My orthodontist sent me the following treatment update on mutual patient. We have been trying to become more airway aware in our treatment approach to normalize anatomy and avoid removing teeth. This patient is 11.5 years old and is ten months into treatment with a very acute inter-incisal angle. The orthodontist feels premolar extraction may be the best option at this point. Patient is healthy and has no reported signs or symptoms of sleep disturbed breathing. He has not been evaluated by a myofunctional therapist. We did not take a CBCT before beginning orthodontic treatment. I am reluctant to take out premolars but I am not aware of any good alternatives. Thank you for any comments or suggestions. Orthodontist letter follows:

Sean-

Noah started with moderate to severe crowding and my plan called for a therapeutic approach before committing to extractions. Attached is the pre-treatment ceph and the updated progress ceph.

-As you will note, the inter-incisal angle has worsened and is essentially 90 degrees at this point. My long term concern is this leaves him with increased risk for traumatic occlusion and reduced stability. His lip support is good (no issues with lip function or protrusion).

-The torque on #6 is also not optimal and I am lacking in room to bring the root fully into the alveolus.

-Additionally, there is a mandibular asymmetry and we are unlikely to ever have coincident dental midlines and his canine / molar relationship on the right side is weak (close to end to end) and will likely remain so without a TX plan change.

Options to consider moving forward:

1) EXT upper 2nd premolars, EXT LR 2nd premolar (allows for mesial movement of #30 into class I), EXT LL 1st premolar (allows for greater differential midline correction in the lower, canine correction to Class I and improvement in midlines.

2) Extract blocked out LR lateral incisor #26: this would allow for mesial movement of #22-31 for Class II correction to compensate for the mandibular asymmetry. Compromise: overjet of about 2.5mm will be present at the end.

3) Agressive IPR upper and lower incisors, with no improvement in the inter-incisal angle (I am not keen on this option, as it would likely be at the edge of the dentin).

Please let me know your thoughts

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