Case Report Category #:	1
Patient's Name:
Date of Birth:	3/5/1983
Age (years and months):	12 years 5 months

A. Pretreatment Records

Date of Records: 8/21/1995

Diagnosis:

•	Skeletal: The maxilla was protrusive relative to cranial base and the mandible. The mandible was relatively normal anterior-posteriorly. The upper incisors were upright relative to the cranial base and the maxilla. The lower incisors were mildly proclined relative to the mandibular plane. Growth expectations were still good.
•	Dental: She had a Class II Division 1 Subdivision left malocclusion with excess overjet(3mm) and overbite(90%) with palatal impingement. She was in the mixed dentition stage, with primary teeth still present in both arches. There existed adequate arch length in both arches. The lower arch was asymmetric to the right with the lower dental midline off to the right by 2mm.
•	Facial: Due to the protrusive nature of the maxilla, from the profile she looked retrognathic with full lips and good facial lateral symmetry. The upper dental midline matched the facial midline. The lower facial height appeared short with lower lip entrapment.

Treatment Plan: A long single phase of comprehensive orthodontic treatment that would be started now to a limited extent to take advantage of the remaining growth. Referral to a periodontist for correction of hyperplastic maxillary gingiva prior to appliance placement. Upper 2x4 and utilization of a cervical headgear appliance to correct molar relationship on right side. Progression into full appliances as the rest of the permanent dentition erupts, followed by retention in both arches.

Treatment: A maxillary gingivectomy was performed by the periodontist. Then .022 preadjusted prescription edgewise appliances with banded upper first molars and brackets on the four upper incisors were placed. A cervical headgear was delivered with instruction to wear it 10-12 hours each day. This was continued for 13 months and then the brackets were removed while headgear was continued for another 8 months and a set of progress records were taken as the rest of the primary teeth had been lost. Appliances were placed on the rest of the dentition in both arches, residual spaces closed using more Class II mechanics on the right side. Removable retention in the upper arch and fixed retention in the lower arch was used.

•	Initiated Treatment Date: 11/28/1995
•	Appliance Removal Date: 3/27/2000
•	Active Treatment Time Duration: 4 years 4 months

B. Posttreatment Records

Date of Records: 3/28/2000
Retention: Maxillary Hawley retainer and mandibular bonded .032 twisted steel lingual wire from canine-to-canine.

•	Retention Completed Date: Ongoing
•	Retention Duration: Ongoing

History and Etiology: Good overall health with no medical concerns. She had history of good dental care. She reported no TMJ symptoms. The etiology of her occlusion can probably be related to hereditary factors. The chief concern was the "overbite of the front teeth" and the esthetics of her smile. Growth expectations were still good.

Diagnosis:

•

Skeletal: The female patient of Caucasian descent presented with a protrusive skeletal relationship between the maxilla and the cranial base as indicated by the increased SNA and relative to the mandible as indicated by the increased ANB. The mandible was normal realtive to the cranial base, although she looked mandibular retrognathic. The mandibular plane angle was flat. The lower incisors were protrusive relative to the mandibular plane and the upper incisors were upright relative to the maxilla as well as the cranial base. Growth expectaions were still good.

•

Dental: She had a Class II relationship on the right side and a Class I relationship on the left side with excess overjet(3mm) and overbite(90%) with palatal impingement by the lower incisors. There existed adequate arch length in both arches and she was still in the mixed dentition. The lower arch had a moderate curve of Spee. The lower arch was asymmetic with the lower off to the right by 2mm. The maxillary incisor gingiva was hyperplastic and needed to be reduced prior to placement of appliances. The upper right central incisor had a defect in the facial enamel of unknown origin and this had been restored by her pediatric dentist.

Treatment Plan: Due to her age and eruption pattern it was decided to treat her with a long single phase of treatment rather than two phases and to begin treatment now to take advantage of her remaining growth and cooperation. Referral to the periodontist was the first step followed by .022 preadjusted prescription edgewise appliances using an upper 2x4 and utilization of a cervical headgear appliance to correct molar relationship on right side to a Class I and overcorrect on the left side. Progression into full appliances as the rest of the permanent dentition erupts, and use Class II elastics or a spring on the right side. If cooperation or growth are lacking, then a set of midtreatment progress records with all the teeth erupted will determine if extractions and/or surgery would be required to correct the malocclusion. Removable retention in the upper arch and fixed retention in the lower arch.

Specific Objectives of Treatment
Maxilla

•	A-P: Decrease protrusion of maxilla.

Mandible

•	A-P: Relate mandible to the maxilla better.
•	Vertical: Open vertical dimension to decrease overbite.

Maxillary Dentition

•	A-P: Procline upper incisors and hold upper dentition as is as mandible grows forward developing a Class I relationship bilaterally with normal overjet.
•	Vertical: Maintain similar vertical relationship.
•	Intermolar Width: Maintain similar width.

Mandibular Dentition

•	A-P: Move right side dentition anteriorly relative to the left side and the opposing arch to develop a Class I relationship bilaterally with normal overjet.
•	Vertical: Decrease curve of Spee and develop good overbite.
•	Intermolar / Intercanine Width: Maintain similar width.

Facial Esthetics: Develop better balance between the relative positions of the maxilla and mandible, improve the smile esthetics and decrease lower lip entrapment by decreasing overbite/overjet.

APPLIANCES .022 preadjusted edgewise appliances with bands on molars and brackets on rest of dentition. Utilization of a cervical headgear appliance and Class II mechanics more on the right side.

Treatment Progress: Periodontal surgery improved the gingival relationship. .022 preadjusted prescription edgewise appliances were placed with bands on the upper molars and brackets on four upper incisors. Cervical headgear was used with instructions to wear it 10-12 hours each day. This was continued for 13 months and then the brackets were removed and headgear only continued for another 8 months until the rest of the permanent dentition erupted. A set of progress records were taken, indicating overcorrection on the left side to super Class I with excess spacing in both arches, more in the upper than the lower. The decision was made to continue with full appliances and proceed non-extraction using Class II mechanics on the right side during space closure. Initial alignment was accomplished with .016 and .018 NiTi wires and then leveling with sequential steel wires until .019x.025 wires were placed. Then a "Eureka Spring" was used on the right side during space closure for 4 months. Subsequent to space closure and removal of the spring, a progress panelipse was taken to check root length and alignment so finishing bends to align the roots could be placed. Class II elastics were used for another 6 months to finish closing the overjet and develop good symmetry. The occlusion was detailed with finishing bends. Occlusal equilibration and esthetic recontouring were completed the day of debanding with delivery of retainers.

Results Achieved Maxilla

•	A-P: The maxilla stayed similar in its relationship to the cranial base.

Mandible

•	A-P: Mandible came anteriorly through growth
•	Vertical: Overbite was decreased through growth of the ramus and relative intrusion of the incisors.

Maxillary Dentition

•	A-P: The upper arch dentition was held well in its position relative to the maxilla despite good facial growth. Good dental changes from the headgear to create excess spacing in the upper arch in which we were able to retract the upper incisors.
•	Vertical: Incisors intruded relative to occlusal plane.
•	Intermolar Width: Increased during headgear wear and went back to original width.

Mandibular Dentition

•	A-P: Came forward with mandibular growth, more so on the right side due to Class II mechanics on that side resulting in a Class I occlusion with good overjet.
•	Vertical: The lower incisors were relatively intruded to decrease the depth of overbite.
•	Intermolar / Intercanine Width: Stayed similar.

Facial Esthetics: Mandible appears less retrognathic and smile esthetics improved with better lower lip relationsip.

Retention: A mandibular lingual .032 twisted steel wire was bonded from canine-to-canine and the central incisors the day of debanding. This should be maintained as long she can clean around the wire and if needed after a year, a night time removable Hawley can replace the wire. A maxillary Hawley retainer was delivered two days after debanding. Instructions given for full time wear for three months and then a long term regimen of night time wear was prescribed.

Final Evaluation of Treatment: The overall outcome of her treatment was good in that we met most of our objectives, regained lower arch symmetry and achieved a solid occlusion with good overjet and overbite. The facial esthetics were well balanced and the headgear had a positive effect on the treatment outcome. The duration of treatment was long but fortunately the patient was not impatient. As indicated on my scoring sheet, when scoring the models, I recognized a number of deficiencies in the alignment of the teeth, the marginal ridges, the occlusal relationship and occlusal contacts and the root alignment of the lower left premolars and upper left canine. Follow up since debanding has seen good stability of the occlusion and retained closure of the excess spacing. I expect with a good retention protocol from the patient, the prognosis for long term stability is good. The restorative dentist made the recommendation to have the third molars extracted. The upper left central incisor had a partial fracture, that was present prior to treatment. The tooth was later restored with a veneer.

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