Clinical Bytes

Clinical Bytes - Case 4

PATIENT’S NAME:	Case 4 - NS	DOB:	8/27/1990
RECORDS SET	A	B
RECORDS DATE:	10/17/2003	7/26/2005
PT. AGE:	13-1	14-11

	SINGLE PHASE
INITIATED TX DATE:	11/3/2003
COMPLETED TX DATE:	5/19/2005
ACTIVE TX DURATION:	18.5 months

HISTORY AND ETIOLOGY:

Patient presented to office with chief complaint of ‘crooked teeth’ as well as compromised smile esthetics. Medical history was unremarkable with respect to dental/orthodontic treatment. Genetic/hereditary etiology.

DIAGNOSIS

Skeletal:

Class II skeletal with ANB of 5 degrees

Dental:

Adolescent dentition; maxillary and mandibular spacing; class II molars full step+ left side, end-on right side; 100% deep bite; buccal crossbite of the maxillary right 1^stand 2^ndpremolars

Facial:

Face is ovoid and symmetrical; upper and lower face heights are approximately equal; 100% of maxillary central incisors are visible on fully animated smile; facial profile appears mandibular retrognathic; obtuse nasio-labial angle and deep labiomental fold.

*** maxillary intermolar width was measured from the facial aspect of the distobuccal cusps of the maxillary molars; mandibular intermolar width was measured from the facial aspect of the central buccal grove of the mandibular first molars; intercanine width was measured from the mid-facial aspect of the mandibular canines ***

Specific Objectives of Treatment

Maxilla (all three planes):

Maintain maxilla’s vertical and transverse position; maintain or retract ‘A’ point / maxilla to reduce AP discrepancy

Mandible (all three planes):

Maintain mandible’s vertical and transverse position; maintain or reduce (counter clockwise rotation) mandibular plane angle; anticipate forward growth of mandible to increase mandibular projection

Maxillary Dentition

A-P:

Retract maxillary anterior teeth consolidating maxillary spacing; maintain maxillary molar position

Vertical:

Maintain vertical position of central incisors as well as maxillary molars

Intermolar Width:

Rotate maxillary molars but attempt to maintain overall transverse width, allow for slight expansion to align with maxillary premolars and improve buccal corridors

Mandibular Dentition

A-P:

Protract mandibular molars consolidating mandibular spacing and classifying the molars; torque and upright mandibular incisors

Vertical:

Intrude mandibular anterior teeth to reduce overbite; extrude mandibular molars to reduce anterior deep overbite and level the curve of Spee

Intermolar / Intercanine Width:

Allow for slight intercanine and intermolar expansion to coordinate archform with the ovoid maxillary archform

Facial Esthetics:

Maintain maxillary incisors display on full smile; reduce labiomental fold depth by increasing mandibular projection; maintain transverse symmetry

TREATMENT PLAN:

Non-Extraction Treatment: level and align; coordinate arches; correct premolars crossbite discrepancy; consolidate maxillary spacing utilizing maximum retraction via inter-arch and intra-arch mechanics; close mandibular spacing utilizing maximum mandibular molar protraction using inter-arch mechanics; classify molars and canines into class I; 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; placed fixed-bonded edgewise 0.022” Roth Rx appliances on maxillary and mandibular dentition; initial leveling and aligning using heat-activated superelastic arch wires; advanced to stainless medium dimension steel arch wires (0.016x0.022ss) and start class II elastics (1/4” 6oz) to retract maxillary anterior teeth and protract mandibular molars; once space was consolidated and molars classified, full dimension arch wires (0.019x0.025ss) were placed and detailing bends were made; intra-arch mechanics were used at the end of treatment to close remaining spaces; appliances were debanded; teeth polished; removable Hawley retainers were delivered

Results Achieved

Maxilla (all three planes):

Vertical position of maxilla was maintained; maxilla (A-point) was retracted (likely due to the retraction of the dentition while the maxilla’s AP position was maintained); maxilla’s transverse position was maintained

Mandible (all three planes):

Mandible grew forward and downward consistent with normal facial growth and development; the mandibular plane angle was maintained; transverse mandibular position was maintained

Maxillary Dentition

A-P:

Maxillary incisors were retracted; maxillary molar position was maintained

Vertical:

Vertical position of the maxillary incisors and molars remained unchanged

Intermolar Width:

Maxillary molars were rotated and expanded slightly to match the premolar transverse position

Mandibular Dentition

A-P:

Mandibular molars were protracted; mandibular incisors were torqued and the incisal edges retracted to accommodate the maxillary retraction and mandibular growth

Vertical:

Mandibular incisors were intruded and mandibular molars extruded to reduce the overbite

Intermolar / Intercanine Width:

Intermolar and intercanine width increase slightly; archform was maintained and coordinated with the maxillary archform

Facial Esthetics:

Display of anterior teeth on full smile and buccal corridors were maintained; depth of labiomental fold was reduced along with an increase in chin/mandibular projection resulting in straighter less convex facial profile as well as more ideal lip projection.

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:

The treatment objectives for this patient were met resulting in class I molar/canine relationship as well as improved facial and dental esthetics and functional results; patient’s compliance as well as favorable growth were important factors which led to the success of this case. Anchorage and space closure control were also vital to assure correction of the dental classification and overjet. It is quite impressive how we can capitalize on growth and space closure to correct difficult dental discrepancies. With continued compliance during the retention phase, I would expect the results to remain stable. The patient and parents were very pleased and satisfied with the results. I informed them on the restorative option to bond the maxillary lateral incisors to establish a more ideal crown morphology, but they are quite happy with the esthetics at present time.

Pre-treatment frontal view	Pre-treatment profile view	Pre-treatment smile view
Pre-treatment cephalometric film	Pre-treatment ceph tracing	Pre-treatment panoramic film
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  smile view	Post-treatment frontal occlusion
Post-teatment right occlusion	Post-treatment left occlusion	Post-treatment maxillary view
Post-treatment mandibular view	Post-treatment ceph	Post-treatment ceph tracing

Post-treatment panoramic film