A. Pretreatment Records

Date of Records: 06/05/96

Diagnosis:

• Skeletal: Class II with hypodivergent facial pattern.
• Dental: Class II, div 1, subdivision left with 100% overbite, mild spacing and retroclined upper incisors. Palatally impacted upper right canine. Proportionally small upper left lateral incisor and 2mm diastema with associated interproximal frenum.
• Facial: Mildly convex profile with short lower face height.

Treatment Plan: Upper and lower braces and bite plane. Level and align and make room for upper right canine. Extract retained primary upper right canine. Surgically expose impacted canine and bond attachment. Bring impacted canine into normal position in upper arch. Re-evaluate for possible use of cervical headgear. Refer for evaluation of maxillary labial frenum attachment. Class II's and increase upper incisor lingual root torque. Evaluate upper spacing for bonding to widen small lateral incisors. Finishing. Retention and, if needed, bonding to widen upper lateral incisors.

Treatment: Upper and lower braces and bite plane. Level and align and make room for upper right canine. Extract primary canine and surgically expose impacted canine. Bring impacted canine into its normal position in upper arch. Class II's and increase lingual root torque on upper incisors. Make space for bonding to widen upper left lateral incisor. Maxillary labial frenectomy. Finishing. Retention and bonding to widen upper left lateral incisor.

• Initiated Treatment Date: 08/15/96
• Appliance Removal Date: 07/26/99
• Active Treatment Time Duration: 35 months

B. Posttreatment Records

Date of Records: 08/16/99

Retention: Upper and lower Hawley retainers.

• Retention Completed Date: Ongoing
• Retention Duration: Ongoing

History and Etiology: Overall good medical/dental health width no history of dental trauma, dental habits or upper airway obstruction and no significant TMJ signs/symptoms. Primary etiology is heredity.

Diagnosis:

• Skeletal: Class II with hypodivergent facial pattern.
• Dental: Class II subdiv left with 100% overbite, mild spacing, retroclined upper incisors & palatally impacted UR3. Proportionately small UL2 and 2 mm diastema with associated Maxillary frenum.

Treatment Plan: Upper/lower braces and bite plane. Level, align, and make space for impacted canine. Extract primary canine. Surgically expose impacted canine and bring into arch. Class II elastics & headgear to achieve normal Class I occlusion and torque. Frenectomy and finishing. Upper/lower Hawley retainers.

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

• A-P: A-point maintained or moved posteriorly with headgear wear and increase in upper incisor lingual root torque.

Mandible

• A-P: Achieve some mandibular growth to reduce the ANB difference. Anticipated that the patient would have a significant amount of skeletal growth.
• Vertical: Clockwise mandibular rotation acceptable since low mandibular plane angle.

Maxillary Dentition

• A-P: Level, align, and bring impacted upper right canine into its normal position. Achieve normal upper incisor lingual root inclination.
• Vertical: Some extrusion of upper molars acceptable due to the hypodivergent facial pattern. Maintain vertical position of upper incisors relative to upper lip.
• Intermolar Width: Maintain intermolar width with transpalatal arch.

Mandibular Dentition

• A-P: Level and align and minimize forward movement of lower incisors with use of rectangular archwires during Class II wear.
• Vertical: Level lower arch with lower molar eruption using bite plate and Class II elastics.
• Intermolar / Intercanine Width: Maintain intercanine and intermolar width.

Facial Esthetics: Mild reduction in facial convexity and increase in lower face height.

APPLIANCES Upper anterior bite plate and later a transpalatal arch using Burstone lingual hinge cap first molar attachments, .022 Roth Ormco vertical slot edgewise appliance, and 3 1/2 oz 1/4" Class II elastics.

Treatment Progress: Initially, placed bite plate and upper/lower braces to level, align and make space for impacted canine. Extracted primary canine and surgically exposed impacted canine. Erupted UR3 palatally at first to avoid causing root resorption on adjacent incisors. Then, used long arm spring to bring UR3 into normal position. Class II elastics with upper/lower .019 x .025 TMA and torque to increase upper incisor lingual root inclination. Adjust upper spaces for bonding to widen small UL2. Frenectomy and finishing. Upper/lower Hawley retainers.

Results Achieved (A-P, Transverse, Vertical)

Maxilla

• A-P: A-point moved posteriorly due to increased upper incisor lingual root torque and headgear wear.

Mandible

• A-P: B-point advanced relative to A-point on composite tracings due to horizontal growth.
• Vertical: Counter-clockwise mandibular growth rotation occurred despite wearing Class II elastics

Maxillary Dentition

• A-P: Level, align and bring impacted canine into normal position. Achieve excessive upper incisor lingual root torque.
• Vertical: No significant upper molar eruption. However, upper incisors were intruded reducing incisor display relative to upper lip.
• Intermolar Width: Maintained intermolar width with transpalatal arch.

Mandibular Dentition

• A-P: Level and align and control lower incisor position with only slight labial movement.
• Vertical: Some vertical eruption of lower molars occurred during leveling.
• Intermolar / Intercanine Width: Slight increase in intercanine width occurred while intermolar width remained stable.

Facial Esthetics: Significant reduction in facial convexity occurred with horizontal mandibular growth.

Retention: Patient instructed to wear upper wrap-around Hawley and lower spring aligner retainers full time for nine months. After that time, patient will be instructed to wear retainers at night and she will be referred for evaluation of third molars.

Final Evaluation of Treatment: Achieved a very good result in a low mandibular plane angle Class II malocclusion with a severely impacted upper right canine. The impacted canine was first moved palatally to avoid causing root resorption on adjacent roots and then inferiorly and distally into its normal position. Placed too much lingual root torque on upper incisors, however, this did not compromise dental esthetics. Primarily horizontal, counter-clockwise growth occurred reducing skeletal and dental Class II relationships, but also maintaining short lower face height. Achieved a nice overbite correction. Bonding to widen the UL2 was done after debanding. Molar buccolingual inclinations, root angulations and alignment could have been better.