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CLINICALSECTION
The BOS MOrth Cases Prize 2009
Andrew Thomas SheltonLeeds Dental Institute and Seacroft Hospital, Leeds, UK
This paper describes the orthodontic treatment of two cases that were successfully entered for the 2009 MOrth Cases Prize.
The first case describes the treatment of a class II division 1 malocclusion with increased vertical proportions that was treated
with upper and lower self-ligating appliances and headgear for anchorage support. The second case describes the use of a
Clark Twin-Block appliance, with headgear, followed by non-extraction upper and lower fixed appliances to treat a class II
division 1 malocclusion with an overjet of 14 mm.
Key words: Orthodontics, headgear, self-ligating, high angle, twin-block
Received 10th November 2010; accepted 14th June 2011
Introduction
The BOS MOrth Cases Prize is an annual award for the best
two MOrth examination case presentations. Candidates are
invited to enter from all Royal Colleges in the United
Kingdom. The cases were exhibited at the British Ortho-
dontic Conference, which was held in Edinburgh in 2009.
Case report 1
A 14K-year-old Caucasian female, presented with a class
II division 1 incisor relationship on a mild class II skeletal
base with increased vertical proportions. She had severely
crowded upper and lower arches and an overjet of 9 mm.Her main complaints were crooked teeth and having ‘fang
teeth’ that stuck out. She suffered from recurrent tonsillitis
and seasonal hayfever. She had no notable habits.
Extra-oral assessment
The patient presented with a mild class II skeletal
relationship, with both an increased Frankfort-mandib-
ular planes angle and lower face height proportion. There
was no significant asymmetry in the transverse plane. Her
lips were incompetent at rest and she had increased
incisor and gingival show at full smile (Figure 1; noteFigure 1b does not show the patient in full smile). The
lower lip was 6 mm behind the E plane.1 An assessment
of the temporomandibular joint was unremarkable.
Intra-oral assessment
The patient presented with acceptable oral hygiene al-
though there was some marginal gingival inflammation
associated with the lower anterior teeth. The community
periodontal index of treatment need was 0 in all sextants
apart from the lower anterior, which was 1.
The mandibular arch was U-shaped and displayed
severe lower labial segment crowding (9 mm), with the
LR2 being lingually displaced. The LL6 was grossly
decayed, with only the roots remaining, and the LR6 had
an occlusal restoration. The lower incisors were retro-
clined in relation to the mandibular plane. All permanent
teeth were present (including the grossly decayed LL6)
apart from the third molars. The lower lateral incisors had
an increased mesio-distal width (7.0 mm) in comparison
to the average2 and the lower central incisors (6.5 mm).
The maxillary arch was V-shaped and displayed severe
crowding (12 mm), mainly localized to the upper
canines. All permanent teeth were present apart from
the third molars (Figure 2). The upper incisors were
proclined in relation to the maxillary plane. The upper
lateral incisors had an increased mesio-distal width
(8.0 mm for the UL2 and 7.5 mm for the UR2) in
comparison to the average2 and in relation to the upper
central incisors (10.0 mm). The anterior Bolton ratio3
was found to be 80.8% indicating a relative increase in
tooth width in the lower labial segment.
In occlusion the patient had a class II division 1 incisor
relationship, with an overjet of 9 mm and a reduced and
incomplete overbite. The upper centreline was coincident
with the facial midline and the lower was displaced 3 mm
to the right. The buccal segment relationship was L of a
unit class II bilaterally and the canine relationship was a
K unit class II bilaterally. The left buccal segment
relationship was assessed using the second premolars due
to the absence of a LL6 crown. There were cross-bites,
without displacement, between the lower canines and
upper lateral incisors bilaterally.
Journal of Orthodontics, Vol. 38, 2011, 208–221
Address for correspondence: Andrew Thomas Shelton,
Orthodontic Department, Leeds Dental Institute, Clarendon Road,
Leeds, LS2 9LU, UK
Email: [email protected]# 2011 British Orthodontic Society DOI 10.1179/14653121141470
The pre-treatment PAR4 score was 64, the IOTN dhc5
5a and the IOTN ac 9.
Radiographic assessment
A dental pantomogram (Figure 3) revealed the presenceof all permanent teeth and confirmed the clinical find-
ing of gross caries of the LL6. Bite-wing radiographs
showed no further caries. Bone and root levels were
within normal ranges.
The cephalometric analysis (Figure 4, Table 1) con-
firms most of the clinical findings. Although an ANBof 3u indicates a class I skeletal pattern,6 the Wits7
appraisal of 8 mm reinforces the clinical finding of a
mild class II skeletal pattern. In the vertical plane, the
increased lower anterior face height, anterior face height
ratio and mandibular planes angle (35u) once more
reinforce the clinical picture. Dentally, the upper in-
cisors were significantly proclined at 125u, although this
may be an erroneous value as they were severely rotated.
The lower incisors were minimally retroclined, relativeto the normal value.6
Aetiology
It is likely that both the sagittal and vertical skeletaldiscrepancies were a result of genetic inheritance, with
the mandibular morphology (Figure 4) suggesting a
Figure 1 (a–d) Case report 1: pre-treatment extra-oral photographs
Figure 2 (a–e) Case report 1: pre-treatment intra-oral photographs
JO September 2011 Clinical Section MOrth Cases Prize 2009 209
‘backward growth rotation’. These variations from the
norm are reflected in both the class II buccal segment
relationships, increased overjet and decreased overbite.
The severe crowding seen in the malocclusion is a result
of dento-alveolar disproportion. The lower centre-line
displacement is due to the asymmetric crowding in the
lower labial segment.
Aims and objectives of treatment
1. Camouflage of the class II skeletal pattern;
2. Maintain the upper incisor show during rest and
full smile;
3. Relieve crowding, level and align the arches;
4. Correct the incisal and canine relationship to class I;
5. To achieve 1J class II molar occlusion, due to
excess tooth tissue in the lower arch (see discus-
sion);
6. To achieve a normal overbite of all incisor teeth;
7. To achieve co-incident centre-lines;
8. Improve the morphology and aesthetics of the UR2
and UL2;
9. Finishing and detailing to achieve a functionally
balanced occlusion;10. Retain.
Treatment options
In view of the patient’s maturation and potential forfurther growth the treatment option of growth mod-
ification was deemed inappropriate. The skeletal rela-
tionship, both vertically and sagittally, was not
significant enough to warrant surgical intervention
resulting in the treatment modality of orthodontic
camouflage. The high anchorage nature of the case
meant that there were various options. The use of
miniscrews to control both the vertical and sagittalanchorage was an alternative option to headgear. In
terms of upper extractions there was the option of the
loss of canines or first premolars with the potential
additional loss of first molars, depending on the an-
chorage control. In the lower arch there was considera-
tion made as to whether or not an extraction was
required in the lower left quadrant or not. The treatment
plan was devised in consultation with the patient’swishes and to maximize treatment success.
Treatment plan and rationale
1. High pull snap-release Kloehn bow headgear with a
Masel safety strap (Ortho-Care UK Ltd, Bradford,
UK). This allowed for both anchorage control inthe antero-posterior and vertical dimension;
2. Extraction of the UR4, UL4, LR6 and LL6. In the
upper arch this allowed for relief of crowding,
reduction of the overjet and optimal smile aes-
thetics. In the lower arch the extraction pattern was
dictated by pathology (LL6) and the presence of a
restoration (LR6);
Figure 4 Case report 1: pre-treatment lateral cephalogram
Table 1 Case report 1: pre-treatment cephalometric analysis.6,7
Variable Pre-treatment Normal value
SNA (u) 80 81 (3)
SNB (u) 77 78 (3)
ANB (u) 3 3 (2)
Wits appraisal (mm) 8 0 (1.77)
Upper incisor/mx (u) 125 109 (6)
Lower incisor/md (u) 86 93 (6)
Lower incisor edge to upper
incisor root centroid (mm)
1 >2
Inter incisal angle (u) 115 135 (10)
MMPA (u) 35 27 (4)
Anterior face height ratio (%) 62 55 (2)
Lower lip to E plane (mm) 26 22 (2)
Figure 3 Case report 1: pre-treatment OPG
210 Shelton Clinical Section JO September 2011
3. Upper and lower Damon MXH 0.02260.028-inch
slot pre-adjusted edgewise fixed appliances (Ormco,
Europe) ‘standard torque’ prescription. This self-
ligating system was chosen in order to attempt to
maximize early alignment and reduce the anchorage
requirement. It is appreciated that there is no
strong evidence to support these reasons, although
with the treatment being so anchorage demanding
it was felt that any possible benefit would be
helpful;
4. Interproximal reduction of the UR2, UL2 and the
lower anterior teeth. This would be dependent on
the occlusal fit and smile aesthetics when assessed in
the latter stages of treatment;
5. Retention in the form of a 0.0175-inch twist-
flex stainless steel bonded retainer UL2–UR2 and
Figure 5 (a–e) Case report 1: intra-oral photographs of the initial placement of the appliances
Figure 6 (a–e) Case report 1: intra-oral photographs following early alignment
JO September 2011 Clinical Section MOrth Cases Prize 2009 211
LL3–LR3, and, upper and lower vacuum-formed
retainers. This retention regime was chosen as a
result of the initial severe displacements and
rotations seen in the anterior segment.
Treatment progress
Start – Following the initial assessment, records and
consent process, a Kloehn facebow was fitted with snap-
release high-pull headgear and a Masel neck strap, with
force levels set at 400 g bilaterally. The patient wasadvised to wear the headgear for around 12–14 hours
daily. Once good compliance was established the patient
was referred to her general practitioner for extraction of
the upper first premolars and lower first molars.
Month 4 – Approximately 2 weeks following the extrac-
tions upper and lower pre-adjusted edgewise appliances
(DamonH 3MX) were placed. The initial aligning arch-
wires were 0.014-inch, nickel titanium. Light, spaced
powerchain was placed between the UR6–UR3 and the
UL6–UL3. The UR2, UL2 and LR2 brackets were not
bonded and temporary glass ionomer cement was placed
occlusally on the lower second molars to avoid the patient
biting the lower brackets. Lacebacks were placed between
Figure 7 (a–e) Case report 1: post-treatment extra-oral photographs
Figure 8 (a–e) Case report 1: post-treatment intra-oral photographs
212 Shelton Clinical Section JO September 2011
the lower 7–5 bilaterally to protect the long span of wire
and attempt to encourage distal movement of the lower
premolars and mesial movement of the lower 7’s
(Figure 5).
Month 6 – Space for the LR2 was opened using nickel
titanium pushcoil between the LR3 and LR1, on 0.018-
inch nickel titanium archwire, following the alignment
of the other lower anterior teeth (Figure 6).
Month 8 – Having progressed through to a 0.018-inch
stainless steel archwire in both arches, it was noted thatthere was some loss of anchorage in the upper buccal
segments. This was mainly due to a period of poor
compliance with headgear, coupled to the elastic traction
applied from the upper first molars to the canines. At this
stage the elastic traction was stopped and pushcoil was
placed between the upper central incisor and canine
bilaterally.
Month 9 – At this stage there was sufficient space to
bond the upper lateral incisors and the LR2. The upper
laterals were attached to the pushcoil with ‘heavy’ zing
string and glass ionomer cement was applied occlusally
to the upper molars to open the occlusion and provide
an intrusive force. A 0.014-inch copper nickel titanium
archwire was fully ligated in the lower arch and one visitlater in the upper.
Month 12 – As per the Damon philosophy, an
archwire sequence of 0.01660.025-inch copper nickel
titanium, 0.01960.025-inch copper nickel titanium was
then followed in both arches.
Month 17 – Repositioning of the UR2, UL2, UL5 and
LL7 was required, with a 0.01960.025-inch TMA being
utilized to control the LL7 before progressing to a
0.01960.025-inch stainless steel working archwire in
both arches. The lingual tipping of the lower second
molars, in addition to the large archwire span, made it
difficult to control these teeth.
Month 20 – Once the lower second molars were
under control space closure was completed with 12
mm nickel titanium light closing coils, with labial
crown torque placed anteriorly to maintain the incisor
relationship. Class II traction (Green 3.1 oz) was used
bilaterally to maintain the buccal segment and incisor
relationships.
Month 24 – Finishing and detailing involved inter-
proximal reduction of the upper laterals for aesthetic
reasons and lower 3–3 to improve tooth fit and control
labiolingual position. Second order finishing bends were
placed in the UR5, UL5, LR4 and LR5, in addition to
individual crown torque in the UL2. A box elastic (Blue
3.4 oz) was also used unilaterally, on the right side
Figure 9 Case report 1: near end of treatment lateral
cephalogram
Figure 10 Case report 1: cephalometric superimposition
Table 2 Case report 1: near end of treatment cephalometric analysis.
Variable Near end of treatment Change
SNA (u) 78 22
SNB (u) 75 22
ANB (u) 3 0
Wits appraisal (mm) 3 25
Upper incisor/mx (u) 107 218
Lower incisor/md (u) 94 8
Lower incisor edge to upper
incisor root centroid (mm)
2.5 1.5
Inter incisal angle (u) 125 10
MMPA (u) 34 21
Anterior face height ratio (%) 59 23
Lower lip to E plane (mm) 2 8
JO September 2011 Clinical Section MOrth Cases Prize 2009 213
to fully correct the buccal segment. Enamelplasty was
completed on the UL2, UL1 and UR1 to improve smile
aesthetics.
Month 27 – The patient was debonded 27 months
following the start of active treatment aged 16 yearsand 9 months. Passive placement of fixed retainers
(0.0175-inch twistflex) in the upper (2–2) and lower (3–
3) arches was undertaken. Vacuum-formed retainers
were fitted in the upper and lower and the patient was
advised to wear them for two days full time and then
night time only.
Case discussion
The patient’s initial complaint, of the ‘fang’ teeth sticking
out, was addressed and she had a significant improvement
in both her facial and dental appearance (Figures 7a–d
and 8). This was coupled with an apparent improvement
in her psychological well-being.
Skeletally, there was minimal mandibular growth
during the treatment period (Figures 9 and 10) with
no change in the ANB (Table 2). The anterior change in
Nasion led to a decrease of 2 degrees in both SNA and
Figure 11 (a–d) Case report 2; pre-treatment extra-oral photographs
Figure 12 (a–e) Case report 2: pre-treatment intra-oral photographs
214 Shelton Clinical Section JO September 2011
SNB. The 5 mm improvement in the Wits7 appraisal has
been a result of both a change in B-point due to a slight
forward positioning of the lower incisors and a change
in the occlusal plane. In the vertical dimension there has
been some growth of the maxilla (Figure 10), but
increased differential growth in the upper anterior face
height has led to a decrease of 3% in the lower anterior
face height ratio.
The post-treatment smile aesthetics (Figure 7b) are
satisfactory, with a consonant smile arc and acceptable
gingival and incisal show on full smile. Although she has
had a slight increase in the incisor show at rest,
(Figure 7a) maturation changes in the soft tissues8 are
highly likely to improve this with time. This slight
increase, as a result of retroclination of the upper
incisors (Figure 10) and unfavourable backward growth
rotation, has occurred despite the use of high-pull
headgear. The gingival margin of the UL2 is slightly
lower than the UR2 (Figure 8b) which is most likely a
result of delayed maturation of the soft tissues following
torqueing of this tooth. Although acceptable, the UL2 is
minimally under-torqued (Figure 8d) compared to the
UR2. Inverting the UL2 bracket may have improved
this, although the starting positions of both the upper2’s were very similar and UR2 achieved an optimal
position at the end of treatment.
The canine relationship at the end of treatment was
class I on the left with a slight class II tendency on the
right hand side. This was a consequence of a Bolton
discrepancy,3 loss of anchorage and the desire to
improve the smile aesthetics by mesio-distal reduction
of the upper laterals to a width of 7.0 mm. This wascountered by interproximal reduction in the lower labial
segment, although the morphology of the lower incisors
limited the amount that could be undertaken. To
achieve a class I occlusion with a normal overbite and
overjet an anterior Bolton ratio of 77.2% was the aim. A
reduction of 3.0 mm in the tooth width in the lower
labial segment was required, but this was not quite
achieved. The molar relationship was marginally greaterthan class II bilaterally (Figure 8a,c). The fact that an
Angle’s 1J class II relationship was achieved was a
result of an excess of tooth tissue in the lower arch, as a
consequence of upper premolar extractions and lower
molar extractions. There was a slight rotation on the
upper 6’s, which has helped with the reduction of upper
arch residual space. This was accepted for this reason.
There was a 0.5 mm centre-line discrepancy (Figure 8b),which was a result of the loss of anchorage on the right
hand side.
The post-treatment PAR4 was 5 indicating a 92%
reduction.
Case report 2
A 10-year and 11-month-old Asian female of Indian
extract, presenting with a class II division 1 incisor
relationship on a moderate class II skeletal base, average
vertical proportions and a 14 mm overjet. The patient’s
Figure 13 Case report 2: pre-treatment OPG
Figure 14 Case report 2: pre-treatment lateral cephalogram
Table 3 Case report 2: pre-treatmentcephalometric analysis.6,7
Variable Pre-treatment Normal value
SNA (u) 78 81 (3)
SNB (u) 71 78 (3)
ANB (u) 7 3 (2)
Wits appraisal (mm) 13 0 (1.77)
Upper incisor/mx (u) 131 109 (6)
Lower incisor/md (u) 93 93 (6)
Lower incisor edge to upper
incisor root centroid (mm)
22 >2
Inter incisal angle (u) 103 135 (10)
MMPA (u) 31 27 (4)
Anterior face height ratio (%) 53 55 (2)
Lower lip to E plane (mm) 0 22 (2)
JO September 2011 Clinical Section MOrth Cases Prize 2009 215
main complaints were that her upper teeth stuck out and
that she had gaps between them. She had a history of
thumb sucking, which stopped at the age of 9 years. The
patient was fit and well medically.
Extra-oral assessment
The patient presented with a moderate class II skeletal
relationship, with an average Frankfort-mandibular
planes angle and lower facial height. The chin point
was found to be slightly to the left of the facial midline.
Her lips were incompetent, with increased incisor and
gingival show at rest and full smile. The upper lip wasfound to be short (16 mm). The lower lip, in the relaxed
position, lay behind the upper incisors (Figure 11). The
lower lip was on the E-plane.1 An assessment of the
temporomandibular joint was unremarkable.
Intra-oral assessment
The oral hygiene was acceptable and the community
periodontal index of treatment need was 0 in all
sextants.
The mandibular arch was U-shaped with retained lower
second primary molars. All other teeth, from secondpermanent molar to second permanent molar, were pre-
sent. The lower teeth were potentially well aligned and the
lower incisors were at a normal angulation relative to the
mandibular plane.
The maxillary arch was U-shaped, with all permanent
teeth present from first molar to first molar and 14 mm
of spacing. The upper incisors were proclined relative to
the maxillary plane (Figure 12). There were no sig-nificant tooth size discrepancies.
The pre-treatment PAR4 score was 44, the IOTN dhc5
5a and the IOTN ac 9.
Radiographic assessment
The panoramic radiograph (Figure 13) confirmed the
presence of all permanent teeth (in good eruptive posi-tions) apart from the upper third molars. Root morphol-
ogy and bone levels were normal, although there was
possibly occlusal caries in the lower first molars.
The cephalometric analysis (Table 3) of the pre-
treatment cephalogram (Figure 14) confirmed the clin-
ical picture of a moderate class II skeletal pattern and
proclined upper incisors (131u).
Aetiology
It is likely that the increased overjet was due to a
combination of the sagittal skeletal discrepancy and pro-
clination of the upper incisors. The skeletal discrepancy
Figure 16 (a–d) Case report 2; post-functional extra-oral photographs
Figure 15 Case report 2 – high pull headgear
216 Shelton Clinical Section JO September 2011
was substantially a consequence of genetic inheritance,
whilst the incisor proclination resulted from the, now
terminated, thumb sucking habit and the presence of the
lower lip trap. The increased incisor show during rest and
full smile was due to the shortened upper lip, which was
also not able to drape freely due to the proclination of the
upper incisors (Figure 11c). The lower centre-line dis-
crepancy was related to a mild transverse mandibular
asymmetry (Figure 11a) which was most likely a result of
genetic inheritance, although environmental factors such
as trauma cannot be discounted.
Aims and objectives of treatment
1. Further investigate suspected caries in LR6, LL6
and treat accordingly (GDP);
2. Sagittal improvement of the class II skeletal
pattern;
3. Attempt to reduce the incisor show during smile
and rest;4. Close spacing, level and align the arches;
5. Correct incisal, canine and molar relationship to
class I;
6. Co-incident centre-lines;
7. Finishing and detailing to achieve a functionally
balanced occlusion;
8. Retain.
Treatment options
In view of the patient’s potential for growth and theirskeletal pattern it was felt that orthodontic camouflage
would be both difficult and would result in poor aes-
thetics. It was for this reason that functional treatment
was chosen. The treatment plan was devised in consulta-
tion with the patient’s wishes and to maximize treatment
success.
Treatment plan and rationale
1. GDP to take bitewing radiographs and restore the
LR6 and LL6 if deemed appropriate;
Figure 17 (a–e) Case report 2; post-functional intra-oral photographs
Table 4 Case report 2: end of functional phase and near end of
treatment cephalometric analysis.
Variable Mid-treatment
‘End’ of
treatment Change
SNA (u) 82 80 2
SNB (u) 76 74 3
ANB (u) 6 6 21
Wits appraisal (mm) 2 2 211
Upper incisor/mx (u) 116 113 218
Lower incisor/md (u) 108 97 4
Lower incisor edge to upper
incisor root centroid (mm)
6.5 5.5 7.5
Inter incisal angle (u) 105 125 23
MMPA (u) 32 32 1
Anterior face height ratio (%) 58 55 2
Lower lip to E plane (mm) 4 4 4
JO September 2011 Clinical Section MOrth Cases Prize 2009 217
2. Clark Twin-Block functional appliance with high
pull snap-release Kloehn bow headgear with a
Masel safety strap (Ortho-Care UK Ltd, Bradford,
UK). This was to improve the sagittal skeletal
discrepancy and to control the vertical dimension.The design of the appliance was:
N labial bow – to retrocline the proclined upper
incisors;
N midline expansion screw – to maintain the trans-
verse dental relationship;
N lower incisor capping – to attempt to avoid overproclination of the lower incisors;
3. Stage records – to assess the skeletal and dental
changes that occurred during the functional appli-
ance treatment and consequently inform futuretreatment mechanics;
4. High pull headgear, to maintain the sagittal and
vertical changes;
5. Upper and Lower Fixed appliances:
N ‘VictoryH’ series pre-adjusted edgewise (3M,
Unitek, Monrovia, CA, USA), 0.02260.028-inchslot, MBT prescription;
N Lacebacks in the UR, UL and LR quadrants were
chosen to attempt to avoid mesial tipping of the
upper canines and to help correct the centre-line;
6. Retention in the form of a 0.0175-inch twistflexstainless steel bonded retainer UL2–UR2 and
potentially LL3–LR3, and, upper and lower
vacuum-formed retainers. These forms of retention
were chosen as a result of the initial spacing in the
anterior segment and the potential for proclination
of the lower incisors due to the treatment mechanics
used.
Treatment progress
Start – Following the initial assessment, records and
consent process, the GDP was contacted and advised to
take bite-wing radiographs bilaterally and treat any
pathology as appropriate. After the radiographs had
been completed and no restorations were indicated, a
Clark Twin-Block appliance and high pull snap-release
(Figure 15) Kloehn bow headgear with a Masel safety
strap (Ortho-Care UK Ltd, Bradford, UK) was fitted.
Approximately 400 g of force were applied bilaterally
and the patient was advised to wear the headgear
12 hours per day and the Twin-Block appliance 24
hours per day. The patient was given a diary to fill in to
record the hours of wear of the headgear and was
reviewed 4 weeks later to check for compliance and ease
of wear.
Month 5 – The appliance was activated with the
addition of light cure acrylic to the upper blocks after
5 months. Midline expansion started at 5 months into
treatment and at the end of the functional phase of
treatment (Figures 16 and 17) high-pull headgear was
fitted to bands on the upper first molars.
Month 9 – Stage records (Table 4, Figures 18 and 19)
indicated that there had been a 15u proclination of the
lower incisors and so upper and lower fixed appliances
were placed with an MBT prescription in order to try
and control the lower incisors.
Month 17 – Despite multiple breakages, poor oral
hygiene and poor attendance the patient progressed to
the final working archwire (0.01960.025-inch stainless
Figure 18 Case report 2: end of functional appliance treatment
lateral cephalogram
Figure 19 Case report 2: mid-treatment cephalometric
superimposition
218 Shelton Clinical Section JO September 2011
steel) with the inclusion of all second molars. At this
point in treatment the buccal segments were in a class I
relationship and following space closure in the upper
incisor region, there was only space between the upper
lateral incisors and canines. A stainless steel undertie
ligature was placed bilaterally between the second molar
and canine and powerchain was added from canine to
canine. The anterior space did not close easily and so the
upper archwire was cut distal to the first molars to
decrease friction in the system.
Month 25 – With the anchorage under control, the
patient was advised to stop wearing the headgear. Final
detailing and finishing involved 2nd order bends on the
UL5 and UR1 and class III traction (Green 3.1 oz) on
the left hand side and class II traction on the right hand
side to correct the centre-line. Enamelplasty was com-
pleted on the upper central incisors to improve smile
aesthetics.
Month 30 – The patient was debonded 30 months
after the start of active treatment aged 13 years and 5
months. Passive placement of fixed retainers (0.0175-
inch twistflex) in the UL2–UR2 and LL3–LR3 was
undertaken. Vacuum-formed retainers were fitted in
the upper and lower and the patient was advised to
Figure 20 (a–d) Case report 2: post-treatment extra-oral photographs
Figure 21 (a–e) Case report 2: post-treatment intra-oral photographs
JO September 2011 Clinical Section MOrth Cases Prize 2009 219
wear them for two days full time and then night time
only.
Case discussion
In addition to the skeletal and dental improvements
with treatment (Figures 20 and 21), a pleasing aspectwas an apparent improvement in her psychological
well-being. Her excellent smile aesthetics gave her the
confidence to smile without looking away, as demon-
strated by the pre- and post-treatment photographs.
There has been no significant worsening in her
incisor and gingival show at rest (Figure 20a) and
full smile (Figure 20b) as a consequence of treat-
ment. In line with the evidence with regard to softtissue maturation8 this should improve in time. The
lack of significant vertical development has been
reflected cephalometrically (Figure 22) in the minimal
changes seen in the maxilla and mid-face (Table 4,
Figure 23).
The success of treatment has been mainly due to
dentoalveolar changes, favourable mandibular growth
and maxillary restraint as a consequence of the functionalphase of treatment (see Table 4). The retroclination of
the upper incisors had not led to an unaesthetic
nasolabial angle, even though there had been a small
amount of growth of nose growth. Although the muscle
tone was likely to be different, the cephalometric
superimpositions (Figure 23) show the change in upper
incisor inclination has allowed the upper lip to drape
naturally.The buccal occlusion was class I and well-interdigi-
tated which will potentially enhance long-term stability.
The final relationship of the lower incisors to the upper
incisors in terms of inter-incisal angle and incisor edge
to root centroid position9 should confer axial loading
and stability of the overbite reduction.
It must also be remembered that the patient now has
habitually competent lips which, in addition to the
retention regime, should enhance stability of the overjet.
Although there was a minimal amount of proclination
of the lower incisors by 4 degrees and the thumb sucking
habit had stopped, it was felt appropriate to provide a
lower bonded retainer.
The upper and lower centre-lines were co-incident with
each other at the end of treatment although both centre-
lines were 1 mm to the left of the facial midline. The
current evidence10 suggests that this minor discrepancy
does not lead to an aesthetic disadvantage.
The post-treatment PAR4 was 2 indicating a 95%
reduction.
Acknowledgement
I would like to thank all the staff in the Orthodonticdepartments at the Leeds Dental Institute and St Luke’sHospital, Bradford who helped me in the treatment ofthese two cases. In particular I would like to thank MrSimon Littlewood and Mr James Spencer for theirguidance and clinical knowledge.
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Figure 22 Case report 2: near end of treatment cephalogram
Figure 23 Case report 2: cephalometric superimpositions
220 Shelton Clinical Section JO September 2011
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JO September 2011 Clinical Section MOrth Cases Prize 2009 221