How Does BHO Approach a Complex or Difficult Alignment Case?
Complex cases start with a full 3D digital diagnostic workup and are mapped tooth by tooth before any appliance is recommended. The case is then matched to the system that suits the movements required — Invisalign with advanced tools, InBrace, LightForce braces, or a combination of them. Complexity does not mean fewer options. It means the plan is built with more precision, and the appliance is chosen last, not first.
That order matters more than anything else on this page. Most disappointing orthodontic outcomes in difficult cases are not caused by the appliance being wrong; they are caused by the case being under-diagnosed and then forced into whichever appliance the office leads with.
Below is what actually makes a case complex, how the diagnostic workup changes the plan, how the appliance decision is made, where extractions, anchorage devices and surgery genuinely come into play, and what a complex case realistically means for your timeline.
What Makes an Orthodontic Case Complex in the First Place?
Complexity is about the movements a case requires, not about how crooked the teeth look in a mirror. Some visibly crowded cases are straightforward; some mild-looking cases are not.
Severe crowding with nowhere to put the teeth
When there is significantly more tooth than arch, alignment has to come from somewhere: expanding the arch, reshaping contacts between teeth, or removing a tooth. Deciding which of those is right is the case, and it is decided from records rather than from appearance.
More than one bite issue at the same time
A crossbite next to an open bite, or crowding on top of a deep bite, means the corrections can pull against each other. Sequencing becomes the skill — which problem gets addressed first so the next one does not get worse. We covered this pattern in detail in treating more than one bite issue at once.
Impacted or blocked teeth
A tooth that never erupted, or erupted in the wrong place, has to be given a path and then guided along it. That usually means creating space first and coordinating with another specialist to expose the tooth.
Teeth that have drifted over many years
Adults who lost a tooth, or who finished orthodontics decades ago without retention, often have tipped roots and collapsed spaces. Getting crowns upright over their roots is slower and more technical than moving crowns that look aligned.
A skeletal component
When the jaws themselves are disproportionate rather than the teeth being misplaced within them, the question of how much can be achieved by moving teeth alone becomes central to the plan.
Why Does Diagnosis Come Before Any Appliance Decision?
Because the appliance is a tool, and you cannot choose a tool before you know the job. For difficult cases, the workup is where the outcome is decided.
What the digital workup captures
Planning begins with a complete digital scan and imaging using our in-office 5D iTero and digital radiography. That gives root positions, bone levels, arch width, and the relationship between the upper and lower jaws โ not just the surface of the teeth.
Why root position changes the plan
Two patients can present with identical-looking front teeth and need opposite treatments, because in one case the roots are upright and in the other they are tipped. Aligner and bracket mechanics for those two situations are not interchangeable, and only imaging separates them.
Planning the finish before starting the movement
For complex cases we map the intended finished position first and work backwards to the sequence that gets there. That is what prevents the common failure mode in difficult cases: the front teeth look aligned at month eight and the bite still does not fit together at month twenty.
What experience adds to the records
In our practice, complex cases are where pattern recognition earns its keep. Dr. Monica Madan founded BHO in 2008, and volume in difficult adult cases is what makes it possible to predict which movements will be slow, which will need reinforcement, and where a case is likely to need a mid-course correction — before it happens rather than after.
How Is the Right Appliance Chosen for a Difficult Case?
We offer several systems specifically so a complex case is not forced into an appliance that does not suit it. The choice follows the required movements, your anatomy, and your life.
| System | Where it fits a complex case | Main tradeoff |
|---|---|---|
| Invisalign with attachments, IPR and elastics | Wide range of movements when wear time is reliable; removable for hygiene | Results depend on wearing trays the required hours every day |
| InBrace | Fixed and fully hidden behind the teeth; works without patient compliance | Fixed appliance care and an adaptation period for the tongue |
| LightForce and traditional braces | Maximum control for precise, difficult movements and heavy corrections | Visible on the front of the teeth during treatment |
| Combination approach | Fixed appliances for the hard movements, then aligners to finish | More phases to plan and coordinate |
Why compliance is a clinical factor, not a character judgment
Aligners are excellent at a great deal — but only while they are in the mouth. If a patient’s schedule, habits, or health make 20-plus hours a day unrealistic, a fixed appliance is the clinically better choice, not the lesser one. We would rather have that conversation at the consultation than at month nine.
Where aligners genuinely have limits
Certain movements — significant root uprighting, closing large extraction spaces, some skeletal corrections — are more reliably done with fixed appliances. Our comparison of braces versus clear aligners for complex cases goes through that in more depth.
Combination plans are common in difficult cases
Using braces to complete the hardest movements and aligners to refine the finish is frequently the shortest honest route. Practices limited to one system cannot offer it.
When Do Extractions, Anchorage Devices or Surgery Become Part of the Plan?
These are the parts of complex treatment patients worry about most, so here is when each actually applies.
Extractions
Removing a tooth is considered when there is not enough room to align the arch and expansion or reshaping cannot create it, or when the profile requires it. It is a decision made from records and discussed before treatment starts — never a mid-treatment surprise.
Temporary anchorage devices
Some movements need a fixed point to push against. A small temporary anchor placed in the bone provides it, and it often allows a correction that would otherwise require surgery or extractions.
Coordination with other specialists
Complex cases sometimes involve a periodontist, an oral surgeon, or a restorative dentist. Part of our role is owning the sequence across those providers so each step happens in the right order.
Surgical orthodontics
Where the jaws themselves are significantly disproportionate, a surgical step may be the only way to reach a stable result. That possibility is identified in the workup and discussed openly, including what is achievable without it.
What Does a Complex Case Look Like Month to Month?
Patients rarely ask this, and it is the question that sets expectations best. Difficult cases feel different from routine ones in a specific, predictable way.
The early months often look slower than expected
In many complex plans the first phase is preparation — creating space, levelling the arches, uprighting roots — and preparation is not very photogenic. Visible change can lag the actual progress by months, which is why we show scans rather than relying on how the smile looks in the mirror.
Checkpoints instead of a single promise
Complex cases are planned in phases with defined checkpoints, and at each one the plan is re-checked against the actual tooth positions. If a movement is not responding, it is better to know at the checkpoint than at the end.
Mid-course corrections are normal, not a failure
Biology varies between patients. Revised aligner sets, adjusted mechanics, or added elastics are routine parts of difficult treatment. The warning sign is not a mid-course correction — it is a practice that never mentions one being possible.
Continuity of the treating clinician matters more here
A complex case involves dozens of small judgment calls that build on each other, so seeing the same orthodontist throughout is worth more in these cases than in routine ones. That continuity is one of the practical reasons patients seek out an owner-led practice for difficult treatment.
Retention is part of the plan, not an afterthought
Teeth that were moved a long way, or moved after years of drifting, have more tendency to relapse. The retention plan for a complex case is designed alongside the treatment plan, and it is usually more conservative.
Frequently Asked Questions About Complex Orthodontic Cases
Will a complex case take longer than regular treatment?
Usually, yes. More movements, more sequencing, and sometimes more phases mean a longer active period. The more useful question at your consultation is not how long, but what happens at each stage — a plan with defined phases is a plan someone has actually thought through.
Can Invisalign handle a complex case, or do I need braces?
Invisalign handles a great deal when it is planned properly and worn as prescribed, including many cases other offices call aligner-ineligible. But some movements are more predictable with fixed appliances, and compliance matters. The answer depends on your specific movements, which is why the appliance is chosen after the scan.
My teeth do not look very crooked. Could my case still be complex?
Yes, and this is common. Bite relationships, root angles, and jaw proportions do not show up in a mirror. Cases that look mild and involve a skeletal component or badly tipped roots are frequently harder than cases that look dramatic.
What if another orthodontist told me my case was too difficult?
It is worth a second opinion, because too difficult sometimes means outside what that office’s single appliance system can do. A practice that plans from full records and offers multiple systems may have a route the first one did not. It may also confirm the first answer — but you will know why.
Get a Complex Case Looked At Properly — Before Committing to Anything
The difference between a difficult case that finishes well and one that stalls is almost always the quality of the diagnosis and the honesty of the plan. If your case has been called complicated, or you have been turned away, we will scan it, map it, and tell you what is genuinely achievable and what it would take. You can request your free consultation at any of our four Los Angeles-area locations, or call or text us at (310) 785-0770.