Case Report Category #: 2
Patient's Name:
Date of Birth: 7/24/67
Age (years and months): 25 yrs. 2 mos.

A. Pretreatment Records

Date of Records: 9/27/92
Diagnosis:

Skeletal: Class II skeletal pattern with high mandibular plane angle (SN-Go-Gn 41 degrees and FMA 37 degrees), vertical growth pattern (Y-axis (S-Gn to FH) 64 degrees). U 1 retroclined, L 1 proclined, procumbent, and forward in relation to chin.
Dental: Class II, Division 1, mutilated. 7 mm U anterior crowding with U 3's labial and U 2's palatal to the arch. U rt 654 and 2 in x-bite. Prior exo of L rt 6 and L lf 6 & 7 have led to the typical M tipping of L 7|8 and extrusion of U 6's.
Facial: Dolichofacial. Labially displaced U lf 3 escapes beyond confines of lips when they are touching & some mentalis strain is apparent. RCT & a palatal amalgam contribute to a v. gray U lf 2. Rather severe brown staining present on U 3-3.

Treatment Plan: Extraction of the U 5's with moderate anchorage, upright terminal molars in LA in preparation for pontics to replace the bilateral missing mandibular molars. The final restorations in the L arch will likely involve premolar size pontics for the L 6's and a molar size for the L lf 7. Cosmetic procedures as desired after ortho to remove or mask staining of the U 3-3.

Treatment: Refer for evaluation of U rt 1 for possible RCT - periapical radiolucency noted on initial PA's. Following evaluation/tx of U rt 1, place TPA with U lf 6 activated for expansion, rotation, and torque, full U and L appliances, refer for exo of U 5's and L rt 8 (U lf 8 had been extracted after initial records but before initiation of ortho tx). At least 8 weeks after initial placement, remove TPA, activate U rt 6 and re-cement. At completion of tx, if L pontics not already in place, design retainers to maintain both pontic space and prevent re-extrusion of U 6's.

Initiated Treatment Date: 11/16/95
Appliance Removal Date: 4/20/98
Active Treatment Time Duration: 29 months

B. Posttreatment Records

Date of Records: 6/22/98
Retention: Maxillary Wraparound Hawley with occlusal rest of U lf 6 and 7 to prevent their extrusion, Mandibular Essix 4 - | - 5

Retention Completed Date: Ongoing
Retention Duration: Ongoing

History and Etiology: Genetics - 2 Younger sisters had ant & post x-bite or x-bite tend & greater U than L crowding. Genuine tooth-arch discrep may well have been relieved in LA by the prior exo's. Tipping of L 7|8 & extrusion of U 6's attributed to exo of L 6|67.

Diagnosis:

Skeletal: Class II skeletal pattern with the high mand plane angle and vertical growth pattern. U 1's retroclined, L 1's proclined, procumbent and forward in relation to chin.
Dental: Class II, div 1, mutilated. 7 mm U ant crowding with U 3's labial & U 2's palatal to arch. U rt 654 & 2 in x-bite. Prior exo L 6|67 led to M tipping of L 7|8 & extrusion of U 6's.

Treatment Plan: Exo U 5's - moderate anchorage, L molar uprighting for pontic placement. Selected U 5's vs. 4's primarily b/c by time we were about to initiate ortho, both 5's had large restorations & 4's were virgin. Gen den felt that RCT not indicated for U rt 1 but pt was made aware that RCT may become nec.

Specific Objectives of Treatment (A-P, Transverse, Vertical)
Maxilla

A-P: Maintain - non-grower.

Mandible

A-P: Maintain.
Vertical: Maintain.

Maxillary Dentition

A-P: Want to retract 3's into the arch. Some M movement of the U 6's following exo of U 5's expected and desired to aid in x-bite correction without xs increase in intermolar width.
Vertical: Control - want to minimize extrusion of U molars in presence of vertical growth pattern.
Intermolar Width: Maintain.

Mandibular Dentition

A-P: Maintain.
Vertical: Control.
Intermolar / Intercanine Width: Maintain.

Facial Esthetics: Reduce mentalis strain, bring U lf 3 within confines of lips at rest.

APPLIANCES Transpalatal arch, full upper and lower .022 prescription edgewise appliances.

Treatment Progress: At 9 mo's, placed L .018x.025SS with gabled loop D to L lf 5 & cinched back to ensure occlusal contact of L lf 8 with U lf 7. When sig mobility was observed on L lf 8, elected to place implants for L lf so that L lf 8 could be exo'ed, if nec (see letter). Space for L lf was increased allowing placement of 2 implants, along with bridge for L rt 6, prior to DB. Class III el rt, U 6 to L 3 used full time 9 mo's, Class II el lf, U 2 to L 5 used 5 mo's. AW's then sectioned D to U 3's & triangle el from U 3|2 to L 43|34 used 2 mo's prior to DB.

Results Achieved (A-P, Transverse, Vertical)
Maxilla

A-P: Well maintained - 1 degree reduction in SNA appears to be more related to the retraction of the upper anterior teeth than to actual retraction of the maxilla.

Mandible

A-P: Mandible rotated down and back a small amount (2 degrees as measured at SNB).
Vertical: Mandible rotated down and back a small amount (FMA increased 1 degree and SN-Go-Gn increased 2 degrees).

Maxillary Dentition

A-P: Maxillary composite shows favorable amount of M movement of U 6's along with retraction of U anteriors. 1 to NA was reduced 2 mm, 1 to SN was reduced 6 degrees.
Vertical: Well controlled - no apparent extrusion.
Intermolar Width: Well maintained - unchanged as measured at the central fossa of the 6's.

Mandibular Dentition

A-P: Well maintained - mandibular composite shows a v. slight uprighting as is confirmed by reduction in 1 to Go-Gn of 2 degrees and 1 to NB of 1 mm.
Vertical: Well controlled - no apparent extrusion.
Intermolar / Intercanine Width: The intercanine width was well maintained - no change as measured at the cups tips of the 3's.

Facial Esthetics: Mentalis strain was eliminated, and U lf 3 brought within confines of the lips at rest.

Retention: As is my preference in pre-prosthetic cases, final bridge on L rt was cemented prior to DB, reducing the number of retainer adjmt/remakes. Placement of implants prior to DB eliminated need for precise retention of L lf 8 & pt was again made aware that this tooth may be exo'ed in future. Placed U Wraparound Hawley with occlusal rests for U lf 67 to prevent extrusion & L Essix 4 - | - 5. Pt was instructed to wear U full time for 4.5 months & nights thereafter, L full time 1 week & nights thereafter.

Final Evaluation of Treatment: A very favorable occlusal change was achieved. The implants were restored with crowns 9 months after deband and the occlusal rests for U lf 6 and 7 in the maxillary retainer were removed at that time. At patient's last visit, 22 months after deband, the palatal amalgam which had darkened the U lf 2 had been replaced with composite providing a significant improvement in the color of this tooth. The stability was judged to be excellent at that time and is expected to remain so.