. I started triangle elastics in this case (3/16 inch, 2 ounces), but I would change them from U3/L3–4 to U3/L4–5 now to help with the vertical correction but avoid being in the way of eliminating the lower crowding. As I progress through treatment, those change to 3/16-inch, 3.5-ounce elastics.

Though you will see crossbite elastics of the same size in this case (Fig. 5), I realized that the torque was getting difficult to control while intruding the posterior teeth with TADs, and the patient would be better served left in posterior crossbite, so we did that intentionally and stopped the crossbite elastics completely at 23 months in treatment.

You’ll also see in the progress photos that because of how open his bite was initially, after we completed posterior intrusion the patient ended up with a Class III dental malocclusion that required an auxiliary appliance to correct. Now 36 months into treatment, I chose a Dynaflex CS3 coil spring (Fig. 8), which worked quite well to correct his asymmetric Class III dental issue over the next four months.
Outside-the-Box Smile Design
Fig. 8

Finally, we finished with what we call a “V elastic” (Fig. 9), a 5/16-inch, 3.5-ounce elastic that hooks up from the U6s to L4s to upper post between 2–3s to settle the occlusion. Total treatment time was 42 months, which included a four-month hiatus during the COVID-19 lockdown, as well as several three- to five-month intervals without seeing the patient because of missed or rescheduled appointments.
Outside-the-Box Smile Design
Fig. 9

Results and conclusion

Did I achieve orthodontic perfection? No, I did not. This patient still has a posterior crossbite and a LR8 that will likely require extraction, although I discussed surgical uprighting of that and he refused.

However, did I change this young man’s life? The answer to that, in my humble opinion, is unequivocally yes (Figs. 10–12). His bite is stable, his crowding is gone, he can close his lips together, he loves his smile and he is in a far better situation than he was when he met me. He is thrilled, and so am I.
Outside-the-Box Smile Design
Fig. 10

Outside-the-Box Smile Design
Fig. 11
Outside-the-Box Smile Design
Fig. 12

I took a chance in this particular situation, but all that it required was careful planning and the ability to step outside of what the world tells us is achievable. I think we often set limits on ourselves that exist only because there are not yet enough of us who have taken a step beyond them. Armed with more foresight combined with consistent appointment intervals, I believe a patient like this could be treated in six to 12 fewer months.

Next time you encounter a situation like this, I encourage you to view it as an opportunity, not a handcuff. As a very wise man, Ryan Holliday, once said, “The obstacle is the way.” I hope that I’ve equipped you with some insight and inspiration on how to go back into the world and do things that you didn’t think were possible. It takes effort, but it is certainly worth it, and all you have to do is try and get a little bit better every day.

Author Bio
Mike DePascale A New Jersey native, Dr. Mike DePascale received his orthodontic master’s degree at the University of Maryland in Baltimore. In 2017, he joined the team at Kozlowski Orthodontics, a practice that matched his dedication to high-quality treatment, innovation, efficiency and education.
When DePascale is not in the office, you can find him in his garage gym or coaching CrossFit at a local gym, where he puts to use his passion for personal growth, leadership, and commitment to others. (You may see him there throwing weights around, too!) He believes in pushing boundaries, doing what you love and sharing that with the world.
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