Clinical Bytes

Clinical Bytes - Case 2

PATIENT’S NAME:	Case 2 - GZ	DOB:		12/8/1992
RECORDS SET	A		B
RECORDS DATE:	3/6/2004		3/12/2007
PT. AGE:	11-3		14-3

	SINGLE PHASE
INITIATED TX DATE:	3/6/2004
COMPLETED TX DATE:	1/15/2007
ACTIVE TX DURATION:	34 months

HISTORY AND ETIOLOGY:

Patient presented with chief complaint of ‘overbite’ (overjet) as well as compromised smile esthetics; medical and dental histories were unremarkable with respect to dental/orthodontic treatment. Genetic/hereditary etiology.

DIAGNOSIS

Skeletal:

Class II skeletal, maxillary prognathic; mandibular plane angle appears within normal range

Dental:

Class II molar and canine occlusion; excessive overjet; procumbent maxillary central incisors; maxillary and mandibular crowding; deep impinging overbite; excessive mandibular curve of Spee

Facial:

Face appears ovoid and symmetrical; upper and lower face heights are approximately equal; profile appears convex; maxillary prognathic; deep labiomental fold and everted lower lip; approximately 30% of maxillary central incisors are visible on full smile

*** maxillary intermolar width was measured from the distofacial cusp tip of the maxillary molars; mandibular intermolar width was measured from the mesiofacial cusp tip of the mandibular first molars; intercanine width was measured from the cusp tip of the mandibular canines ***

Specific Objectives of Treatment

Maxilla (all three planes):

Anticipate normal maxillary forward and downward growth; maintain maxilla’s transverse position

Mandible (all three planes):

Maintain mandibular plane angle, avoid clockwise rotation of the mandible; anticipate forward and downward growth of the mandible; maintain mandible’s transverse position

Maxillary Dentition

A-P:

Maintain maxillary molar position; retract and upright the maxillary central incisors (controlled lingual tipping) using maximum anchorage

Vertical:

Maintain maxillary molar position; increase vertical position of the maxillary incisors to improve incisor display during smile (relative extrusion)

Intermolar Width:

Maintain maxillary intermolar width

Mandibular Dentition

A-P:

Torque and translate the mandibular incisors forward to reduce overjet and alleviate crowding; maintain mandibular molar AP position

Vertical:

Intrude the mandibular incisors to aid in bite opening; extrude and erupt the mandibular molars to openbite; erupt mandibular premolars to level curve of spee

Intermolar / Intercanine Width:

Maintain intercanine width; expand mandibular molars slightly – mandibular molars appear lingually tipped – this would aid in alleviating crowding and anterior bite opening

Facial Esthetics:

Reduce profile convexity and straighten profile; retract maxillary lip to reduce maxillary lip prominence; reduce mandibular lip eversion and decrease the labiomental fold depth; improve smile animation by allowing a more natural lip drape

TREATMENT PLAN:

Extract maxillary first premolars; retract maxillary anterior teeth using maximum anchorage to reduce overjet and classify canines; level and align upper and lower arches; alleviate crowding; reduce overbite using mandibular molar extrusion and mandibular incisor intrusion; classify canines using intra- and inter-arch mechanics; close extraction spaces; finish using detailing archwire bends and vertical elastics as needed; retain using removable Hawley retainers.

Appliances AND Treatment Progress:

Treatment plan discussed and informed consent given; extracted maxillary 1^stpremolars; placed fixed-bonded edgewise straight-wire 0.022” Roth Rx appliances on maxillary and mandibular dentition; initial leveling and aligning using heat-activated superelastic archwires; advanced to stainless steel archwires (round 0.020”ss maxilla / 0.019x0.025ss mandible) and start intra-arch mechanics to retract the maxillary canines on the archwire using maximum anchorage supported with class II elastics (1/4” 4oz); the use of the class II elastics was also utilized to erupt the mandibular molars to aid in bite opening; once the canines were fully retracted and classified into class I, the maxillary anterior 2-2 segment was retracted on the archwire en-mass; during this final space closure, interarch elastics were again used to aid in maximizing the anchorage for optimal retraction; once space was closed, overjet reduced, and canines classified into class I, full dimension upper archwire was placed (0.019x0.025ss) and detailing bends were made; intra-arch mechanics were used at the end of treatment to close remaining spaces as well as inter-arch elastics to control the vertical and AP final dental position; appliances were debanded; teeth polished; removable Hawley retainers were delivered [compliance was sporadic during the final stages of treatment which led to increased treatment time]

Results Achieved

Maxilla (all three planes):

The maxilla grew forward and downward – consistent with normal overall facial growth and development; no change noted in the transverse plane

Mandible (all three planes):

The mandible grew forward and downward – consistent with normal overall facial growth and development; no change noted in the transverse plane

Maxillary Dentition

A-P:

The maxillary molars’ position remained relatively unchanged; the maxillary anterior teeth were retracted and lingually tipped to reduce the overjet and lip prominence

Vertical:

The maxillary molars’ vertical position remained relatively unchanged; the vertical position of the maxillary central incisors crowns was increased – relative extrusion subsequent to controlled lingual tipping

Intermolar Width:

Maxillary intermolar width was maintained

Mandibular Dentition

A-P:

The mandibular molars AP position appears unchanged; the mandibular incisors were translated forward

Vertical:

The mandibular molars were extruded; the mandibular anterior teeth were intruded slightly

Intermolar / Intercanine Width:

The mandibular intermolar width was increased, consistent with the molar buccal uprighting (molars were initially tipped lingually); mandibular intercanine width remained unchanged

Facial Esthetics:

The convexity of the profile was significantly reduced and the profile is now straighter and more balanced; maxillary and mandibular lip posture was equally improved and smile animation is now more attractive and natural; mandibular lip eversion and labiomental fold were also corrected to more ideal facial esthetics parameters.

Retention:

Maxillary and mandibular removable Hawley type retainers were fabricated and fitted for patient; retainers are to be worn full time for 6 months and then nightly indefinitely.

Final Evaluation of Treatment:

Treatment objectives for this patient were met resulting in a marked improvement to the dental and facial esthetics as well as occlusion and function. Controlling the anchorage as well as favorable growth pattern were important factors to the success of this case. While sporadic compliance toward the end of the treatment increased the treatment time, the patient eventually complied and nice results were achieved. With continued compliance during the retention phase, I would expect the results to remain stable. The patient and parents are very pleased and satisfied with the results and state that her self confidence and self assurance have dramatically improved.

Pre-treatment frontal view	Pre-treatment profile view	Pre-treatment frontal smile view
Pre-treatment frontal occlusion	Pre-treatment right occlusion	Pre-treatment left occlusion
Pre-treatment maxillary view	Pre-treatment-mandibular view	Post-treatment frontal view
Post-treatment profile view	Post-treatment frontal smile view	Post-treatment frontal occlusion
Post-treatment right occlusion	Post-treatment left occlusion	Post-treatment maxillary view
Post-treatment mandibular view	Post-treatment Cephalometric film
Post-treatment Panoramic film