I wanted to post this in regards to what is considered a "success" or "failure." I am attaching the final clinical images of a recently debonded patient first. I am Obviously concerned about a few different things. Noticeably there is severe gingivitis, poor hygiene, recession, and a poor occlusal result. I had a long conversation with both mom and patient in regards to the next steps and the need to visit a periodontist prior to proceeding with any more ortho (we are hopeful to finish closing spaces and improve the bite after OH and perio is under control). I had not started this case and so this was a bit frightening to see. See images here:

[image:653bdec658954_Close_Up_Smile.jpg]

[image:653be5f2be90d_Frontal_Intraoral_Photo.jpg]

[image:653be5fc7d472_Right_Intraoral_Photo.jpg][image:653be60014241_Left_Intraoral_Photo.jpg]

[image:653be54e8e4b2_Screen_Shot_2023_10_27_at_7_38_25_AM.jpg]

The Case history here though is very important. This patient is is 25 y/o and, as you may have been able to tell, has a unilateral cleft lip and palate on the left side. She has some developmental and behavioral challenges. She started a phase I of orthodontic treatment for expansion and cleft grafting almost 11 years ago when she was 14. She had a 6 year "break" and we initiated treatment again. Subsequently she had orthognathic surgery to correct her occlusion. Once I had a chance to review her initial, I saw the final "result" in a different light:

[image:653be3741d397_Frontal_Intraoral_Photo.jpg]

[image:653be37c17f43_Left_Intraoral_Photo.jpg]

[image:653be384ec2e5_Right_Intraoral_Photo.jpg]

[image:653be3c7c8508_Screen_Shot_2023_10_27_at_12_22_25_PM.jpg]

[image:653be3f0513eb_Screen_Shot_2023_10_27_at_12_23_06_PM.jpg]

Improvement after surgery:

[image:653be41a76610_Screen_Shot_2023_10_27_at_12_23_50_PM.jpg]

[image:653be43cbe964_Screen_Shot_2023_10_27_at_12_24_24_PM.jpg]

I think the takeaway is: there are some cases so complex where we do the best we can. If I had only seen her final position and models I would have considered this case an abject failure. Knowing the history, I have a much different perspective. It doesn't mean we should treat things differently and accept tons of compromises because something is hard, but perspective is hugely important. How do you judge what constitutes a "success" and/or "failure" in your practice?

For this patient, I am hopeful a soft tissue graft will allow us the opportunity to improve the occlusion more, potentially with aligners.