Hi all,

Here is a case I have been wrestling with for several years and would like some input. When this patient came to me, she was 22 years old and was seeing Invisalign and veneers to remedy what she termed as "crooked and yellow teeth." For context, her boyfriend at the time had 20 veneers done by the previous owner of the practice when he was 24 years old. For her part, this patient has had multiple lip fillers, a chin implant, and other augmentations (all of which she denied at the intial consult). Here are her photos from 2014.

[image:IMG_1034.jpg][image:IMG_1035.jpg][image:IMG_1036.jpg][image:IMG_1041.jpg][image:IMG_1042.jpg]

At the time, I did an Invisalign work-up at her request. I was new to Invisalign at the time, so I shared it with my orthodontist, and he agreed that it was a case to avoid, as we might have a difficult time defining and/or achieving what she was looking for. We settled on some in-office whitening and left well enough alone.

Fast-forward 4 years, and the patient continues to seek care. Now 26, and with a dentist who knows a little bit more about dentistry, I continue to be leery of the case. I have now sent her to 2 different orthodontists. One says she's "really a surgical case." The other says "punt." The difference now is that there is now some lateral wear patterns. This patient is a poor historian, but I started to ask some airway questions. She stated that her sleep quality was good, and that it was easy for her to get to sleep and stay asleep. After some further questioning, it was discovered that she habitually takes Melatonin, and sometimes Trazodone if needed. Here are her photos from this year:

[image:IMG_1740.jpg][image:IMG_1741.jpg]

Here you can see where the rotated mandibular lateral fits into #7 on excrusive:

[image:IMG_1746.jpg]

Better shot of the wear:

[image:IMG_1747.jpg]

Contralateral wear on #9 distal:

[image:IMG_1748.jpg][image:IMG_1749.jpg]

Why I suspect airway:

[image:LCooperCeph.jpg][image:LCooperAirway.jpg]

Would love some input as there are a lot of different angles to this case. I have not screened for airway issues yet as the patient doesn't believe that she has any, and is reluctant to pursue anything that doesn't get her closer to her cosmetic goals.

Thoughts?