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Progress
Case Report
How would you
treat this malocclusion?
Case A.K. 10 years, 8 months
treatment plan Used
treatment progress
The two-stage treatment was selected primarily because
of the patient’s willingness and parent’s assurance that
she would demonstrate excellent cooperation needed
to achieve a Class I mutually protected occlusion with
excellent esthetics.
The Phase I treatment objective was to eliminate the
harmful habit and begin the process of minimizing
vertical growth and closing the attendant open bite via
autorotation of the mandible.
profile
right buccal
Treatment began with cementation of a fixed “crib”
style habit appliance and insertion of high-pull headgear. The patient wore the headgear 10 hours per day.
After seven months of successful habit control the
appliance was removed and a transpalatal bar was
inserted in order to correct the mesially rotated maxillary left first molar and centric interference. Progress
records reveal good bite closure­.
relaxed
smiling
frontal intraoral
Maxillary Occlusal
38
PHASE I – Case A.K. 10 years, 8 months
left buccal
Mandibular Occlusal
PCSO Bulletin • summER
2011
Case Report
progress panorex
progress Cephalometric Measurements
progress cephalometric x-ray
initial
progress
Mean
SNA (º)
85.1
85.0
82.0
SNB (º)
76.0
77.7
80.0
ANB (º)
9.2
7.4
2.0
U1 - NA (mm)
2.5
2.0
4.3
U1 - NA (º)
16.8
17.4
22.8
L1 - NB (mm)
6.4
5.6
4.0
L1 - NB (º)
30.5
26.5
26.8
41.0
33.0
31.1
23.0
84.5
95.0
MP to SN (º)
42.7
FMA
34.4
IMPA (L1-MP) (º) 91.8
progress cephalometric tracing
summER
2011 • PCSO Bulletin
39
Case Report
right buccal model
frontal intraoral model
Mandibular Occlusal
Maxillary Occlusal
PHASE II – Case A.K. 11 years, 10 months
Phase II was initiated when the second molars were
erupting. Continuation of vertical control was paramount. The patient was asked to wear a full coverage
removable lower occlusal splint adjusted in centric on a
full time basis. The purpose of the splint was to discourage vertical dentoalveolar development in the mandible.
Cooperation was excellent. The entire maxillary arch
was banded in a .022 true straight-wire self-ligating
appliance. The arch wire sequence began with a .014
nickel titanium followed by .020 X .020 nickel titanium
and progressing to a .019 X .025 copper nickel titanium
and finally a .019 X .025 stainless steel.
A transpalatal bar with a raised acrylic button was eventually placed in order to allow the tongue to exert an
intrusive force on the first molars. The patient continued
high-pull headgear wear as well. After 18 months of
lower splint wear, lower fixed appliances were placed
and the process of finishing continued. Arch wire
right buccal
40
left buccal model
sequencing in the mandible was the same as the maxillary arch. As a final fixed appliance finishing measure,
the bicuspids were brought into occlusion via 3/16 inch
6-ounce elastics worn from the maxillary first bicuspids
to the mandibular first bicuspids and maxillary second
bicuspids to the mandibular second bicuspids. This was
accomplished on a maxillary arch .019 X .025 stainless
steel arch wire and .019 X .025 flexible braided arch wire.
Since the torque on the maxillary incisors was adequate,
placement of a full sized .021 .025 stainless steel wire was
not indicated. No anterior vertical elastics were used.
In order to attain good lateral and protrusive occlusal
function and to attain optimal centric closure, the patient wore a gnathologic positioner fabricated on centric
mounted casts for one month after fixed appliance
removal (full time for two weeks followed by four hours
in the evening and sleep time for two weeks.) The patient
was retained with maxillary and mandibular wrap-around
Hawley appliances.
Maxillary Occlusal
left buccal
PCSO Bulletin • summER
2011
Case Report
Post-Treatment
Case A.K. 14 years, 2 months
RESULTS ACHIEVED
The patient and parents were extremely
satisfied with the result. The case took 40
months to complete, but the family knew at the
onset of treatment that it would take longer than
the “typical orthodontic case.” The patient’s
excellent cooperation during all phases greatly
contributed to the success of the treatment.
Final hinge axis mounted casts reveal the
profile
Of note, post-positioner mounted casts reveal a
coincident centric relation and centric occlusion
relationship (CPI recording), which in the
opinion of the author should enhance the longterm stability of the occlusion and TM joint
health. Post-treatment clinical examination
reveals an absence of joint noise.
relaxed
right buccal
smiling
frontal intraoral
Maxillary Occlusal
summER
occlusion closed via autorotation of the
mandible. The final frontal intraoral reveals a
slight lower midline deviation to the left, which
can be attributed to the asymmetry of mandible.
2011 • PCSO Bulletin
left buccal
Mandibular Occlusal
41
Case Report
right buccal model
frontal intraoral model
Maxillary Occlusal
final cephalometric x-ray
Editor’s Comments
This case was treated exceptionally well. The vertical
control throughout the entire course of treatment
undoubtedly played a pivotal role in the success of the
case – from an occlusal and esthetic standpoint. Molar
eruption was very well controlled. The maxillary and
mandibular molars extruded slightly, but the amount
equaled the condylar growth and as a result over the
course of the entire treatment the mandibular plane
angle to SN was reduced slightly.
42
left buccal model
Mandibular Occlusal
final panorex
Dr. Scott Murray received his orthodontic training
from the University of California San Francisco. He
is a graduate of the Roth/Williams two-year program
for Functional Occlusion. He is a
Diplomate of the American Board of
Orthodontics and an active member
of the Roth-Williams International
Society of Orthodontists. He has
practiced in Visalia, California since
1981. For questions regarding this
case please email Dr. Murray at
[email protected].
Dr. Murray
PCSO Bulletin • summER
2011
Case Report
final cephalometric tracing
general superimposition
maxillary superimposition
mandibular superimposition
final Cephalometric Measurements
initial
progress
final
Mean
SNA (º)
85.1
85.0
82.1
82.0
SNB (º)
76.0
77.7
77.1
80.0
ANB (º)
9.2
7.4
4.9
2.0
U1 - NA (mm)
2.5
2.0
3.6
4.3
U1 - NA (º)
16.8
17.4
24.2
22.8
L1 - NB (mm)
6.4
5.6
8.7
4.0
L1 - NB (º)
30.5
26.5
30.1
26.8
MP to SN (º)
42.7
41.0
42.6
33.0
FMA
34.4
31.1
36.2
23.0
84.5
90.4
95.0
IMPA (L1-MP) (º) 91.8
PCSO Bulletin
Case Report Editor:
Andrew Harner, dds, ms
(Huntington Beach,
California)
S
For Pre-Treatment of Case A. K., see page 25.
summER
2011 • PCSO Bulletin
43