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Bite Turbos Meet Outside-In Aesthetics by Dr. Chad Foster

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Bite Turbos Meet Outside-In Aesthetics   

A case presentation with a conscientious approach

by Dr. Chad Foster

Introduction
I am a huge advocate of always evaluating cases from the outside-in. This means for every new patient in my office I strictly evaluate the facial photos first, then the smile, then the teeth. Always in that order. Every time. In my opinion, if an orthodontist truly seeks to understand the etiology of the issues within the scope of our ability, and in particular aesthetics, this is the only way to diagnose. I realize that is a bold statement, but I strongly believe it to be true.

Mild retrognathic cases with half-step Class II occlusion with compensated or proclined lower incisors and mild crowding are some of the best ones to discuss from a diagnostic/treatment planning perspective because they are everyday cases that are often true borderline cases. They can most often be well treated several ways but there is great subtlety within the compromised non-surgical options.


Case presentation
This 15-year-old female presented to our office with a chief concern of crowding. Evaluating facial non-smiling photos first, a mildly deficient chin projection and a mildly prominent nose were the facial (macro-aesthetic) features that struck me as most out of harmony. She is mildly retrognathic in the mandible with associated Class II occlusion. Jaw position and the ideal plan of orthognathic surgery was discussed with patient and parent, but they refused this option. The maxilla is well positioned, the maxillary posterior premolars and molars show mild lingual inclination (a common compensation when the mandible is retrognathic) and the crowding in the maxilla alone (if not considering the retrognathic mandible) does not on its own require extractions to idealize alignment and finish with upper incisors at ideal AP position within her face. This to me is a non-extraction maxillary arch ideally. Even if the patient and mom accepted mandibular advancement, I would not have extracted in the maxilla in this case.

This case might not strike you as a vertically sensitive patient in the same sense that a dolichofacial or open bite patient might, but she absolutely qualifies for that term, and I will explain why. Any vertical opening in these mildly retrognathic cases with weak chin projection unfavorably further drops the mandible down and back via clockwise rotation. An advantage of extracting upper bicuspids in this case would potentially be in the vertical dimension.

Extraction treatment mechanically can favor bite closing while non-extraction treatment tends to favor bite opening. In my opinion, if one was to pursue non-extraction treatment in mildly retrognathic cases like this that show weak chin projection, it is of the utmost aesthetic importance to not further weaken the deficient chin projection by opening vertical—at all. Orthodontics at the highest level and particularly facial and smile aesthetics is a game of millimeters.
Bite Turbos Meet Outside-In Aesthetics
Fig. 1
Bite Turbos Meet Outside-In Aesthetics
Fig. 2
Bite Turbos Meet Outside-In Aesthetics
Fig. 3

Bite turbo
This is where strategic bite turbo positioning can be a major benefit—put the force of occlusion to work for your treatment goals! This girl is in a bite turbo presentation I give as she is a great example of how bite turbos on all molars is a winning strategy in vertically sensitive patients. I would categorize mildly retrognathic patients (where mandibular advancement is not chosen by the patient) as vertically sensitive. Arguably she is also already mildly vertically deficient—short-face/brachyfacial.

However, it is important to understand that normalizing the vertical (via clockwise mandibular rotation) will unfavorably come at odds with chin projection. Making one better makes the other worse. Pick your poison or compromise in these cases because you cannot have it all without orthopedic mandibular advancement. In most of these cases I find that the weak chin is aesthetically more dominant than a mildly short face. This is a generalization and obviously each case is unique. When that is the case, I will choose to accept a slightly short face rather than further weakening a weak chin. In this girl shown here, facially her weak chin stands out more than the deficient vertical.

There is another important reason to avoid opening vertical in cases like these when attempting non-extraction. If the lower jaw drops any degree down and back, not only does chin prominence worsen, but you are worsening the severity of the Class II occlusion.

This means that more Class II elastics will be needed, and the lower incisors will need to procline further forward to couple with the upper incisors, which is often unfavorable. This is another reason why this case is quite vertically sensitive.
Bite Turbos Meet Outside-In Aesthetics
Fig. 4
Bite Turbos Meet Outside-In Aesthetics
Fig. 5

Conclusion and considerations
The case finished in 15 months. In my hands, she is a bit older than when I ideally use a Herbst in female patients. She was treated in three wires in each arch (for more info on my three-wire treatment, please check out the free CE course at orthotown.com/onlinece). Class II elastics were used but they were mostly at night and only full time for the first two visits and then one visit after final IPR. IPR was used in both arches and light early IPR was done in the upper arch at the first three visits (for more info on early IPR, check out my previous OT article on that topic). Key to my mechanics—bite turbos were on all her lower molars for the first eight months and successfully limited any bite opening to protect chin projection. Her SN-GoGn decreased two degrees despite the use of Class II elastics, which tend to favor bite opening.

Upper and lower incisor angulation was an important consideration from the beginning. U2-2 brackets were flipped/inverted because I knew I would want to very slightly compensate the upper incisors to limit the degree of proclination of the lower incisors. In this way the upper incisors were intentionally finished just a bit under-torqued (finishing wires were 16x25SS in both arches). If more positive labiolingual torque (arguably more ideal) was placed in the upper incisors, this would have necessitated that the lower incisors be proclined even further forward than where they ended up (which is slightly more forward from where they started).

In my pre-treatment evaluation, I noted that she had the type of alveolar housing (thickness) that would well tolerate mild lower incisor tipping/proclination. Not every borderline patient has this favorable housing for the lowers and, in my opinion, it is an important feature to consider, arguably much more important than cephalometric numbers alone in many cases. I refer to this as an especially important non-math consideration in borderline cases.

Evaluating outside-in aesthetically, I like her post-treatment profile better than the pre-treatment profile. To me, the weak chin projection does not appear as deficient. Her smile aesthetics (mini aesthetics) are also pleasing, with good dental fullness within her smile and good vertical incisor display and smile arc.

Extracting bicuspids in the maxillary arch (the normal jaw) to compensate it to the deficient lower jaw is a reasonable plan to consider in some mildly mandibular retrognathic borderline cases. Sometimes, given all factors involved, it is the best plan out of all the other non-surgical compromised options.

Without a doubt though, in many of those cases (particularly this one), the final fullness and projection of the maxillary dentition within the smile and face would not be the same when it is compromised to match the deficient mandible via upper bicuspid extractions.

And in some cases, conscientious use of bite turbos can be the unsung hero.
Bite Turbos Meet Outside-In Aesthetics
Fig. 6
Bite Turbos Meet Outside-In Aesthetics
Fig. 7
Bite Turbos Meet Outside-In Aesthetics
Fig. 8a
Bite Turbos Meet Outside-In Aesthetics
Fig. 8b
Bite Turbos Meet Outside-In Aesthetics
Fig. 8c

Author Bio
Dr. Chad Foster Dr. Chad Foster is Orthotown’s editorial director, a board-certified orthodontist and owner of Butterfly Orthodontics in Phoenix. A graduate of Chapman University, he earned a Doctor of Dental Surgery and a master’s degree in craniofacial biology, and completed his orthodontic residency at the University of Southern California. Foster writes and lectures internationally on the topic of orthodontic aesthetics.



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