Dr Waseem Farooq presents orthodontic treatment for a patient with coexisting hyperflexible joints that have previously impacted TMJ performance.
A 24-year-old female patient presented expressing concern about the appearance of her dentition. The prominent issues were incisal retroclination in the maxilla, and crowding in the mandible. As a result, she was extremely self-conscious, and felt treatment would be of benefit to her personal well-being.
This case was particularly noteworthy as the individual also experienced hyperflexibility of her joints and related temporomandibular joint (TMJ) disorder. Any treatment would need to consider how to work within the greater maxillofacial structure safely.
As the patient expressed interest in pursuing orthodontic treatment, an assessment of her dentition and TMJ health was carried out.
Initial assessments
Oral hygiene required immediate improvement, and the need for an effective morning and night regimen was discussed. A dental hygienist referral was made for further support. Despite this, no teeth had a poor prognosis.
The lower arch presented 4mm of crowding, and retroclination in the labial segment. Rotations were observed on the LR3-LR4, as well as lateral displacement of the LL5 by 2-4mm. The buccal segment featured 2mm of crowding. In the upper arch, the patient was experiencing 2mm of crowding with rotations on the UR2 and UR3, and retroclination of the upper incisors.
She exhibited a Class I incisal relationship, as well as an overjet of 1mm and a 50% overbite. Each canine relationship was Class I, and her right-side molars followed suit, but the left molars were in a Class II relationship by a ¼ unit.
The patient displayed a Class I skeletal pattern, with an average soft tissue biotype. Regarding her joint
hyperflexiblity and TMJ disorder, she had a 40mm mouth
opening and experienced clicking in both left and right TMJs with deviation on opening and closing of the mouth.
The necessary impressions were taken, as well as X-ray images to assess her bone health, which was adequate for care.
Treatment options
The treatment options presented to the patient included:
- No treatment, monitor progression with regular dental hygienist visits
- Fixed orthodontic treatment to address alignment and overbite
- Removeable orthodontic treatment to solely address alignment
The use of fixed brackets may have been preferable when looking to correct the 50% increased overbite and rotations in a predictable manner. I had spoken with my IAS Academy mentor, Dr Asif Chatoo, who would support me on the case – he agreed that this would be the optimal treatment approach.
However, the patient had a preference towards clear aligners, citing the aesthetic advantages the solution provided. It would be beneficial to her confidence, and though it may only be possible to align the teeth without addressing the overbite, it would still deliver a positive result.
A SureSmile treatment plan was created, which presented the range of movements expected of each tooth. This was discussed with Dr Chatoo, and we were both confident in achieving a positive outcome. The plan was amended to reduce the pressure put onto the dentition over a long-term treatment, in effect slowing down each stage to ensure progress could be closely monitored. This would allow for the hyperflexible joints to be monitored without unnecessary strain and unfavourable movements.
The final plan was approved by the patient who then provided informed consent.
Orthodontic care
Orthodontic careInterproximal reduction (IPR) was carried out on the straight contact points, using the SureSmile treatment plan as a guide – but not the rule. Where the first step of IPR was carried out, a minimally invasive approach was taken, and only a proportion of the IPR completed. For example, if 0.3-0.4mm was recommended, then just 0.1mm of tissue would be removed, and movement monitored from there.
Additional engagers and buttons were placed in the first session, which would guide movement 
with the removable aligners. Engagers were placed on the UR3, UL3 and UL5 in the maxilla, and LR3-LR5 and LL3-LL4 in the mandible. Buttons were also placed on the LR6 and LL6 to utilise elastics.
The patient was shown how to apply 3/16 medium 4.5 Oz elastics, as well as how to use and maintain the aligners. Minimum wear of 22 hours per day was recommended.
At 4-week intervals the patient returned for new 
aligners, and a progress review. IPR was carried out with the conservative approach over time. The need for an effective oral hygiene routine was reinforced at each appointment, and observed.
Compliance was also, for the most part, optimal. This meant that there were very few changes necessary to the engagers. Dr Chatoo was consulted throughout the progression of treatment to ensure appropriate IPR was completed and that the case proceeded well.
No issues were experienced regarding the patient’s existing hyperflexible joints and orthodontic care. This was assessed at each appointment, and the patient shared anecdotally that she had not experienced lockjaw since beginning treatment, though this may be coincidence rather than causation. There is little evidence in the available literature to suggest that orthodontic care can reliably benefit TMJ disorders.[i]
Compliance with treatment waned momentarily near the end of care. This coincided with the observation that optimal right-side occlusion had been achieved, but left molar occlusion displayed a gap that was not completely settled. The importance of elastics was reinforced, but still the occlusion did not settle by the next appointment. The available options included the addition of more aligners, or trimming the current aligners at the left-side premolars-molar region, and letting the occlusion settle naturally. This was discussed with Dr Chatoo, who indicated the latter approach would deliver an optimal result.
The final aligner was trimmed at the premolar-molar region, and reviewed at 6 weeks. The targeted Class I occlusion was achieved without further difficulty.
Case review
With the desired outcome achieved, impressions were taken for a fixed and removable retainer from the IAS Laboratory. These were provided to the patient, who was instructed to wear the removable retainers daily, before progressing to night time wear for life.
The patient has been reviewed since at 3 months post-treatment, and she is delighted with the final outcome. I am equally happy with the result, especially in a case which required a slow and steady approach to adequately monitor for the hyperflexible joints and associated TMJ problems.
It’s a case that I wouldn’t have considered taking without the assistance of Dr Asif Chatoo, and my experience with the IAS Academy Advanced Diploma course. The support is paramount, and it gives you confidence in such a case. If there is the potential for difficulties to be encountered, you recognise that a mentor can help you at each step, and any problems will be amended in a timely and patient-friendly manner. I’ve 
recommended the IAS Academy to other clinicians, knowing how this support can continue to support patients in the future.
For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)
Author Bio
Dr Waseem Farooq is a dentist and mentor at Broxtowe Lane Dental Clinic, Colosseum Dental UK, Nottingham with an interest in orthodontics and restorative dentistry. Dr Farooq qualified as a dentist in 2002. He has been providing orthodontic care since 2015, and has attended several courses in advanced restorative techniques and orthodontic treatments to keep his knowledge up to date.
[i] Bora, P., Agrawal, P., & Bagga, D. K. Relationship Between Orthodontics and Temporomandibular Disorders. European Journal of Molecular & Clinical Medicine, 7(8), 2020.
