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CASE REPORT
POST-TREATMENT
How would you treat this malocclusion?
CASE: M.C., 23 years, 11 months
TREATMENT PLAN
Treatment option #2 was selected: Comprehensive
orthodontic treatment with full-fixed appliances and
extraction of four first bicuspids. Placement of temporary
anchorage devices (TADs) for absolute anchorage during
space closure and to assist with upper incisor intrusion.
Level and align, close spaces and detail.
TREATMENT SEQUENCES
The patient was referred to her general dentist for restoration of the carious lesions on her third molars and a
pretreatment evaluation. Following review of informed
consent, treatment was initiated with placement of four
temporary anchorage devices in attached gingiva between
the second bicuspids and first molars in all four quadrants. The TADs were inclined apically at about 15-20º.
The patient was referred for extraction of all four first
bicuspids. Banding of the first molars and bonding of the
second bicuspids and cuspids was completed with .018"
edgewise MBT prescription appliances to begin segmental retraction of the cuspids. Following completion of the
extractions, initial leveling was completed with a .016"
nickel titanium wire and space closure was initiated on a
.016" SS wire using a power chain attached to the TADs
and the cuspids in each quadrant. The second and third
molars were also banded.
Following two months of space closure it was observed
that the cuspids began to tip buccally on the segmental
wires, so a continuous .016" SS wire was placed with
a step to bypass the incisors in each arch. Segmental retraction was then completed on the continuous archwire.
Extraction spaces closed rapidly due to the fact that the
apex of the cuspids was already in a favorable position
allowing a portion of the space closure to occur with
only a tipping action.
Two months after placement of the continuous archwires
the space closure was nearly complete and appliances
were placed on the upper and lower incisors. By this
time, the crossbite had already been corrected by retraction of the lower cuspids, making alignment of the upper
incisors possible without discluding the bite. The anterior
teeth were leveled and aligned with sequential nickel
titanium and steel wires up to .0175" x .0175" SS square
wires for five months.
Following leveling and alignment, an auxiliary .016" SS
intrusion arch extending from an auxillary tube on the
upper first molar bands and anchored to the upper TADs
was tied distal to the upper lateral incisors to intrude the
upper anterior teeth.
The teeth were intruded for five months until an open bite
was created and then COS was placed into a lower .0175"
x .0175" square steel archwire to help close the bite.
A panoramic radiograph was then taken and repositioning of the appliances was completed followed by three
additional months to relevel. Detailing in .0175" x .0175"
SS wires was undertaken for seven months followed by
one month of finishing elastics. The total active treatment
time was 25 months. The patient was given upper and
lower Hawley retainers and instructed to wear them full
time for six months before tapering down to nights-only
wear.
PROGRESS PHOTOS 12 MONTHS IN TREATMENT
PROGRESS RIGHT BUCCAL PHOTO
36
PROGRESS INTERORAL PHOTO
PROGRESS LEFT BUCCAL PHOTO
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CASE REPORT
POST-TREATMENT
FACIAL PHOTOS
PROFILE REPOSE
FRONTAL REPOSE
RESULTS ACHIEVED
The esthetic and functional results achieved were good.
The case could have been completed using traditional
mechanics, but the reduction in the patient’s mentalis
strain and excessive lip fullness was maximized while
maintaining an esthetic final profile. This was accomplished with absolute molar anchorage from the TADs
as demonstrated in the superimpositions. Her gingival
display was reduced by about 3mm through the intrusion
mechanics, although it might be said that she remains with
a somewhat “gummy” smile. The patient, however, was
very pleased with the results and the amount of gingival
display for a young adult female is within an esthetic
range. A well intercuspated posterior occlusion was
achieved with cuspid guidance in lateral excursion and
posterior disclusion in protrusion. The patient elected not
to have the worn upper and lower lateral incisors restored.
This resulted in uneven gingival margins with the upper
left lateral incisor being longer than the upper right lateral
incisor and the lower cuspids significantly longer than
the lower incisors. However, most of the attrition was
disguised with some careful enameloplasty. Prognosis for
stability is good.
FRONTAL SMILING
and indirect anchorage when the molars were held
in a vertically stable position by the TAD while the
utility arch intruded the anteriors. With the use of
the TADs, Dr. Budd achieved absolute anchorage
of the molars during incisor retraction and upper
incisor intrusion, thus allowing reduction of the
mentalis strain and improvement of the patient’s
gummy smile.
MAXILLARY OCCLUSAL
EDITOR’S COMMENTS
This is a nicely treated case and a great example of
using TADs for direct and indirect anchorage. The TADs
were used for direct anchorage when the canines were
retracted by powerchain attached directly to the TAD,
MANDIBULAR OCCLUSAL
RIGHT BUCCAL
FRONTAL
LEFT BUCCAL
POST-TREATMENT INTRAORAL PHOTOS
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CASE REPORT
POST-TREATMENT
LATERAL CEPHALOGRAM
MAXILLARY SUPERIMPOSITION
POST-TREATMENT PANOREX
CEPH VALUE
PRE-TX
POST-TX
MEAN
SNA
86
86
82
SNB
78
79
80
ANB
8
7
2
MP-SN
35
34
33
U1-NA
23
18
22
U1-NAmm
4
1
4
L1-NBmm
12
9
4
L1-NB
39
33
30
L1-MP
107
100
90
MANDIBULAR SUPERIMPOSITION
This case was treated by Dr. John Budd during
his residency at UCSF. The supervising faculty
member for the case was Dr. Gerald Nelson,
UCSF Curriculum II 1965, Health Sciences
Clinical Professor.
Dr. Budd received his undergraduate degree
in finance from Brigham Young University in
2001. In 2005 he earned his Doctor of Dental
Surgery degree from UCSF and continued at
UCSF for his orthodontic specialty training
until June, 2008. He is currently practicing
in Phoenix, Arizona.
GENERAL SUPERIMPOSITION
PCSO Case Report Editor:
Andrew Harner, DDS, MS,
Huntington Beach, CA
DR. BUDD
38
DR. NELSON

For Pre-Treatment of Case M.C., see page 30.
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