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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


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


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



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


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


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)



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)


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


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



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


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


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


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.

References

1. Ricketts RM. Perspectives in the clinical application of

cephalometrics. The first fifty years. Angle Orthod 1981; 51:

115–50.

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Figure 22 Case report 2: near end of treatment cephalogram

Figure 23 Case report 2: cephalometric superimpositions


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