A. Pretreatment Records

Date of Records: 5/6/97

Diagnosis:

• Skeletal: The maxilla and mandible are both related retrognathic in relationship to the anterior cranial base. However both are related well to each other.
• Dental: Class I malocclusion. Posterior right crossbite. Anterior crossbite. Severe upper and lower crowding. Upper midline left. Lower right of facial midline.
• Facial: Convex facial profile. Minimal upper and lower lip strain. Nasiolabial angle within normal limits. Well balanced anterior vertical facial height.

Treatment Plan: Comprehensive oral examination by the family dentist. Hyrax type banded rapid palatal expander. Surgical extraction of the four first bicuspids. Full banded orthodontic treatment followed by retention.

Treatment: Hyrax type banded rapid palatal expander. Full upper and lower .022 ACo prescription edgewise appliances. Removable transpalatal bar attached to the upper 6's. Elastics as needed. Remove appliances and retain with a gnathologic positioner.

• Initiated Treatment Date: 6/17/97
• Appliance Removal Date: 1/7/99
• Active Treatment Time Duration: 31 months

B. Posttreatment Records

Date of Records: 1/11/99
Retention: Gnathologic positioner

• Retention Completed Date: Ongoing
• Retention Duration: Ongoing

History and Etiology:
Medical: Good overall health with no history of serious diseases or trauma. The family did indicate that patient was under medical care for being under weight.
Dental: Excellent.

Diagnosis:

• Skeletal: The maxilla and mandible are both related retrognathic in relationship to the anterior cranial base. However both are related well to each other. Mandibular plane within normal limits.
• Dental: Class I malocclusion. Minimal overbite, 4mm overjet. Severe upper, moderate lower crowding. Posterior right and anterior crossbite. Upper midline left, lower right.

Treatment Plan: Hyrax type banded rapid palatal expander. Band upper and lower 5, 6, 7- bond 3-3. Removable transpalatal bar attached to upper 6's. Surgical extraction of the upper and lower first bicuspids. Level, align, coordinate close spaces. Retain with gnathologic positioner.

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

• A-P: The patient was post menarchial, not much growth was anticipated. If any anterior movement of the maxilla occurred during treatment it would be helpful.

Mandible

• A-P: The patient was post menarchial. Little change in the A-P position of the mandible was anticipated.
• Vertical: Did not want to change the vertical position of the mandible.

Maxillary Dentition

• A-P: Eliminate crowding: correct the axial positions of the upper incisors, achieve sufficient labial root torque on the upper left lateral incisor. Correct midline.
• Vertical: The maintenance on the vertical position of the incisors was important due to the fact that there was insufficient overbite at the initiation of treatment.
• Intermolar Width: Expansion was necessary to correct the posterior crossbite.

Mandibular Dentition

• A-P: Eliminate crowding without excessive proclination of the lower incisors. Level curve of Spee and correct midline.
• Vertical: Maintain throughout treatment.
• Intermolar / Intercanine Width: Maintain throughout treatment.

Facial Esthetics: Improve facial balance. Improve smile esthetics.

APPLIANCES Hyrax type banded rapid palatal expander. Full banded .022 ACo edgewise appliances. Removable transpalatal bar. Elastics as needed. Retain with gnathologic positioner. Treatment Progress: The hyrax expander was delivered. The patient was instructed to turn the appliance twice per day, each turn was 1/4 mm. The patient turned for seventeen days. The appliance was left in place for twelve weeks before removal. Full upper and lower .022 ACo edgewise appliances were placed except the upper and lower 4's. Extractions of the first bicuspids were performed. Leveling and alignment were performed with sequential archwires increasing to .019 x .025 Ni-Ti. Closing arches completed the space closure. Elastics were used to detail the occlusion.

Results Achieved (A-P, Transverse, Vertical)

Maxilla

• A-P: The A-P position was well controlled.

Mandible

• A-P: The A-P position was well controlled.
• Vertical: Minimalized clockwise rotation. The mandibular plane actually reduced during treatment. FMA reduced 15 to 14 degrees. SN-Go-Gn reduced 32 to 31 degrees.

Maxillary Dentition

• A-P: Relieved crowding, retracted upper incisors, aligned dentition.
• Vertical: The dentition did realize some intrusion and retraction.
• Intermolar Width: Expanded 1mm.

Mandibular Dentition

• A-P: Relieved crowding, prevented untoward labial movement of the lower incisors. The lower incisors were retracted 5.5 degrees.
• Vertical: Leveled the curve of Spee.
• Intermolar / Intercanine Width: The intermolar width was reduced 1 mm. The intercuspid width was maintained.

Facial Esthetics: Improved smile esthetics.

Retention: A gnathological positioner was delivered at the time of debanding. The patient was instructed to wear the appliance full time except meals for 3 days. The patient was seen for final records after three days. The patient was then instructed to wear the appliance for four hours daytime and all night for six weeks. The patient will then be instructed to wear the appliance at bedtime for twelve months. The third molars were recommended for removal at the final record/consult appointment.

Final Evaluation of Treatment: Given the severity of the problem I was pleased with the final outcome. The patient was well motivated and very cooperative throughout treatment. There is a marginal ridge discrepancy between the first and second molars. The anterior coupling is good and the molars and cuspids are a solid Class I. I was pleased with the torque achieved on the upper left lateral incisor. There was a slight anterior Bolton discrepancy. Bonding will be performed on the upper left 2. A critical review of the pretx records reveals some things that could have been much better; 1) both facial photos the patient appears to be looking to the left. 2) there is "redeye" associated with the frontal photos. 3) Mutilated pan film.