Pacific Coast Society of Orthodontists Bulletin Fall 2021 - 36

Case Report
How would you treat this malocclusion?
Posttreatment
Case K.A. 18 years, 9 months
Treatment Objectives
Treatment goals for this patient were to
improve facial harmony and establish consonant
smile arc as well as a Class I dental
relationship. Additional objectives included
attaining ideal OB and OJ, achieving ideal
maxillary and mandibular incisor inclinations,
alleviating crowding, and leveling
the curve of Spee, while maintaining lip
competence.
Treatment Alternatives
Option 1: Comprehensive orthodontic
treatment, nonextraction, C-palatal plate
fixed with palatal miniscrews for molar
distalization and intrusion
Option 2: Comprehensive orthodontic
treatment, extraction of U4s, reciprocal
space closure using closing loops, Class II
elastics as needed
Option 3: Comprehensive orthodontic
treatment, extraction of U4s and L5s,
close the maxillary space with maximum
anchorage using temporary skeletal
anchorage devices in the posterior
region, reciprocal space closure in the
mandibular arch using sliding mechanics
or closing loops
Option 4: Comprehensive orthodontic
treatment, camouflage treatment with
Class II elastics, interproximal reduction
(IPR) on both maxillary and mandibular
incisors
Option 5: Surgical approach with extraction
of L4s and bilateral sagittal split osteotomy
for mandibular advancement combined
with comprehensive orthodontic
treatment
Treatment Plan
Of the five options given, the first option
was chosen. Because the patient's nasolabial
angle was already obtuse, orthodontic
treatment options with extractions were
ruled out to avoid further increasing the
Figure 5. Progress intraoral photographs show (left) the maxillary arch was bonded and
(right) the C-palatal plate was placed
nasolabial angle. The patient and her mother
desired to avoid surgery, if possible, since the
patient felt she was having too many surgeries
already, including her past nasal surgery
and upcoming tonsillectomy in 3 months.
Therefore, option 1 using C-palatal plate was
considered the best option for her, as it was
the most conservative treatment method
using the maximum anchorage to most effectively
distalize the maxillary arch and close
the open bite intruding the posteriors.
Treatment Progress
Treatment first began with fitting bands on
U6s and impressing the maxillary arch with
the bands. At this time, two impressions
were taken, one for the lab to fabricate the
palatal arch with mesially pointed hooks for
applying distalizing forces, and the other
one for customizing the C-palatal plate.
Based on the palatal width and its shape,
the C-palatal plate with proper width was
selected and bent to be almost flush to
the palatal surface. Both arms of the plate
were placed slightly away from the palate
just enough to allow access to elastomeric
chains. A guide jig for C-palatal plate placement
was created by three-dimensional
printing. The jig was laid on top of the plate
matching the screw holes. Putty was used to
fix the set of the guide jig and the plate on
the model and prepare for precise positioning
of the plate and miniscrews on the patient.
The patient was advised to have both
U8s extracted to facilitate distalization of
her maxillary arch. Only UL8 was extracted,
as her general dentist found that extracting
UR8 was too aggressive at that point.
When the patient returned one month after
extraction, the C-palatal plate and three palatal
miniscrews were given. First, the C-palatal
plate was positioned using the putty
from the model, making sure that the plate
was at the desired location. While holding
the plate with assistance, three miniscrews
(1.8 × 6 mm, Jeil Medical Corporation, Seoul,
Korea) were placed through the holes of
the C-palatal plate. After it was placed, the
palatal arch soldered onto the bands of U6s,
partnering with the C-palatal plate, was
also delivered. The elastomeric chain was
engaged from the C-palatal plate to the
hooks of the palatal arch for distalization of
the whole maxillary arch. This elastomeric
chain was hooked at the most medial site
of the C-palatal plate to induce intrusion of
the posterior dentition as well. As the patient
came from a far distance and desired
treatments to be done as much as possible
at each visit, her U7-7 were bonded with
0.022-inch slot MBT prescription brackets,
and 0.014-inch NiTi archwires were placed
(Figure 5). One week later, the lower 7-7 were
bonded, and 0.014-inch NiTi archwires were
engaged.
36
PCSO Bulletin
Fall 2021
Pacific Coast Society of Orthodontists Bulletin Fall 2021

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Fall 2021
