Pacific Coast Society of Orthodontists Bulletin Fall 2021 - 37

Case Report
Two months into her treatment, a 9-mm
NiTi closed-coil spring was used on top of an
elastomeric chain on each side to activate
the C-palatal plate. About one week later,
the patient returned with irritated palatal
tissue at the plate around the miniscrews.
The patient had tenderness with this palatal
inflammation. The two distal miniscrews were
tightened, as they had become slightly loose.
However, the anterior miniscrew had to be
removed, as it was judged to be failing. The
patient was advised to use a Peridex (chlorhexidine
gluconate 0.12%) oral rinse twice a day
for two weeks and was reminded to include
the plate area when brushing her teeth.
Two months after this visit, the patient
returned with overgrowth of the palatal
tissue on the most anterior side where the
miniscrew was removed. Therefore, it was
decided that only the two miniscrews distal
to the plate were to be used until they could
hold up. The same 9-mm NiTi closed-coil
springs were used for continuous activation
of the C-palatal plate. Existing elastomeric
chains were replaced with new ones. We
placed 0.016 × 0.022-in NiTi wires in both
arches. Class II elastics (3/16 inch, 6 oz) were
added for full-time wear. At this time, the
patient was recovering from her tonsillectomy
performed on her one month prior.
When the patient progressed into her sixth
month of treatment, an elastomeric chain
was used on the maxillary arch to close
slight diastemas distal to U2s. Anterior
box elastics (5/16 inch, 4 oz) were added to
be engaged on all four lateral incisors for
extrusion of the incisors as Class II elastics
continued. More activation was made
on the C-palatal plate by an elastomeric
chain replacement. Another activation was
conducted on the plate two weeks after
this visit. This time, elastic threads were
used instead of elastomeric chain, on top of
the NiTi coil spring. As both the canine and
molar relationship on the left side required
more Class II correction, two elastic threads
were tied on the left side and one on the
right side. We placed 0.019 × 0.025-inch
NiTi wires in both maxillary and mandibular
arches for more torque. Rotational wedges
were placed on all four 3s to correct their
Figure 6. Progress intraoral photos at 8 months in treatment
slight rotations. We noticed that the patient
started showing tongue thrusting. To stop
this, tongue spurs were boned on U2-2, and
the patient received tongue exercise instruction.
One month later, Class I canine relationships
were achieved bilaterally. No more
activation of the C-palatal plate was done,
although Class II elastics and anterior box
elastics of the same pattern continued. Two
weeks later, which was now eight months
into treatment, Class I molar relationships
were also achieved bilaterally (Figure 6).
The pattern of wearing full-time elastics
changed to vertical elastics (3/16 inch, 6
oz) from U4,5 to L4,5 for both right and left
sides. The pattern of anterior elastics (5/16
inch, 4 oz) also changed to midline elastics
from UL2 to LR2 for nighttime only.
At 10 months into the treatment, the C-palatal
plate was removed after being used for 8.5
months. From this time on, the focus of the
treatment became detailing while maintaining
the canine and molar relationships.
Since the patient came back with the upper
archwire slid to the right side, composite
stops were cured distal to the U2 brackets
to prevent the same accident. Slight Class
II relapse appeared on the right side, while
overcorrection showed on the left side. While
anterior elastics were stopped, bilateral Class
II elastics (3/16 inch, 6 oz) were instructed
again to achieve Class I relationship on both
sides. Meanwhile, detailing such as de-rotation
of LL2 with an open-coil spring was done.
Bracket repositioning was performed one
month later. Archwire sizes were dropped to
0.016-inch NiTi in both arches. The patient
was instructed to stop all her elastics for
the first month after this visit. Then, she
was told to wear anterior box elastics again
for nighttime only during the next month.
After two months of being in 0.016-inch NiTi
wires, 0.019 × 0.025-inch NiTi wires were
placed once again, which were used for one
month. With this wire to maintain torque, an
elastomeric chain was engaged to U6-6 to
close small diastemas appearing at U2-2. Bite
turbos that were placed at initial bonding
to prevent breakage of mandibular molar
brackets were removed to evaluate her true
OB and OJ. Broken tongue spurs were not rebounded,
as both OB and OJ were improved.
For further improvement, doubled-up Class II
elastics for full-time and anterior box elastics
for nighttime only were instructed.
Her final archwire was a 0.019 × 0.025-inch
TMA for the last two months of her treatment.
Space closure was maintained by
placing a new elastomeric chain every visit.
Detailing was conducted through wire bending
and elastics. After one month of doubling
up and showing improvements in her OJ,
the patient was told to use single Class II
elastics on each side for one month. For her
last month of treatment, she was instructed
to wear vertical elastics of a different
pattern on each side: UL3,4,5 to LL3,4,5 on the
left, and UR3 to LR3,4 on the right. Anterior
box elastics lasted until she was deboned.
IPR was conducted on U2-2 to retract the
maxillary incisors more and to reduce the
OJ slightly with an elastomeric chain. IPR
was done on L2s to retract the mandibular
Fall 2021 PCSO Bulletin
37
Pacific Coast Society of Orthodontists Bulletin Fall 2021

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