Sibling Rivalry by Dr. Nick Riccio

by Dr. Nick Riccio

• Class III skeletal pattern (hyperdivergent)
• Class III dental relationship
• Constricted dental arch forms
• 5 mm anterior open bite (Y-type)
• Reverse curve of Spee with intruded lower incisors
• Mild maxillary spacing
• Mild mandibular crowding
• Normal airway findings
• Tongue thrust habit

• Class III skeletal pattern (hyperdivergent)
• Class III dental relationship
• Constricted dental arch forms
• 5 mm anterior open bite (Y-type)
• Intruded maxillary incisors with inadequate incisal display
• Moderate maxillary and mandibular crowding
• Constricted upper airway findings
• Tongue thrust habit

Fig. 1: Initial records (Patient A)

Fig. 2: Initial records (Patient B)

Fig. 3: Initial records (Patient A)

Fig. 4: Initial records (Patient B)

Fig. 5: Initial records (Patient A)

Fig. 6: Initial records (Patient B)

1. Reverse curve of Spee with intruded L3-3: Extruding the lower incisors with aligners felt like the more predictable approach to closing the Y-type open bite, and a notable advantage here was being able to maintain the existing incisal display on the upper, since upper incisors are notoriously difficult to extrude with aligners. Limiting posterior extrusion was further supported by the intermaxillary plastic.
2. Mild upper spacing plus normal airways: Aligners were fully compatible with this case, as there were no significant concerns with achieving good arch form development and coordination.
3. Patient preference as a motivating factor: Patient preference alone cannot drive appliance selection, but Patient A had a strong desire to avoid braces, and that became a source of motivation to approach this case boldly with aligners. When you can offer a treatment modality the patient genuinely prefers, that goodwill carries real weight—especially in a demanding case where high compliance is essential to success.

1. Inadequate incisal display with intruded U3-3: Extruding the upper incisors felt more predictable with braces, leveraging differential anterior-posterior bracket positioning, supported by bite-closing elastics and posterior bite blocks to help mitigate unwanted posterior extrusion.
2. More severe crowding with constricted airways: Maximizing dentoalveolar expansion on the upper arch was a priority, and braces with Damon mechanics felt like the best path to achieve that. The facially and gingivally ectopic canines were engaged intentionally while open coiling around the initially unengaged upper laterals helped expand arch form maximally. Triangle bite-closing elastics from U3 to L3/L4 were used during initial leveling and aligning; once space allowed engagement of the upper laterals in a broader arch form, the approach transitioned to box-type anterior bite-closing elastics—a high-compliance ask that Patient B met admirably.
3. Competitive swimming as a contributing factor: Again, this alone did not drive the decision, but the documented effects of prolonged aligner wear in competitive swimmers, including discoloration and erosion, were a meaningful clinical consideration. Braces were the more appropriate choice given Patient B’s training demands, and fortunately, Patient B was receptive to this recommendation.

Fig. 7: Progress records (Patient A)

Fig. 8: Progress records (Patient B)

Fig. 9: Progress records (Patient A)

Fig. 10: Progress records (Patient B)

Fig. 11: Progress records (Patient A)

Fig. 12: Progress records (Patient B)

Fig. 13: Final records (Patient A)

Fig. 14: Final records (Patient B)

Fig. 15: Final records (Patient A)

Fig. 16: Final records (Patient B)

Dr. Nick Riccio is a board-certified orthodontist who trained at Montefiore Medical Center in the Bronx. He co-owns and operates a dual-service pedo-ortho practice in Hinsdale, Illinois, with his dual board-certified wife, Dr. Susan Blair. He and Susan were honored with the distinction of “40 under 40” by Incisal Edge magazine. Riccio cofounded and runs a de novo study club called “Masterminds,” exploring a wide range of topics from clinical innovations to practice management to health and wellness topics.