James Andrews Orthodontics

“More than lip Service” - Bowman and Johnston

Historically, extraction therapy was blamed for “dished-in” profiles and narrowed smiles. That narrative stuck — despite weak evidence.
All orthodontic treatment should be Diagnosis driven with clear treatment objectives - with careful consideration to where you want the incisors to sit with respect to ideal facial aesthetic

The literature tells a fairly clear story:

• Bishara et al. — lay panels rated both extraction and non-extraction cases as esthetically improved.
• Washington University data — ~90% of premolar extraction patients showed improved profiles.
• Bowman & Johnston — no evidence that properly indicated extractions inherently flatten faces.

Extraction is not a philosophy.
It’s a biomechanical tool.

In this case:
✔ Dental protrusion , proclined lower incisors withanterior crowding
✔ Lip prominence beyond the facial envelope
✔ Need for controlled incisor position to respect anatomy and long term biological health

The result?
Balanced profile.
Improved lip competence.
Maintained smile width.
Harmonious facial proportions.

Orthodontic “fashions” change.
Biology and diagnosis don’t.

One-treatment-fits-all thinking is the real risk — not premolar extraction.

Bimaxillary Advancement & Obstructive Sleep Apnea

Most orthodontic interventions marketed for sleep-disordered breathing show variable, modest, or unpredictable effects.

Evidence supporting - Maxillomandibular (bimaxillary) advancement shows
• ~80–85% surgical success (≥50% AHI reduction)
• ~35–40% surgical cure (AHI

When the “Limitations” of Aligners can actually be an Advantage

Aligners can't, for obvious reasons, generate intra-slot couples and have limited capacity to deliver large sustained moments. Consequently, they naturally favour tipping tooth movements rather than translation

In this specific case of moderate upper spacing, an increased overjet, proclined maxillary incisors and a 50% overbite, I felt it was a suitable appliance for efficient and effective treatment.
We are 14 months in treatment and are in the first refinement phase. Class II elastics have been worn to increase anchorage.

Key points include:
- Controlled crown tipping was preferred.
- Large M: F ratios weren’t required.

*If this case had required bodily movement through torque expression and precise root positioning, aligners would have been an unsuitable choice.
*You can still note an inadequate root tip on the maxillary incisors despite building in overcorrection on the cartoon.
This will be corrected with a segmental lingual fixed appliance
In orthodontics, it's vitally important to select the appliance that precisely meets the treatment objectives.

A pretty boring case. Never perfect unfortunately

Shower- No fads. No miracle appliances. No promises to “grow airways.”

This case was treated with conventional fixed appliances, guided by sound diagnosis, biomechanics, and respect for biology—not the latest trend.

✔️ Teeth moved within bone
✔️ Facial balance maintained
✔️ Periodontal health protected
✔️ Stable, predictable occlusion

Orthodontics doesn’t need constant reinvention.
And good outcomes don’t require selling fear, gimmicks, or exaggerated claims.

We’re not here to market appliances.
We’re here to treat patients properly.

Because good orthodontics has always been evidence-based

Case in Progress.
Initial@presentation
Severe U/L Crowding, Deep overbite, Retroclined incisors, dental arch asymmetry, congenitally missing lower incisor. Mild Skeletal C- II base.
Segmental combined with straight wire mechanics
12 months in Rx

The “hyperdivergent” patient.
Due to the skeletal complexity of the problem, hyperdivergent retrognathic patients are among the most difficult for orthodontists to treat. It is imperative to treat these patients for both esthetic and functional reasons. Hyperdivergent growth patterns are generally established early and most do not improve over time.
The key to correcting hyperdivergent malocclusion is often to induce a counterclockwise rotation of the mandible to reduce the vertical height.
Orthognathic Surgery is often required for severe cases. Orthognathic surgery treatment objectives is frequently are to reduce the vertical height and rotate the mandible to achieve a more favorable profile.

Tooth transposition is defined as the positional interchange of two adjacent teeth, especially their roots, or the development or eruption of a tooth in a position occupied normally by a non- adjacent tooth.
• tooth transposition has a mean prevalence of 0.33%.
• no gender difference
• more frequently in the maxilla than in the mandible
• more unilaterally than bilaterally
• quadrant localization: no left- or right-side predilection in the maxilla or mandible .
Case managed temporarily with digitally designed injection molded composite resin…

A case suited well to a hybrid appliance.
Deep overbite with mild COS
Mild lower crowding
Bolton discrepancy- Small laterals
Case treated with upper fixed appliance as the maxillary incisors required precise movement to intrude while at the same time palatal root torque. Anchorage with C-II elastics.
Lower IPR to balance the Bolton

MALFORMED MAXILLARY INCISORS
The most common malformed tooth is the maxillary lateral incisor. It is often referred to as “pegged”. These malformed laterals generally have two different shapes Some are cone-shaped, and others resemble the shape of a normal lateral incisor, but are significantly narrower, thinner, and shorter. If a lateral incisor is only slightly narrower than normal, and the problem is bilateral, the orthodontist may decide not to provide space to restore the tooth during orthodontic treatment. If the width discrepancy is only slight, the influence n the anterior occlusion, and the impact on esthetics may be indistinguishable. If the malformation is unilateral, however, or if the width discrepancy is significant, esthetics and occlusion could be affected adversely if the malformed tooth or teeth are ignored.
Other interesting things of note in this case was an iatrogenic lateral open bite created from a prefabricated silicone appliance…. 🤦🏻‍♂️

Dentists often encounter patients with missing or malformed teeth. The maxillary lateral incisoris the second most common congenitally absent tooth. There are three treatment options thatexist for replacing missing lateral incisors. They include canine substitution, a tooth-supportedrestoration, or a single-tooth implant. Selecting the appropriate option depends on the patients age, malocclusion,specific space requirements, tooth-size relationship, and size and shape of the canine.The ideal treatment is the most conservative option that satisfies individual esthetic and functionalrequirements. More often than not the ideal option is canine substitution.
Although the orthodontistroutinely should position the canine in the most esthetic and functional location, the restorative dentist often needs to place a resin or porcelain veneer to re-create normal lateral incisor shape and color.
We can recontour the canines to mimic the lateral with some judicious enamelplasty. Kokich wrote excellent articles the importance of interdisciplinarytreatment planning to achieve optimal esthetics.