Pacific Coast Society of Orthodontists Bulletin Winter 2023 - 49

Case Report
How would you treat this malocclusion?
Posttreatment
Case I.C., 14 years, 9 months
Treatment Objectives
The following objectives were established after
thoroughly studying the patient's chief concern
and the existing problems:
◾ Refer for further evaluation of her upper
airway
◾ Decrease the gummy smile
◾ Decrease the long lower facial third
◾ Eliminate the lip incompetence
Treatment Alternatives
The following two options were provided to the
patient and her parents during the consultation:
◾ Option 1: Debond and wait for growth to
be completed, followed by jaw surgery to
manage the gummy smile.
◾ Option 2: Start initial posterior intrusion with
temporary anchorage devices (TADs), followed
by anterior intrusion with nickel-titanium (NiTi)
wires, while in the posterior, the previously
attained vertical positions are held with the
TADs. This strategy would theoretically address
all treatment objectives without surgery.
Treatment Plan
I demonstrated our past success using TADs for
posterior intrusion to close open bites without
extruding maxillary incisors. I also explained that
using the same strategy, we could attempt to
intrude the posterior teeth above the existing
occlusal plane, hold that vertical position with
the TADs, and then use fixed appliances and NiTi
wires to intrude the incisors up to the newly
established occlusal plane. This would also allow
counterclockwise rotation of the mandible to
help with the Class II correction and shorten the
lower face height to a more pleasing proportion.
Moreover, the difficulty with, and unpredictability
of, correcting the gummy smile without surgery
was discussed with the family. However, they
elected to pursue the second treatment option,
understanding that if it was unsuccessful, they
could still plan for future surgery as needed.
Treatment Progress
Before starting continued orthodontic treatment
in my office, the family sought another
Figure 8. (A) TAD placement, Triad set-up, and TAD activation with elastomeric chains; (B-D) posterior
intrusion began, and the Triad acrylic created an iatrogenic open bite; (E-G) after two and half
months of intrusion, two 1.8 mm × 10 mm miniscrews were placed on the mandible
Figure 9. Comparison of smiling views: (A) pretreatment (when the patient was transferred), (B)
after seven months of intrusion
opinion from an ENT, who diagnosed her with
enlarged adenoids and recommended their
removal. His assessment was that the upper
airway was " close to full occlusion " because of
the enlargement of the adenoids. The family
planned for this surgery during the patient's
approaching holiday break from school.
In October 2018, all brackets were removed and
replaced with self-ligating Ormco (Brea, California)
Damon Q .022 " brackets. TADs (1.8 mm × 10
mm; Ace Ortho Bone Screw, Ace Surgical Supply
Co., Inc., Brockton, Massachusetts) were placed
buccal and palatal of the maxillary molars and
bicuspids (Figure 8). The upper archwire was
Winter 2023 PCSO Bulletin
49
Pacific Coast Society of Orthodontists Bulletin Winter 2023

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Winter 2023
