English translation

Abstract

The reason for writing this article, was because everywhere I go around the world to lecture
the question I get most often asked is ¿how do you finish a case? what tricks and what secrets do you
have to finish a case? Finishing I realized was what everyone wanted to know.

Before I start I want to say that there are no secrets or tricks in finishing, there are simply
guidelines. However, before explaining the guidelines, I have to insist that the most important aspect
when it comes to finishing is the desire to want to reach excellence when finishing a case.This takes
time and effort and so the second question is ¿are you willing to dedicate time and effort to finishing.
The desire for excellence must be part of your treatment goal.

Finishing, is not easy, but it is not impossible, you simply have to dedicate time, desire and
effort to achieve it and finally, follow some basic rules. These rules consist in always starting with the
transverse problem, then dealing with the vertical component (my God, how important this is and how
little importance ii is given) and finally, the anterior posterior relationship.

My teacher and mentor Dr. Roth, always said that to finish a case to excellence, you had to
finish the lower arch first and then the upper arch, or at least always be one step ahead in the lower
arch. This advice contains a large amount of the logic and we will talk about this in our article.

Another important aspect is the treatment objectives. The objectives have to be both functional
and aesthetic and this is another aspect that we are going to cover in this article.

Excellent finishing consists of achieving aesthetics and function. As the saying goes "beauty is
short lived" and I would add, that function is fundamental for stability and longevity. Our goal must be
to create stable cases over time and, above all, long lasting cases.

In this article, we are going to explain all the aspects that we consider fundamental to finish a
case to excellence. We will also give many illustrated examples and guidelines that we feel are
important to achieve excellence in finishing.

At the end of the article, we will present a fully detailed case where many aspects developed
throughout the article have been taken into account in order to obtain an excellent final result.

KEY WORDS: occlusion, dental aesthetics, smile aesthetics, bioesthetics

 In our daily clinical practice, one of the biggest challenges that orthodontists face is to finish
our cases well. All orthodontists know that this last phase of detailing and completion is the most
difficult and the most time-consuming and that many times treatment is extended. Despite this, in
courses and conferences, we are frequently asked what is the secret of finishing a case? How do you
finish your cases? This clearly demonstrates the fact that orthodontists around the world have the
desire to finish their cases excellently. (Fig. 1)

Figure 1: Completed orthodontic case treated at the Martín Goenaga clinic in San Sebastián.

Before continuing, we must ask ourselves "what is the definition of a well-finished case"?
What are the attributes that make a final result an excellent result? This is exactly what we want to
do in this article. Share with you what we believe is a well-finished case and how to ensure that our
cases finish with the highest degree of excellence. We do not want to repeat what has been said on
numerous occasions, but it is so true and important that we will risk repeating it "begin with the end
in mind", we all know it, we have all heard it many times and despite this, it is still true today as it
was yesterday. However, for us the word “begin” is synonymous with “diagnose”. That is
“Diagnose with the end in mind”. To finish a case well, a complete and comprehensive diagnosis
must first be carried out in each and every one of the patients and this will be the FIRST STEP to an
excellent finish.1

It is for this reason that in the FACE philosophy we have been insisting for many years on
carrying out a complete diagnosis (of each part of the stomatognathic system) of each case in order
to carry out a treatment plan based on each of the treatment objectives. This was perfectly
understood by Dr. Roth and that is why he frequently repeated “we spend too much time treating
and not enough time diagnosing”.2
 The purpose of this article is to help the clinician take into account all the details necessary
to obtain an excellent finishing of the cases. It seems essential to us to begin by remembering and
insisting on those general objectives to which we must direct all our cases. Obtaining results that are
stable over time is directly related to the quality of a finished case: 3

Treatment Objectives

1. Functional occlusion (orthopedic stability)

2. Dental and facial aesthetics
3. TMJ health
4. Periodontal health
5. Airway
6. Long-term stability and longevity
7. Rejuvenation effect
8. Patient satisfaction (Fig. 2) 4

Figure 2: FACE treatment goals.

 The first strategy that we propose to obtain an excellent final result is to draw up a checklist
of aspects to be achieved with orthodontic treatment.5 This “checklist” should be at hand in each
chair and should be consulted during all treatment. Before proceeding with the removal of the
appliance, it must be verified that each of the points on the list have been obtained. If that is done
throughout the treatment, we will not reach the final stages with everything still left to do. In our
clinic, this list is present at each chair and we keep it in mind every time the patient comes to the
office. (Fig. 3)

Figure 3: List of treatment objectives to take into account during treatment and before proceeding to
removing the appliances. This list is printed on each of the chairs in our clinic so that you always
have it on hand.

Based on the treatment objectives, in this article we are going to explain step by step what
we feel is a well treated case according to the FACE principles. As is well known, our goals are
always function and aesthetics. Our final objective is always to obtain optimal esthetics and an ideal
functional occlusion. One cannot finish a case looking only at aesthetics and think that this is a well
finished case, ideal aesthetic always has to go hand in hand with ideal occlusion.
 1. FUNCTIONAL OCCLUSION (ORTHOPEDIC STABILITY)

Focusing on the occlusal aspect, it is inevitable not to refer to the famous Six Keys of Dr.
Andrews, which the FACE group totally supports. According to this author, the following objectives
must be met:
1) a correct molar relationship,
2) a correct coronary mesiodistal angulation (tip),
3) a correct coronary labiolingual angulation (torque),
4) absence of rotations,
5) absence of spaces and diastemas and
6) a correct curve of Spee.

Below we describe in detail each of the Six Keys of Dr. Andrews (Fig. 4)
Figure 4: Andrews Six Keys. a) Key 1: interarch relationship (7); b) Key 2: crown inclinations; c)
Key 3: crown torque; d) Key 4: absence of rotations; e) Key 5: absence of spaces; f) Key 6: correct
curve of Spee .
 Another document that serves as a guide to obtain functional occlusion objectives are the
requirements proposed by the American Board of Orthodontics (ABO).7 The objectives of the ABO
begins with 1) correct alignment of all teeth, this is obvious and is an important factor to achieve
with any orthodontic treatment and is essential to achieving a good functional occlusion. However,
when we talk about alignment, we are not only talking about crown alignment but also root
alignment in all three planes of space.

The final position of the roots is essential for the stability of any orthodontic case. Crowns
move quickly and on many occasions we think that the tooth has moved “en masse”, but what has
moved is the crown but not the root. This means that when we remove the orthodontic appliances,
the crown returns to the position where the root is located and this simple observation is one of the
main reasons for relapse. Many of the relapses we see are due to this aspect of treatment. In
addition, the correct position of the roots is very important for obtaining periodontal health.8 (Fig.
5)

Figure 5: a) The importance of a good alignment of the crown and root of the upper and lower
incisors for periodontal health, functional occlusion and stability (important to avoid relapse)
 On many occasions, the prescription that we use in lower incisors of -1º and + 6º / -6º if we
want to compensate for class II´s or class III´s respectively is enough to achieve the ideal alignment
of the roots. However, in cases where individual torque is required, we can use brackets with extra
torque or torquing aids such as Warren Springs®.9 (Fig. 6)

Figure 6: Warren Spring® auxiliary to give radiculolingual torque in this case to the lower incisors
in order to correctly position the root prior to a connective graft.

In the upper and lower anterior regions, the incisal edges and lingual surfaces should be used
as reference guide to assess their correct alignment(crowns and roots). The contact points of the 4
anterior teeth plus those of the two canines must be well aligned and the gingival margins of the
lower incisors lingually must also be well aligned. These two aspects help us decide if we have
good three-dimensional positioning of the lower incisors.

The correct alignment of the upper and lower incisors in addition to the obvious importance
of aesthetics is also of great importance in terms of function. The position of the incisors plays a
fundamental role in condylar position, in the correct arc of closure, in the anterior guide and in
long-term stability.10 (Fig. 7)
Figure 7: Post orthodontic case where the incisors lack torque and as a consequence the condyles
are subsequently impacted in the fossa.

A clear example of the relationship of the position of the incisors and its impact on the
condylar position is evident in Class II-2. When we have a lack of torque in the incisors and
therefore a greatly increased interincisal angle, this affects the condylar position which is a factor of
occlusal instability and that can lead to many problems such as TMD dysfunction, tooth wear,
changes in the chewing pattern and the onset of parafunction. 11 (Fig. 8)

Figure 8: Class II division 2 case with clear posterior impaction of both condyles.
 However, when the incisors are very protruded and we have a diminished interincisal angle,
this closed angle produces poor anterior guidance due to an insufficient overbite and in turn does
not allow for posterior disocclusion. The lack of posterior disocclusion produces interferences that
results in wear facets and condylar positional changes.10

In the posterior region of the upper arch, the ABO uses the mesiodistal central grooves of the
premolars and molars as a reference for evaluating alignment. In the lower arch, apart from the
grooves it also takes into account the buccal cusps of the premolars and molars.7

While the ABO in the lower arch only takes into account the buccal cusps of premolars and
molars, we, as in the upper arch, also take into account the alignment of the central grooves. (Fig. 9)

Figure 9: The grooves and cusps of molars and premolars must be correctly aligned with each other.

One of the most frequent errors seen in the evaluation of cases by the ABO is the
misalignment of the second molars. For this reason, we insist that the second molars must be
banded or bracketed and incorporated into the arch in all cases. (Fig. 10)
Figure 10: Note the lack of alignment of the second molars as these teeth are not included in the
appliance.

Failure to include them can cause interferences (fulcrums) that are responsible for a long
chain of pathological situations as outlined in the following table. (Fig. 11)

Figure 11: Consequences of the fulcrum.

 On many occasions, the aforementioned fulcrums will be the cause of a slide between the
maximum intercuspation and the stable condylar position (CO-CR), being one of the most
important reasons for relapse in all three planes of space.12 (Fig 12)

Figure 12: Post orthodontic relapse (anteroinferior crowding) as a consequence of the posterior
fulcrum and CO-CR slide.

These posterior interferences or fulcrums can also cause temporomandibular dysfunction.13

(Fig 13)
Figure 13: a) Schematic drawing of how the CO-CR discrepancy can be the cause of
temporomandibular dysfunction, wear and occlusal trauma due to mandibular advancement as a
consequence of a fulcrum. Courtesy of SAM®. b) Clinical example of a CO-CR discrepancy.
Courtesy of Dr. Kazumi Ikeda.

In addition, the fact of not incorporating these molars in the arch during orthodontic
treatment can often cause a greater loss of anchorage.

We recommend too routinely draw the grooves of the molars and premolars with a pencil on
the models to have better visualization of the existence or not of posterior alignment. We sometimes
draw these grooves directly in the mouth with a pencil to once again better visualize the alignment
of the grooves. In other occasions we do it on the intra treatment models obtained from the patient
during treatment and this helps us finish the cases with ideal posterior occlusion. (Fig. 14)

Figure 14: Molar and premolar grooves marked with pencil in order to more clearly visualize the
posterior alignment.
 The second aspect that the ABO takes into account is the levelling of the marginal ridges.
This will have a direct relationship with the cusp-fossa relationship of the opposing teeth and is
essential for good posterior occlusion. (Fig. 15)

Figure 15: Occlusal contact points when there is a correct cusp-fossa relationship.

Posterior alignment is essential to obtain orthopedic stability, that is, simultaneous bilateral
contacts between the upper and lower teeth and a vertical pattern of chewing with a single arc of
closure. (Fig. 16)ç

Figure 16: Simultaneous and bilateral contact points in a single vertical closing arch.
 Furthermore, the correct alignment of the marginal ridges is directly related to the curve of
Spee and maximum intercuspation. (Fig. 17)

Figure 17: It is important during our treatment to flatten the curve of Spee so that there is a good
posterior occlusion and thus avoid interference in working and balancing.

The curve of Spee is necessary to maintain an efficient masticatory system, an adequate

muscular balance and an ideal functional occlusion.14 The levelling of the curve of Spee is achieved
sometimes by intrusion, sometimes with extrusion and at times with protrusion of teeth,.Whatever
mechanics is used for the levelling of the curve of Spee, the treatment mechanics used for each
patient needs to be determined individually by the VTO (Fig. 18)
Figure 18: Examples of levelling of the curve of Spee. a) Flattening of the lower curve of Spee with
archwires with inverted curve of Spee and microscrews between canine and first premolar (indirect
anchorage) b) Flattening of the inferior curve of Spee with archwires with inverted curve of Spee
and microscrews between lateral incisor and canine (direct anchorage) c) Upper and lower utility
arch.
 The fact of having the marginal ridges, the cusps and the fossae at the same level will
produce an alignment of the cementoenamel junction. This limit should be 2mm from the alveolar
bone in patients with a healthy periodontium. This will automatically level the alveolar bone and
therefore promote periodontal health.15 (Fig. 19)

Figure 19: Post-treatment orthodontic orthopantomography showing a correct levelling of the

alveolar bone.

Another aspect that the ABO takes into account, like Andrews in the 6 keys of occlusion is
the bucolingual inclination (torque) of the teeth. The fact of having adequate torque of the anterior
teeth will also be essential when it comes to achieving a good functional occlusion. A lack of torque
of the anterior teeth will make difficult to achieve a correct canine and molar class I. (Fig. 20)

Figure 20: The lack of torque of the upper anterior teeth will not allow a correct molar and canine
class I relationship. Image by: Andrews LF. Straight wire. The concept and appliance. 3ed. San
Diego, CA: L.A Wells; 2003.
 From a functional point of view, the lack of torque of the upper incisors can cause the
condyle to displace distally, often producing joint symptoms due to compression of the bilaminar
area.11

The correct position of the roots of the upper anterior teeth within the alveolar bone (torque)
continues to have a double occlusal and periodontal benefit. When good torque is achieved, the
extremely fine anterior bone of the maxilla is protected, as shown by the studies by Braut et al15
using CBCT images. These studies affirm that the thickness of the alveolar bone at the
anterosuperior region, in most cases is very thin (the greatest thickness would be between 0.5 to 0.7
mm), being greater than 1mm in only 4.6% of the central incisors. (Fig. 21)

Figure 21: Roots correctly positioned within the alveolar bone (torque).

A similar situation occurs in the upper canines where the vestibular bone is very thin, for this
reason we prefer to avoid using negative torque prescriptions for the canines in order to avoid
producing dehiscences and fenestrations. The negative torque of the canines also does not protect
the fundamentals of occlusion, since this negative torque can in many occasions limit Bennet's side
shift by invading the space necessary for this movement to occur. This in many instances can be the
beginning of parafunctional movements. (Fig. 22)
 Figure 22: a) Dehiscence of canines. Note how thin the buccal table of the alveolar bone is,
so we must take it into account when correctly positioning the teeth within it. b) case with excessive
coronolingual torque where the bulge caused by the root of the canine can be appreciated. This can
lead to dehiscence and fenestrations in the vestibular bone.

In fact, there are many cases in which we use “working brackets”. These are brackets that
have + 20º torque, (-20º if we place them upside down) and this helps us correct the torque and
place the roots within the alveolar bone. Once this is achieved, we reposition the bracket
corresponding to the tooth with the normal prescription. The working brackets are valid for both
maxillary and mandibular canines. In addition to this beneficial effect of the periodontium,
achieving a correct position of the canines will be essential in lateral movements and in achieving a
vertical chewing pattern. (Fig. 23)
Figure 23: a) Case where coronobuccal torque of the canines is observed thanks to the use of
working brackets. b) pre and post-treatment smile where positive torque has been given to the
canines and bicuspids.

Regarding the arch shape that we must achieve during dental alignment, our preferences are
wide arches at the anterior region and semi-flat in the buccal segments. We like to achieve
maximum bicanine width possible within the biological limits. This type of arch will allow a correct
disocclusion in lateral movements and good interdigitation and function (avoiding interferences).
The narrower the arch in the anterior area, the more difficult it is to achieve good disocclusion in
the lateral movements. In addition, this position of the canines visually produces greater arch width
and aesthetically a wider smile. (Fig. 24)

Figure 24: FACE archform.

 Regarding posterior torque, the prescription of the molar tubes will play a fundamental role
in obtaining the correct roque necessary. Obtaining correct torque will be critical, especially of the
maxillary second molars, which in many cases present positive torque with “hanging” palatal cusps.
This alone can be responsible for the increase in the Wilson curve, producing the much dreaded
“fulcrum”16. (Fig. 25)

Figure 25: Orthopantomography where the fulcrum caused by the upper second molars can be seen
and how this changes the condylar position.

The so-called fulcrum is an occlusal interference that we previously mentioned in this article with an
explanatory diagram of all its consequences. The flattening of the Wilson curve will be key in eliminating
interferences (fulcrums) and is a critical factor in order to obtain orthopedic stability. (Fig. 26)

Figure 26: Posterior view of pre and post-treatment models showing how the Wilson curve has been
flattened with treatment (essential to obtain orthopedic stability). Courtesy Dr. Jorge Ayala.
 Knowing the negative consequences that a fulcrum can produce, it is essential to correct the
torque of the second molars. For that we have:

1.) Transpalatal bars (Fig. 27)

Figure 27: Transpalatal bar to correct the torque of second molars. Courtesy Dr. Jorge Ayala.

2.) Buttons on the lingual of the second molars to be able to use elastomeric chains linked to
the transpalatal bars on the first molars to help change the position of the palatal cusp . 17 (Fig. 28)

Figure 28: Lingual buttons on the second molars used to correct the torque with a transpalatal bar
on the first molars and elastomeric c-chains.
 3.) Molar tubes with -30º torque of the FACE prescription. Many may think that -30º torque
(Face Evolution® - Forestadent) is excessive but we know from research that the play that exists
between the tube and the arches can reach -17.8º (with 0.019x0.025 of steel). For this reason we
developed the tubes with -30º torque, to compensate for the play in the archwire/tube interface.
Thanks to these tubes we can obtain our objective of flattening the curve of Wilson more
efficiently18 (Fig. 29)

Figure 29: Examples of cases where the positive torque of second molars has been corrected thanks
to the prescription of the tubes.
 4.) Micro-screws placed palatally: this will help us intrude the palatal cusps and in turn
flatten the curve of Wilson.19 (Fig. 30)

Figure 30: Microscrews placed in palatal position to give negative torque to second molars.

The inadequate torque of the first and second molars can have harmful consequences due to
the imprecise distribution of the lateral and oblique occlusal and masticatory forces. These forces
are aggravated when the condyle is poorly positioned in the glenoid fossa in any instances due to
improper torque of the posterior teeth. When the occlusal forces are distributed along the
longitudinal axis of the posterior teeth(physiological forces), this reduces the occlusal overload and
the forces are evenly distributed. As Okeson20 rightly says, “orthopedic stability exists when the
stable intercuspal position of the teeth is in harmony with the stable musculoskeletal position of the
condyles in the fossa. When this relationship exists, functional forces can be applied to the teeth and
joints, without damaging the tissues” (Fig. 31)
Figure 31: Orthopedic stability: harmony of the stable musculoskeletal position of the condyles with
the stable intercuspal position of the teeth. Image courtesy Dr Ryan Tamburrino.

When Orthopedic Instability exists as described by Okeson20, there is a lack of harmony

between the stable musculoskeletal position of the condyles and the intercuspal position of the
teeth. The occlusal and masticatory forces are not distributed uniformly and there is a concentration
of forces that can produce occlusal overload which is responsible for such problems as dental wear,
periodontal changes and TMJ alterations. (Fig. 32)

Figure 32: Orthopedic instability: lack of harmony between the stable musculoskeletal position of
the condyles and the intercuspal position of the teeth. Image courtesy Dr Ryan Tamburrino.
 With our orthodontic treatment we should do everything possible to change a horizontal
chewing pattern for a vertical chewing pattern where there is no need for adaptation.Adaptation on
many occasions is synonymous with tooth wear, abfractions, recessions, and joint problems.

In order to distinguish between what is orthopedic stability or instability, there is no doubt

that an articulator mounting will help us enormously. The mounted models will facilitate diagnosis
in all three planes of space (vertical, sagittal and transverse) from a stable musculoskeletal position
of the joint.21

The first articulator mounting (pretreatment mounting) helps us identify the amount of
discrepancy that exists between the musculoskeletally stable position (centric relationship) and
maximum intercuspation. In addition, it allows us to know exactly where the first contact or
fulcrum is and which is the cause of the discrepancy in order to be able to eliminate it. This is a
decisive first step in order to achieve excellent finishing. An undiagnosed vertical problem will
make it difficult to achieve good intercuspation of the posterior teeth. Diagnosis is the key to
excellent finishing.22 (Fig. 33)

Figure 33:Mounting of pretreatment models. Existence of RC-OC discrepancy in the same case.
 Doing an intra-treatment mounting at approximately mid-treatment is a critical step toward
ultimate success. We cannot stress enough the importance of stopping and rethinking a treatment
plan when you have achieved 70-80% of your goals. A good analogy is when you go on a trip and
you want to know where you are (you know where you started from) and be able to get to the goal
without taking too many round trips. The intra-treatment mounting gives us a lot of information in
the three planes of space that will help us finish the case achieving all the treatment objectives. Our
experience shows us that thanks to intra-treatment mountings, the duration of treatment is shortened
by between 3 and 5 months since it helps us to go directly to the objective without taking detours.
This mounting helps us plan the proper treatment mechanics needed to finish the case. For example,
if vertical control is needed, the occlusal and skeletal relationships in all three planes of space and
informs us of approximately how much time remains to finish treatment. (Fig. 34)

Figure 34: a) Mounting of intra-treatment models. There is still a RC-OC discrepancy that we must
correct. b) First contact causing RC-OC slide.
 In this phase of the treatment, it will be important to accompany this mounting of models
with facial and intraoral photographs, as well as a panoramic radiograph in order among other
things, to assess the degree of root parallelism or the presence of root resorption. A lateral
teleradiography is also recommended, which will allow a vertical and sagittal assessment of the
position of the incisors. As a general rule in the vertical plane the incisal edge of the upper incisor
should be 3-4 mm below stomion superior and the incisal edge of the lower incisor should be at the
height of stomion superior. In the anteroposterior direction, the upper incisor should be at or slightly
in front of ENA(anterior nasal spine) never behind and the lower incisor at Pg (especially in a
mesofacial class I patient). Although these parameters are important, it is even more important that
the incisors are well positioned within the alveolar bone of the palate and the alveolar bone of the
symphysis.23 (Fig. 35)

Figure 35: Intra-treatment assessment of the position of the upper and lower incisors in the sagittal
and vertical planes. Image courtesy Dr Renato Cocconi.
 Another of the most important aspects of intra-treatment records (setup, photos, X-rays…) is
that it allows us to accurately visualize the position of the brackets of all the teeth in both arches.
We all know how important it is for a good finish that the brackets are perfectly cemented in the
three planes of space. However, the visualization that is made of brackets positions directly in the
mouth has nothing to do with what is seen on the models. You are amazed at how many braces you
have to recement when you incorporate this procedure on all of your patients. On the other hand, it
is one of the fundamental keys to finish the case perfectly. Once the braces are recemented, it is
surprising to see how the case improves in a short time and those favorable changes are essential to
finalize the case.

The post-treatment mounting carried out approximately 3 months after removing the
appliances (to allow the teeth to settle) will be of great help to us when it comes to visualizing small
interferences that will prevent us from achieving our goal of orthopedic stability in the long term.
To resolve these small interferences, we resort to occlusal adjustment, which consists of the
elimination of prematurities in inclined planes and non-functional cusps. These post-treatment
models are used to first make an occlusal adjustment on the plaster models and then transfer it to the
mouth to achieve functional stability RC = OC.24 (Fig. 36)
Figure 36: a) Post-treatment mounting. In the upper picture before occlusal adjustment and in the
lower picture after occlusal adjustment. b) Time of occlusal adjustment.

When we make an occlusal adjustment we rely on the following scheme to remember the
dental contact points necessary for occlusal stability. (Fig. 37)

Figure 37: Image for occlusal adjustment. In each chair of our clinic there is a copy of the occlusal contacts
that helps us when making adjustments.
 A tool to achieve even greater precision with the final occlusion, that is to say, simultaneous
and homogeneous bilateral contacts, we use OccluSense® (Bausch), which is an electronic device
that reproduces digitally the occlusal contacts using a special occlusal paper with sensors theat
register the patient's occlusal contacts. Those contacts appear on the screen of the computer/tablet
and that helps us to know where we have to make the occlusal adjustments. (Fig. 38)

Figure 38: Occlusense® helps us to be more precise in our adjustments

The post-treatment mounting will also be a good tool for communication between specialists
in multidisciplinary cases in which the final treatment plan requires prosthetic treatment in order to
achieve all the goals.25 (Fig. 39)

Figure 39: Waxing on post-treatment orthodontic models for the prosthodontic phase. In the past it
was done in an analog way; Today we have programs that allow us to make these wax-ups virtually
after a scan of the mouth.
 Regarding the overbite that we must achieve at the end of treatment, we see often how many
cases fail in this aspect by leaving an incomplete overbite for example less than 3mm of overbite.
Overbite is very important we want to achieve adequate anterior guidance, the lack of sufficient
overbite does not allow a correct posterior disocclusion the so-called Christensen phenomenon.26

This phenomenon occurs when during protrusion or lateral movements of the mandible the
condyle resting on the eminence as it moves forward descends downwards, achieving the
disocclusion of the posterior teeth. During eccentric movements there must be a total absence of
contacts of the posterior teeth. Thanks to the disocclusion, interferences that can cause so much
damage are avoided. This in many instances is responsible for occlusal instability which in turn can
produce dental wear which leads to loss of vertical dimension and temporomandibular alterations.
To avoid interferences, our experience tells us that incisor guidance is achieved when we have at
least 3 to 4 mm of anterior overbite. (Fig. 40)

Figure 40: Ideal overbite drawing.

 The correct amount of overbite also helps us obtain correct exposure of the upper incisors at
rest. If the lower incisor are well positioned vertically that is to say at the height of upper stomion
and there is an overbite of 4mm that automatically produces an ideal exposure of the upper teeth at
rest. A good exposure of the incisor at rest facilitates good incisor guidance and also favours
proprioceptive closure, functionally helping the mandible to close in a stable arc of closure. If the
lower incisor coincides vertically with upper stomium and the upper incisor has 3 to 4 mm of
overbite this automatically gives us all the aesthetic and functional objectives. (Fig. 41)

Figure 41: Ideal relationship of the incisors to the lips. Rufenacht CR. Fundamentals of Esthetics. Chicago,
Illinois: Quintessence Publishing Co; 1990.

Regarding overjet and according to the ABO criterion, it must be zero, that is, there is
contact (proprioceptive) between the upper and lower incisors at the same time that the posterior
teeth enter into occlusion. However, when measured from the buccal aspect of the upper incisor to
the buccal aspect of the lower incisor. when these contacts are present there is usually a 2-3 mm
overjet That is why differences appear between "0" mm and "2 to 3" mm when speaking of overjet
if we use dental contacts or vestibular surface of the incisors as reference. (Fig. 42)

Figure 42: a) Ideal overjet measured using incisor edge; b) or occlusal contact.
 We must not forget that these ideal measurements of overjet and overbite are also directly
related to the correct anatomy of the crowns and the harmony of the skeletal bases. When these are
not ideal is when dental compensations(protrusion or retrusion of the incisors) are necessary when
we have a class II or class III skeletal relationship.

A cephalometric measurement reference that is very useful is the WITS index27, which, by
drawing perpendicular lines, relates point A and point B with respect to the occlusal plane (points
AO and BO). The normal values according to the authors will be -1 for men and 0 for women, so
that as the WITS value moves away from these values, the greater the differences between the
skeletal bases. The greater the dentoalveolar differences the more dental compensations will be
needed. The more the discrepancy the more difficult it becomes to obtain the ideal overbite and
overbite. Based on a good diagnosis, we will know this before starting the treatment and we will be
able to resort to either camouflage treatment, prosthodontic rehabilitation or orthognathic surgery to
resolve the skeletal discrepancy (Fig. 43).

Figure 43: Witts Analysis.

 Another aspect that we consider important to achieve the desired functional occlusion is that
the cusp of the upper canine must rest between the lower canine and the first premolar. It’s place is
not in the center of the embrasure between the canine and the bicuspid, as can still be seen in many
texts. The tip of the canine should have a slight mesial relationship to the distal marginal ridge of
the lower canine. This slight mesial inclination will be decisive for achieving good canine guidance
during lateral movements as it facilitates posterior disocclusion.28 (Fig. 44)

Figure 44: Note the tip of the canine with a slight mesial relationship with respect to the distal marginal
aspect of the lower canine.

Another of the most important factors when finishing a case is taking into account the
importance of the finishing sequence. The teeth have to be placed in their ideal position following a
logical sequence that takes into account function and aesthetics. The first thing we have to be clear
about is the importance of finishing the lower arch first. The main reason we need to finish the
lower arch first is the position of the lower incisor. The lower incisor is the template for placing the
upper teeth. If we finish the upper incisors first and if the lower incisors are not where they should
be according to the cephalometric objective planned by the V.T.O, it will be necessary to reposition
the lower incisors to obtain the desired result. This movement called “round tripping” opens the
possibilities for root resorption and without any doubt unnecessarily lengthening treatment time.
When doing the V.T.O and placing the upper incisor over a well placed lower incisor, all dental and
skeletal objectives and functional and aesthetic objectives are taken into account.
 Knowing this very important aspect, the perfect sequence to routinely finish a case in an
ideal way is to first place the lower incisor in its ideal position in the three planes of space, then the
lower canines are placed with their correct torque and inclination. ideal to be able to get adequate
canine guide. The next thing is to place the lower buccal segments aligning the marginal ridges, the
occlusal grooves and the buccal cusps.Once the teeth are ideally positioned from the incisors to the
molars, the next thing is to flatten the curve of Spee and obtain a correct arch shape .

Once an optimal lower arch has been obtained, the upper arch begins with the molars. The
second molar and the first molar have to be aligned by levelling the marginal ridges and occlusal
grooves. Once their torques have been aligned and corrected, we place the premolars by re-aligning
the occlusal grooves, the marginal ridges and the buccal cusps. Next the upper canines and the
importance of the ideal torque (preferably positive torque) to give aesthetics and function. When
placing the upper canine, the correct inclination is very important to obtain an adequate canine
guide that will avoid interferences both in working and in balancing. Finally, the upper incisors are
placed with their ideal torque, their correct inclination with respect to the lower incisor. Now it is
understood why we give so much importance to the lower incisor (Fig. 45)

Figure 45: Our objective is to finish the lower arch before the upper arch, however, sometimes for
various reasons the upper arch is advanced with respect to the lower arch and in those cases we put
closed coils to stop moving teeth in the upper arch and continue in the lower arch until we are ahead
in the lower arch.
 In cases of two upper bicuspid extractions (4 + 4) and where we are going to leave a class II
molar relationship, it will be important to achieve the following objectives to finish the case
excellently:

1) A class II molar relationship and a class I canine relationship

2) An increased radiculolingual torque of the upper incisors
3) A mesially rotated first molar (use 0º rotation tubes to occupy more space and thus compensate
for the Bolton discrepancy)
4) A mesially rotated second premolar
5) Occlusal adjustment of the mesiolingual cusp of the first molar and sometimes the mesiolingual
cusp of the second molar. (Fig. 46) .29

Figure 46: a) Occlusal drawings in cases of upper premolar extractions where a class II molar is
present Andrews LF. Straight wire. The concept and appliance. 3ed. San Diego, CA: L.A Wells;
2003. b) Clinical case with extraction of 2 upper bicuspids 16 years post treatment.
 In those cases in which there is a large amount of wear on the posterior teeth, it will be
preferable not to achieve posterior contacts and rather intrude these teeth, leaving a posterior space
that allows for the restoration of these teeth. During treatment (once intruded) we must reconstruct
these worn molars either with temporary crowns or with provisional composite restorations before
the final restoration of the molars after removal of the appliances. The posterior cusps (centric
stops) are vital for maintaining the vertical dimension and maintaining the stability of the condyle in
the fossa. As we can see, they are very important for orthopedic stability.30 (Fig. 47)

Figure 47: a) intrusion of premolars and provisional reconstruction. b) Once the premolars have
been reconstructed, we proceed to remove the occlusal stops on the first molars to later reconstruct
these teeth provisionally and thus recover the patients correct vertical dimension.

Regarding the inter-arch relationship transversely, in order to achieve a correct functional

occlusion, it will be essential to achieve well-positioned posterior teeth (centered and straightened)
in the alveolar bone. This will also give long-term stability of the dentition, health of the
temporomandibular joint and health of the periodontium. (Fig. 48)
Figure 48: Molars with correct torque and correctly placed post orthodontics.

Therefore, the first thing we need to do and it is essential, is a correct diagnosis of possible
transverse skeletal discrepancies between both the maxilla and the mandible. Good transverse
skeletal relationship will be necessary for good molar relationship once the teeth are correctly
positioned in the bone. To diagnose this aspect, the use of CBCT and in our case the Penn
Analysis31 is important for a correct cross-sectional measurement. Ideally, the width of the maxillary
alveolar bone should be 5mm (2.5mm / side) greater than that of the mandible. Of course, in the
case of small variations, this can be orthodontically compensated and therefore between +2 to +5
mm of discrepancy is acceptable. If the difference is less than 2 mm, the maxillomandibular
transverse discrepancy should be solved with either orthodontic maxillary expansion or surgically
depending on the severity of the discrepancy if we want to achieve good interrarch relationships.
For this we have SARPE, MARPE, corticotomies, orthognathic surgery, etc. (Fig. 49)
Figure 49: Penn analysis a) location of the points where the transverse measurement is made b)
measurement made of the maxillary and mandibular alveolar bone. c) ideal transversal
 For all the aforementioned, it is convenient when we are going to perform expansion of the
maxilla of cases that have dental compensations, we first start by decompensating the molars and
bicuspids. It is important to correctly position them within the alveolar bone in order to know
exactly how many mm of expansion are necessary to achieve a good transverse relationship.32 (Fig.
50)

Figure 50: a) It is important to assess the cross-sectional problem once the molars have been
decompensated. B) Clinical case where a quad helix has been used to decompensate prior to
expansion with a Hyrax-type expander.
 We must also take into account the importance of the frontal occlusal plane (cant). In order
to achieve a good finish, this aspect of the skeletal bases is very important. It is necessary to have
the two frontal occlusal planes perfectly level with the bipupillary plane. 33

Excellent finishing, on excellent bracket position.Therefore, the key to success in finishing

is to recement brackets regularly throughout treatment. Dr Roth used to repeat frequently "do not
wait until the end of the treatment to recement brackets, do it the minute you see a poorly cemented
bracket, change it immediately". We cannot expect to obtain an excellent finished case with the
same bracket position throughout treatment. Although it is true that since the incorporation of
digital planning of the position of the brackets and indirect bonding this need has been greatly
diminished. But despite of all these advances, it is essential for a good finish to reposition brackets
on a regular basis throughout treatment. (Fig. 51)

Figure 51: a) Digital planning of the position of each bracket b) Indirect bracket placement splint.
 For example, the correct positioning of brackets will play a fundamental role in cases of
correction of cants of the occlusal plane. We must remember that the occlusal plane must be parallel
to the bipupillary plane. The cementing of brackets when the cant is to be corrected should be done
on one side in a more occlusal position than the contralateral side to facilitate the levelling of these
teeth and the plane. (Fig. 52)

Figure 52: Cementation of brackets more occlusal on the right side than the left side in order to
level the cant of the occlusal plane.

With the introduction of skeletal anchorage, the solution of a cant has been greatly
simplified.33 (Fig. 53) In addition to the aforementioned correct positioning of brackets, we have
other treatment strategies that will facilitate excellent correction of the occlusal cant.
Figure 53: a) Activation of the unilateral microscrew for correction of the cant. b) evolution of a
clinical case in which we have corrected the cant with activation from a microscrew placed in the
first quadrant.

Another very important aspect is the introduction of bends in the archwire or the use of
braided archwires that facilitate excellent intercuspation. The great advantage of finishing cases
with braided archwires is that they allow us to recover a single occlusal plane. It must be taken into
account that when we have two very rigid archwires in the upper and lower arch two occlusion
planes are produced, making it difficult for the teeth to occlude. Thanks to the braided wire arches
and their flexibility and with the help of intermaxillary elastics, we convert the two occlusion planes
into a single occlusion plane and this facilitates a perfect intercuspation of the teeth without losing
all the dental movements achieved previously.34 ( Fig 54)

Figure 54: Finishing with braided archwires.

 Although currently somewhat in disuse by the profession, the use of a gnathological
positioner is still the "gold standard" to excellent finishing. Nothing like the positioner to achieve an
ideal occlusion at the end of treatment and an even greater condylar seating.35 This is because the
gnathological positioner is built using models mounted on the articulator with reference to the
patient's arc of closure, which allows a do a set up that respects function by obtaining a RC=OC
relationship.36 (Fig 55)

Figure 55: Manufacturing of gnathological positioner.

 2. DENTAL ESTHETICS

Although it is very difficult to separate function and aesthetics as they are closely related, we
will now go on to explain further the macro and micro dental aesthetics. We will see all the different
aspects of esthetics that we need to take into account to achieve a well finished case.

Details to take into account for an optimal esthetic finish:

1. Dental proportions
2. Dental shape
3. Dental characterization (texture, gloss ...)
4. Incisal edges
5. Colour
6. Dental contacts
7. Dental axis
8. Gingival health
9. Gingival embrasures
10. Presence and height of papillae
11. Gingival zenith
12. Levelling of gingival margins
13. Smile arc
14. Smile symmetry
15. Black triangles
16. Gingival exposure at rest and smile
17. Buccal corridors
18. Midlines
19. Lip volume
20. Facial aesthetics (lower third, lip competence, profile ...)
 Logically, achieving the aforementioned aspects will not always be possible only with
orthodontic treatment. That is why the importance of creating teams and having a good
prosthodontist and expert in dental aesthetics to be able to achieve “all” the objectives. That is why
having a good prosthodontist in the team is essential, as they say "a good orthodontist needs a good
prosthodontist and vice versa”

Dental aesthetics is on many occasions the main motivation of our patients, and that is why
it is of the utmost importance for us. Optimal dental aesthetics depends above all on proportions and
therefore we routinely always measure mesiodistal widths and anterior tooth lengths, in order to
diagnose alterations in proportions and Bolton discrepancies. Day after day, we find ourselves with
the need to do anterior tooth reconstructions in order to solve the problems of lack of ideal
proportions.

Reconstructions of anterior teeth are also essential to obtain our functional objectives since
with wear and tear on many occasions there is no anterior guide and therefore posterior
disocclusion. According to Dr. Peter Dawson founder of the Dawson Academy, "Determining the
correct incisal edges accurately is the second most important decision a dentist must make regarding
occlusion (centric relationship is first in importance)." The position of the incisal edges influences
the aesthetics of the patient's smile, phonetics, lip comfort, functional zone, anterior guidance,
posterior disocclusion, and tooth contour. Therefore, it is essential to understand the reason for the
reconstruction of the incisal edges with prosthodontics.

As we mentioned at the beginning of this article, an incorrect anterior function in many

cases is the cause of tooth wear of the posterior teeth (centric cusps) which in turn produces loss of
the vertical dimension of occlusion that in the long term can have joint implications. Thus the
functional importance of an adequate anterior guide. Provisional reconstructions can be performed
temporarily before starting orthodontic treatment in some cases and in other cases we do it during
treatment. Reconstructions of the dental anatomy before or after treatment are important to know
where to position the teeth for aesthetic and functional purposes. All provisional reconstructions
will be replaced by definitive reconstructions after removal of the appliances.30 (Fig. 56)
 A

Figure 56: a) Provisional pretreatment orthodontic rehabilitation of severe wear that is replaced by
definitive rehabilitation after removal of the appliance. b) Provisional reconstructions performed
intra-treatment once anterior spaces were opened with orthodontics in order to return ideal dental
proportions.
 According to Bob Lee, founder of the Bioesthetic School and based on the study of teeth
without wear, the ideal length of the central incisors and canines should be between 9.6 and 11.7
mm and that of the lateral incisors between 7.8 and 9.5 mm. The lower incisors should measure
between 7.8 and 9.5 mm. It must be evaluated in each case and if it is deficient, such as in cases
where there is dental wear, we must resort to prosthodontics to restore the teeth to an ideal length
and width that allows us to recover their ideal proportions and thus obtain our aesthetic and
functional objectives.37 -43 (Fig. 57)

Figure 57: Morphology and ideal proportions of the anterior teeth. Courtesy of Ken Hunt

According to Dr. Robert Lee, “restoring worn anterior teeth and posterior tooth cusps,
restores the symmetry and beauty of the lips, facial expressions and help obtain the biological
model”.44 (Fig 58)

Figure 58: Restoring worn anterior teeth and posterior tooth cusps, restores the symmetry and
beauty of lips and facial expressions. Dr Robert Lee in: Rufenacht CR. Fundamentals of Esthetics.
Chicago, Illinois: Quintessence Publishing Co; 1990.
 Modern digital programs perform dental segmentation and measurements and the time spent
in the past measuring teeth has been reduced dramatically and even more important greater
precision. (Fig 59)

Figure 59: Digital tooth segmentation and measurement programs a) DDP Ortho b) Orthoanalyzer.
 The anterior superior dental proportions are key to dental aesthetics, and one of the most
used methods to verify this is by using the “golden ratio tool”, which involves measuring the true
width of the central incisors and the apparent measurements of the lateral and canine incisors from a
front view, which must maintain a 1:1.618 ratio. This knowledge comes historically from the
Greeks who attributed an aesthetic character to objects whose measurements kept the golden ratio.45
(Fig 60)

Figure 60: Golden proportions. Courtesy Dr. Ken Hunt.

In addition to the axis of the anterior teeth, the gingival zenith (the most apical point of the
gingival contour) is also important. In maxillary teeth, it is usually located distal to the tooth axis.
Placing the gingival zenith in its ideal position is also a factor to take into account for optimal
aesthetics. In many instances to place the zenith in the correct position we need to change the
position of the brackets in order to tip the incisors and thus correctly position the gingival zeniths. 46
(Fig. 61)

Figure 61: Dental Micro-esthetics - Dental axis and gingival zenits.

 A well finished case must achieve correct angulation of the roots, which should be evaluated
by means of a panoramic radiograph. If the roots between adjacent teeth are divergent and
perpendicular to the occlusal plane, there will be enough bone between the roots. The amount of
alveolar bone between the roots is a determining factor for obtaining interdental papillae,
periodontal health and stability. We know from Tarnow's work that the distance from the
interproximal contact point and the crest of the alveolar bone is of utmost importance for the
presence of interdental papillae. The probability of obtaining papillary is 100% if the distance
measured between the crest of the alveolar bone and the contact point is 5mm or less, 56% if it is
6mm and 27% if it is 7mm or more .47 (Fig. 62)

Figure 62: The importance of the bone-contact point distance to obtain interdental papillae according to Dr
Dennis Tarnow.

There are also other factors to take into account that influence the existence of interdental
papillae. The interproximal contact point, which in turn is influenced by the morphology of the
teeth, the divergence of the roots and the amount of bone present between the roots. In patients with
periodontal disease, the interproximal bone is deficient and it is very common to observe the so-
called “black triangles”. According to Kokich, these black triangles, in addition to the
aforementioned root divergence or the presence of advanced periodontal disease, they can also can
appear in those cases in which the interproximal contact point is short and incisal.48 Another aspect
to take into account in finishing of our cases is to eliminate the black triangles. To resolve this
problem in many instance interproximal reduction of the teeth may be useful, with this flattening of
the proximal surface brings the interdental contact point closer to the alveolar crest and thus helps
close the spaces. Another solution, thanks to the advances in the world of composites, is to model
the dental anatomy in an ideal way by means of reconstructions with these materials (Fig. 63).

Figure 63: a) Factors influencing the appearance of black triangles b) Resolution of black triangles
thanks to composite reconstructions.

An important factor for the aesthetics of the smile is the “smile arc”. This arc if formed by
the relationship of the upper incisal edges with the contour of the lower lip when smiling. It will be
harmonious if the incisal edges of the upper teeth follow the contour of the lower lip. In this regard,
the correct cementing of brackets will play a fundamental role.49 (Fig. 64)

Figure 64: Harmonic smile arc.

 In order to be more precise in obtaining the ideal position of the teeth (zenith, inclinations,
root divergence etc etc), it is important to cement / recement the brackets of the anterior superior
teeth as many times as necessary. And to be even more precise, it is essential to position yourself
facing the patient. In addition, this will also be important to achieve a good levelling of the gingival
margins and the inclinations of the anterior teeth. (Fig. 65)

Figure 65: Correct position for a good cementing of brackets on the anterior teeth .

Another important factor to take into account are the buccal corridors considered as the
space between the vestibular surfaces of the posterior teeth and the labial commissures when the
patient is smiling.50-52

Buccal corridors can be skeletal or dental in origin. Almost all patients with maxillary
hypoplasia, that is, retruded maxillas, suffer from buccal corridors. In these cases it is difficult to
correct this problem only by treating the teeth and for a satisfactory final result it is essential to
advance the maxilla (sometimes advance and expand the maxilla) .However, when the problem is
dental, we can expand, give positive torque to posterior teeth or a combination of both to correct the
buccal corridors.53,54
 What is of utmost importance to correct the buccal corridors is that the canines and
bicuspids have positive torque (we use a working bracket with a torque of +20 in the upper canines
and 0º in the upper bicuspids and the corresponding brackets in the lower arch) that it will give us a
much broader smile and in this way it will also help us to reduce the buccal corridors. Expansion is
undoubtedly important to correct this problem, however posterior expansion may be contraindicated
in cases where we have thin vestibular buccal bone. In these cases we can resort to corticotomies
where the bone will accompany the tooth and correct this problem.55 (Fig. 66)

Figure 66: a) Clinical case where upper arch expansion has been performed thanks to corticotomies
b) Pre and post orthodontic treatment smile after superior expansion with corticotomies; note a
much broader smile with the decrease in the buccal corridors.
 Dental exposure with the lips at rest is also an aspect that we must assess in our patients and
one of our goals is to achieve ideal exposure with our treatment. This is a factor of great importance
if we want to achieve the goal of rejuvenation, and even more so if we take into account that the
exposure of the upper incisors decreases over the years. The ideal exposure is between 3 to 4 mm in
women and 1 to 2 mm in men.56 Once again, in order to achieve this aesthetic objective that is so
important for the final esthetic outcome, we will have to resort to reconstruction of the incisal edges
of the upper incisors with prosthodontics. (Fig. 67)

Figure 67: Exposure of incisors with lips at rest pre-treatment and post-treatment (rejuvenation
objective).

Regarding the gingival aspect, with our treatment we must align and level of the gingival
margins. The margin of the central incisors and canines should be at the same level and that of the
lateral incisors 1 mm below the centrals. (Fig. 68)
Figure 68: a) Drawing where we observe the ideal relationship of the gingival margin between
central incisor, lateral incisors and canines. Image courtesy Dr. Ken Hunt b) Clinical case where we
see uneven gingival margins and corrected thanks to orthodontics

The gingival margins of the posterior upper teeth also play a fundamental role in the
aesthetics of the smile, decreasing from the canine to the molars.57 (Fig. 69)

Figure 69: Drawing showing a correct levelling of the gingival margins of posterior teeth, which
must be descending from the canine to the molar. Image courtesy Dr. Kent Hunt.

An uneven relationship between the components of the smile (lips, teeth and gums) can
generate an unesthetic smile, specially the gummy smile when more than 3mm of gingival exposure
at full smile.

This alteration should be considered at the beginning of the treatment since it can be caused
by a short upper or hypermobile lip, excess vertical maxillary growth or by a passive or active
alteration of the gingival apparatus.58 (Fig. 70)
Figure 70: Orthodontic correction of the gummy smile. Courtesy of Dr. Iñigo Gomez Bollain

In the case of excess gingival exposure the ideal treatment can range from gingivectomy,
flap surgery with or without ostectomy, apical positioned flap or periodontal surgery with
osteotomy in cases of active eruption. 59 (Fig. 71)

Figure 71: a) A gingivectomy performed in a case with altered passive eruption b) a case pre a post
gingivectomy and a clear improvement in the smile.
 At present, the treatment of excessive gum exposure (gummy smile) is treated with
microscrews. The TADS are an ideal anchor to be able to intrude the 6 anterior teeth andintrude the
corresponding gingiva and thus solve the problem. In cases where there is a maxillary vertical
excess, sometimes instead of maxillary orthognathic surgery (impaction), we can compensate it
with microscrews intruding the entire maxilla.60 (Fig. 72)

Figure 72: Correction of the gummy smile by means of anterior microscrews.

CLINICAL CASE

A 26-year-old female patient comes to our office referred by a maxillofacial surgeon.Her

chief complaint is an open bite associated with TMJ pain and craneocervical muscle pain. The
patient does not present any disease or take any medication. The patient was previously treated with
orthodontics when she was 14 years old and has been treated by various specialists to treat her
TMD without success.

After taking records consisting of a complete medical history, intraoral and extraoral
photographs, MRI of the joints, CBCT, and mounted models, the following diagnosis of the patient
was done.

In the frontal view, she has slight facial asymmetry and slight lip incompetence. The upper
midline is centered with respect to the facial midline. Dental exposure at rest is correct, although the
upper incisors are extruded due to the severe wear that the patient presents.

Regarding the smile, we observed increased buccal corridors, generalized microdoncia,

severe dental wear and uneven gingival margins.On the lateral view the patient presents,
maxilomandibular retrusion and a convex biretrusive profile.

The upper lip is somewhat but with good projection. The upper incisors show a lack of
torque as they are compensating for the skeletal class II. The nasolabial angle is obtuse with a
prominent nose. The neck-chin distance is reduced and the lower facial third is slightly increased.

Intraorally, the patient presents a molar and canine class I on the right side and a molar and
canine class II on the left side. The lateral segments of the upper arch are collapsed and there are
compensations (lingualization of buccal segments) in the lower arch.She has a crossbite on tooth 25
and an edge-to-edge bite of 24 and 44 due to maxillary compression. The lower midline is deviated
2 mm to the left. There is slight upper and lower crowding. Wilson's curve is greatly increased. The
patient presents a complete open bite and in a stable condylar position she only has one contact in
the upper right second molar.
 The patient presents generalized gingivitis, especially of the anterior teeth. There are no
recessions or abfractions. There is severe dental wear, especially of the anterior teeth which
produces uneven gingival margins. The first molars present amelogenesis imperfecta with a crown
on the upper right first molar. (Fig. 73)


Figure 73: Pretreatment records a) extraoral photographs b) intraoral photographs c) models

mounted on the articulator.

Radiological Study:

In the panoramic radiograph we can observe a slight horizontal bone loss but without
periodontal vertical defects. There are morphological differences in the right and left TMJ. There
are no missing teeth except for the wisdom teeth that were extracted. On the lateral head x-ray and
the cephalometric analysis she has a skeletal class II with mandibular retrusion and a dolichofacial
skeletal pattern.
 With the CBCT we can see that the right condyle (in sagittal view) has an increased
functional space, which indicates that there is a distraction of the condyle and a decrease in its size.
The condyle is well corticalized but it has undergone morphological changes. A reduction in the size
of the head of the condyle and a flattening in its shape have occurred. In the coronal view we see an
increased functional space with a slight medial displacement of the head of the condyle. This
increased space is in many cases the reason for joint noises and disc displacement.

The CBCT images of the left condyle (in sagittal view) show normal anatomy, the only
finding is a slight flattening of the head of the condyle. The shape, size and morphology are within
normal. Functional spaces are adequate. In the coronal view we see that the functional spaces are
correct, although we do see a slight lateral displacement of the condyle due to a functional deviation
produced by a posterior occlusal interference.

Looking at the MRI of the TMJ, in the right condyle we see a total displacement of the disc
without reduction and a limitation in the range of motion. Similarly, we see a flattening on the head
of the condyle and a small osteophyte projecting from the anterior area of the condyle. The disc is
displaced, amorphous and is probably responsible for her limitation on opening. In the left TMJ the
disc is slightly anterior, but with normal anatomy. We also see a limitation on opening, but much
less than that presented on the right side. The disc is normal and functions properly, accompanying
the condyle throughout its movements. (Fig. 74 and 75)
Figure 74: Pretreatment radiological study a) panoramic radiograph b) lateral head x-ray and frontal
x-ray c) right and left TMJ (CBCT) sagittal and coronal view.
Figure 75: Magnetic Resonance Imaging (MRI) of the right and left TMJ’s.
 In summary, the patient presents a skeletal class II, mandibular retrusion and posterior
rotation. The skeletal pattern, condylar resorption, and mandibular posterior rotation are responsible
for the skeletal and dental open bite. In addition, she presents a slight maxillary hypoplasia, which
produces a maxillomandibular biretrusion. There are also dental compensations of the upper
incisors due to the mandibular retrusion and also due to previous orthodontic treatment.

The CO-CR discrepancy is caused by a premature contact of the upper right second molar,
which is related to the TMD signs and symptoms, tooth wear and muscle pain.

Treatment:

Treatment began with periodontal treatment consisting of hygiene and motivation

instructions. Once the periodontal condition improved, we cemented upper fixed appliances to
align, level and recover torque of the upper incisors. (Fig. 76)

Figure 76: Cementation of upper fixed appliances to align, level and torque upper incisors.

Once the upper arch was levelled, the patient began treatment with a repositioning splint.
During splint treatment she was seen by a physiotherapist to relax muscles, recover neck and body
posture and elongation and stretching of the condylar capsule was done to recover functional spaces
and thus alleviate the joint and muscular symptoms. (Fig. 77)
Figure 77: Complete condylar repositioning splint.

Once the stable condylar position was achieved and the joint and muscular symptoms
eliminated, new records were taken and the final treatment plan was carried out. CBCT images of
the condyles demonstrate how the right condyle has seated and healing of the joint has occurred as
seen by the addition of a osteophyte.(Fig. 78)

Figure 78: Right and left TMJ (CBCT) sagittal and coronal post-splint view.
 With the post-splint mounting, a diagnostic set up was performed to determine if the
problem was vertical, transverse or sagittal and thus decide the definitive treatment plan (Fig. 79)

Figure 79: Diagnostic set up on post-splint mounted casts.

Once we diagnosed the case mainly as a vertical problem, we cemented brackets and later
we placed the skeletal anchorage (miniplates). The skeletal anchorage was placed on each side of
the maxilla to allow intrusion of the molars. In order to avoid increasing the torque of the teeth
when intruding, we placed a transpalatal bar with hooks on the first molars to be able to lingualize
the upper second molars. (Fig. 80)

Figure 80: Intra-treatment photographs a) cementation of upper brackets b) skeletal anchorage

(miniplates) on the vestibular and transpalatal bar with hooks for torque control of 7 + 7 by palatal.
 In the lower arch, since the splint was removed composite bite raiser were placed to keep the
condylar position stable and assist in the intrusion of the molars to facilitate vertical control. On the
other hand, the 15-14-24-25 brackets were recemented upside down to give radiculovestibular
torque and thus counteract the “flaring” effect that occurs during the intrusion of the molars and
premolars. (Fig. 81)

Figure 81: Intra-treatment photographs: cementation of lower brackets and placement of bite raisers
to maintain a stable condylar position. In the upper arch, recementation of brackets 15, 14, 24 and
25 upside down for radiculovestibular torque and thus avoiding buccal segment (flaring) during the
intrusion of the molars.

Thanks to the intrusion of the posterior teeth (molars and bicuspids), the open bite was
closed. (Fig 82)

Figure 82: Intra-treatment photographs: complete closure of the open bite.

 The multibrackets fixed appliances were removed after 20 months (Fig. 83)

Figure 83: Post-orthodontic intraoral photographs (the day of removal of the appliance).

The patient was referred to her prosthodontist where a final wax-up (positive and negative
coronoplasty) was done on the post-treatment mounting. (Fig. 84)

Figure 84: Waxing after an occlusal adjustment to reduce the vertical dimension (positive and
negative coronoplasty) on post-orthodontic models mounted on an articulator prior to the final
prosthetic rehabilitation.
 Using the final wax-up, silicone keys were constructed that were used to transfer the
information to the mouth. The teeth were reconstructed with composites (Fig. 85)

Figure 85: Intraoral photographs after final prosthetic restoration.

With treatment, facial changes have improved dramatically. The final facial pictures seem like she
had orthognathic surgery. Thanks to vertical control, we have achieved autorotation of the
mandible, we have shortened the lower facial third of the face, we have increased the projection of
the jaw (chin), we have increased the neck-chin distance and we have improved lip competence and
lip projection thanks to to shortening of the lower third. We have also improved lip support by
giving the incisors adequate torque. Due to the movements made and the reconstruction of the teeth,
we now have an aesthetic improvement of the smile and a correct exposure of the upper incisors at
rest. Lip competence has been completely restored.

Regarding the occlusion, a perfect molar and canine class I has been achieved and the
overbite and overbite have been corrected. The deviation of the lower midline has been completely
corrected. Dental anatomy, size and proportions have been restored thanks to dental reconstructions.
Transversely both arch forms have been corrected and the crossbite resolved. (Fig. 86)
Figure 86: Post-treatment records a) extraoral photographs b) intraoral photographs.

After performing occlusal adjustment with the help of a post-treatment mounting and the
OccluSense®, the premature contacts have been eliminated and therefore we can see how centric
occlusion coincides with maximum intercuspation. There is no longer a discrepancy between RC-
OC and therefore we have achieved the much desired orthopedic stability. (Fig. 87)

Figure 87: Post-treatment mounting.

 The patient no longer has joint sounds, no more muscle symptoms or headaches or neck
pain and a stable occlusion with all teeth having bilateral simultaneous contacts. There is a
functional occlusion, with a disocclusion in protrusive and lateral movements. Without any doubt
we have achieved orthopedic stability.

The post-treatment images of the condyles show how during treatment we have maintained
the condyles in a correct position, and they are completely corticalized and with total healing as
seen with the osteophyte. (Fig. 88)

Figure 88: Final right and left TMJ images (CBCT).

In the lateral headfilm and subsequent tracing, the cephalometric values show that vertical
control has been effective, producing mandibular autorotation. There has been a change in the
occlusal plane and a correct overbite and overbite have been achieved. (The headfilm shown is after
the removal of the appliances but prior to prosthetic rehabilitation) (Fig. 89)
Figure 89: Post-treatment lateral x-ray (we finished with a slightly increased overjet to be able to
reconstruct the lower incisors with composites to obtain function (anterior guide) and recover tooth
anatomy)

Finally, as we have seen in the majority of patients treated with vertical control, mandibular
autorotation has had a positive effect on the airway. (Fig. 90)

Figure 90: Change in the volume of the airways before and after treatment.
 The 3D superimpositions of the pre and post treatment CBCT reveal condylar
seating(especially of the right condyle) as well as mandibular auto-rotation achieved thanks to
vertical control. (Fig. 91)

Figure 91: Pre and post treatment 3D superimpositions of CBCT. Red: pretreatment; Gray: post-
treatment. a) right and left condyle (sagittal view) b) right and left condyle (coronal view) c)
mandible. Courtesy of Paula Zabalegui.
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