Case Report Category #: 7
Patient's Name:
Date of Birth: 6/23/56
Age (years and months): 37 yrs. 0 mos.

A. Pretreatment Records

Date of Records: 6/24/93
Diagnosis:

Skeletal: Class II with and ANB of 9, posterior vertical maxillary excess, increased LAFH of 59%
Dental: Class II division 1 subdivision left, anterior openbite, excessive overjet, mutilated (missing LL6), mesially tipped LL7 LL8, super-eruption of UL6, mandibular midline shift to the left of 3mm, maxillary and mandibular anterior crowding, posterior crossbite on the left, spacing in the lower left posterior, generalized bone loss, tongue interposition habit.
Facial: Maxillary protrusive, mandibular retrognathic, protrusive lips, minimal tooth show upon smiling, mandibular asymmetry to the left.

Treatment Plan: Periodontal clearance. Improve anterior openbite. Establish bilateral Class I canines. Reduce overjet. Upright and mesialize LL7/LL8, closing space on lower left. Level out eruption difference between UL molars. Correct midline discrepancy. Alleviate anterior crowding. Attempt to correct posterior crossbite on left.

Treatment: Extraction of Upper 4's and LR 4. Edgewise appliances. Vertical elastics and short Class II elastics.

Initiated Treatment Date: 8/12/93
Appliance Removal Date: 5/27/97
Active Treatment Time Duration: 45 months

B. Posttreatment Records

Date of Records: 6/10/97
Retention: Maxillary .195 twist bonded 3-3 + full coverage Essix. Mandibular .0195 twist bonded 3-3 + full coverage Essix.

Retention Completed Date: Ongoing
Retention Duration: Indefinite

History and Etiology: Patient presented as a 37 year old African-American female with a chief concern of "overbite and crooked top teeth". Medical history was unremarkable. Dental history included mild generalized bone loss, particularly in the posterior, long term extraction of LL6 due to caries, and several restorations including root canal therapy and PFM crown on LR6.

Diagnosis:

Skeletal: Class II with an ANB of 9, posterior vertical maxillary excess, increased LAFH of 59%.
Dental: Class II division 1 subdivision left, anterior openbite, excessive overjet, mutilated (missing LL6), mesially tipped LL7 LL8, super-eruption of UL6, mandibular midline shift to the left of 3mm, maxillary and mandibular anterior crowding, posterior crossbite on the left, spacing in the lower left posterior, generalized bone loss, tongue interposition habit.

Treatment Plan: Complete periodontal evaluation and schedule for four month prophylaxis. Initial treatment plan was to correct the malocclusion with an orthodontic/orthognathic surgery approach. Patient requested non-surgical plan which included extraction of Upper 4's and LR4 to retract maxillary incisors, establish bilateral Class I canines, correct midline, and alleviate crowding. Place full edgewise appliances to improve arch alignment and overjet, improve anterior openbite, attempt to correct posterior crossbite, upright molars and close space on the lower left. A TPA would be used for anchorage in the maxillary arch. Space closure would be achieved using elastomeric chain and rectangular stainless steel archwires (reduced on the lower left). Vertical elastics would be used to assist with bite closure and short Class II elastics would be used to support space closure. Prognosis was fair to achieve these results with orthodontics only and excellent patient cooperation would be necessary.

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

A-P: No specific objectives on this non-growing adult.

Mandible

A-P: No specific objectives on this non-growing adult.
Vertical: Attempt to maintain, although may open slightly with leveling of molars on upper left, correction of posterior crossbite, and use of Class II elastics.

Maxillary Dentition

A-P: Retract incisors, mesialize right molar if necessary, maintain left molar.
Vertical: Extrude molars, attempt to intrude UL6 although may also extrude UL7 to level out the molars.
Intermolar Width: May expand to correct crossbite.

Mandibular Dentition

A-P: Retract incisors, mesialize molars, especially LL7 and LL8.
Vertical: Extrude incisors, maintain molars.
Intermolar / Intercanine Width: Decrease to correct crossbite/ maintain.

Facial Esthetics: Reduce lip protrusion with incisor retraction; increase tooth show at rest and upon smiling.

APPLIANCES .022 Straight wire edgewise ceramic brackets. Metal brackets on upper 6's and 7's due to perio/bands on lower posterior.

Treatment Progress: Clearance was given for treatment after periodontal evaluation, although sulcus depths of 5mm were present on upper 6's. Bonded to all maxillary molars due to periodontal concerns, therefore a TPA was not used. She was also placed on a four-month prophylaxis recall. Extractions of upper 4's and LR4 were performed. On 8/12/93 Edgewise appliances were placed. Round nickel titanium wires were used to correct rotations and initiate leveling. Midline was shifted and canines were retracted to establish bilateral Class I canines using push coil springs and elastomeric chains on rectangular stainless steel archwires. The lower archwire was reduced on the posterior left to allow for anterior arch stability and ease in mesializing the lower left molars. Class II elastics were used to support these movements. Anterior vertical elastics were used to close the bite. Occlusion was detailed and the case was debanded on 5/27/97. Bonded and removable retainers were delivered at deband. There was no evidence of increased periodontal pocketing post-treatment.

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

A-P: "A" point went back slightly with incisor retraction.

Mandible

A-P: "B" point moved posterior due to clockwise rotation.
Vertical: Increased, possibly due to leveling of upper left molars, correction of posterior crossbite, and use of extrusive forces with the use of Class II elastics, even though anterior vertical elastics were used in conjunction.

Maxillary Dentition

A-P: Retracted incisors/ maintained molars.
Vertical: Extruded incisors/ maintained 6's.
Intermolar Width: Maintained on 6's, decreased on 7's.

Mandibular Dentition

A-P: Retracted incisors/ mesialized molars.
Vertical: Maintained incisors/ slightly extruded molars.
Intermolar / Intercanine Width: Decreased/ decreased.

Facial Esthetics: Lips were retracted with retraction of the incisors and tooth show increased.

Retention: Upon deband, maxillary and mandibular .0195 twist bonded 3-3 retainers were placed. Full coverage Essix retainers were also delivered for maintaining space closure requesting 12 hours/day wear for the first six months followed by sleep time wear indefinitely.

Final Evaluation of Treatment: Overall I am pleased with the outcome of the treatment considering the patient's chief concern was satisfied and most objectives were met. I would have liked to obtain more lingual root torque on the maxillary incisors although the angulation present can be expected with such a large A-P skeletal discrepancy for which the teeth compensate. There was also excessive overjet present on the right central and lateral incisors. UR7 has slight mesio-lingual rotation. Marginal ridge discrepancies were present between U6's/U7's and between L6's/L5's. Radiographically UL3 and LR3 had excess distal root tip. I would still elect to treat the case with a surgical treatment plan but feel that this treatment provided a tremendous service to the patient. The pre-treatment cephalometric tracing was enlarged by 2% due to the use of two different machines.