Case Discussion: Managing an Extreme Skeletal Cant With Limited Treatment Options
- Dr. Amanda Seay
- 1 day ago
- 3 min read
In my latest case discussion, I examined one of the most complex skeletal cant presentations to come through my practice—an asymmetry so significant that it extended beyond the maxilla to the patient’s orbits, eyes, and overall craniofacial structure. The challenge was not simply leveling a dental cant, but determining how to create visual balance when ideal orthodontic, surgical, and imaging options were off the table.
The patient presented with a history of trauma, implant restorations, and recession, along with a deep aversion to CBCT and any form of expansion or ortho. With only teeth #4–13 available for treatment, the question became: How do we design a predictable smile when the anatomy is extreme and the treatment parameters are narrow?
Our starting point was establishing true natural head position—crucial in a case where pupils, commissures, and even ear height were unreliable. Full‑face photos, a digital facebow, and careful rotation of the head behind the DSD oval allowed us to identify trustworthy midline and horizon references. From there, we assessed incisal display, axial inclinations, and vertical position, choosing #8 as our reference point and designing the smile curve outward from that anchor.
The lab’s role was equally essential. With clear facially generated instructions, CMR created a design that brought the patient’s right side down, tucked the canines inward to avoid lip interference, and corrected significant axial flaring without encroaching on her soft‑tissue limitations. Provisionalization allowed us to evaluate not only esthetics and symmetry, but also how well the proposed inclinations and length changes integrated with speech, lip dynamics, and function.
Pink composite was added to the temps to preview future gingival contours, and margin placement was intentionally maintained to preserve bone and grafting options long‑term. Final zirconia restorations used gradated 5Y/4Y material for warmth and strength, with careful posterior chroma to prevent the “bright premolar” effect often seen in mixed‑thickness cases.
The transformation—achieved without orthodontics, without CBCT, and without full‑arch treatment—underscored the power of consistent photography, facially driven design, and precise lab communication. Even under the most restrictive conditions, a balanced, natural smile is still possible when the diagnostic process leads the way.
Inside this case discussion:
Learn how to establish natural head position and reliable facial landmarks when traditional cues are unreliable
Understand why axial inclinations and canine positioning are critical for achieving balance in severe cant correction
See how thoughtful pink/white design and clear lab communication create predictable outcomes when ideal treatment isn’t possible
To watch the step-by-step case breakdown, join the Case Continuum on Dr. Seay's Online Educational Platform, Seay Within, for access to the full library of 60-minute case sessions and clinical tips.
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Dr. Amanda Seay is the award-winning Founder, Chief Executive Officer, and Clinical Director of Expertise Dental in Charleston, South Carolina. Her expertise ranges from complex restorative treatment planning to comprehensive preventative and reconstructive dentistry.
Dr. Seay is a recognized leader in the dental industry and has been featured in various dental publications for her influence and dedication to the profession. She was named the 11th Most Influential Person in Dentistry by Incisal Edge Magazine. She is the 85th dentist in the world who has earned the honor of Fellow Accredited Member status with the American Academy of Cosmetic Dentistry.
Dr. Seay is also the co-creator of imPRES Dental Courses, an internationally recognized dental esthetics continuum. She holds a clinical instructor position at the Kois Center, one of the most prestigious dental institutes in the country, and has published over 70 articles covering the art and techniques of esthetic dentistry. She also serves as the Restorative Section Editor for Inside Dentistry.
She is a Key Opinion Leader for many leading dental companies and is involved in the testing and creation of new dental products. She was named Top 25 Women In Dentistry in 2012 by Dental Products Report. Dr. Seay was the recipient of the Lucy Hobbs 2015 Award for the Woman To Watch in Dentistry.
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