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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 P C S O B U L L ET I N • FA L L 2 0 0 8 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 FA L L 2 0 0 8 • P C S O B U L L ET I N 37 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. P C S O B U L L ET I N • FA L L 2 0 0 8