Orthotown July/August 2024 - 32

Case 1
A 17-year-old male presented to our
offi ce with his mother. He had undergone
orthodontic treatment for the
past 4½ years and had recently had
his braces debonded because of lack of
confi dence in the treating dentist.
On clinical and radiological examination,
he presented with excessively
proclined incisors, mildly proclined
lower incisors, an anterior open bite,
Class III molar and canine relationships,
four missing fi rst premolars
because of previous extractions,
a temporary anchorage device (TAD)
on the right maxillary posterior
region, and an excessively steep mandibular
plane, all on a Class III skeletal
base (Figs. 1 and 2).
Th e patient had brought his pretreatment
records from 4½ years
ago for evaluation. Initial pretreatment
extraoral records revealed a
convex and hyperdivergent profi le
with incompetent lips. Pretreatment
intraoral records revealed severe
crowding on the maxillary arch and
moderate crowding on the lower arch,
buccally and highly positioned maxillary
ectopic canines, Class III molar
relationship on the right and left sides.
Clinical and radiographic evaluation
of the initial pretreatment records
revealed a very steep mandibular
plane (Fig. 3).
In this skeletal Class III hyperdivergent
pattern case, presenting with
four premolars already extracted to
camoufl age the sagittal discrepancy,
a signifi cant loss of anchorage in the
mandible resulted in an excessive buccal
fl aring of the maxillary anterior
teeth in an attempt to allow adequate
dental contacts. Two treatment
options were suggested to the patient
to normalize the occlusion:
JULY/AUGUST 2024 | 32 | ORTHOTOWN.COM
* Th e fi rst consisted of a combination
between an orthodontic
and orthognathic surgery
treatment approach.
* Th e second proposed only orthodontics,
assisted by TADs in the
mandible. After the extraction of
the lower third molars, the mandibular
teeth were to be distalized
using two buccal-shelf TADs.
Th en in the maxillary arch, the
anterior teeth were to be palatally
tipped to achieve satisfactory
overjet and overbite.
Because the patient had been
undergoing orthodontic treatment
for 4½ years before even visiting our
practice, he and his mother expressed
frustration with the treatment's
long duration and unsatisfactory
outcome. Preferring to avoid the
fi nancial strain of orthognathic
surgery, they sought a satisfactory
solution through conservative means
Fig. 1
and opted for the second option.
An informed consent form was
approved and signed to this eff ect.
Th is case was treated using
0.022-by-0.028-inch slot preadjusted
edgewise appliances with an MBT
prescription.
Step 1: Gaining a positive overjet
by distalizing the lower arch
Initially, after extractions of the
mandibular third molars, brackets
were placed only on the lower arch
to level and align the lower dentition.
Leveling was performed on a
0.016-inch nickel titanium (NiTi)
wire, followed by 0.017-by-0.025-inch
NiTi and 0.019-by-0.025-inch NiTi
archwires, respectively.
Once the arch was completely
leveled, two TADs (1.8 by 12 mm) were
placed extraradicularly on the buccal
shelves in the mandible to distalize
the entire lower arch. Two crimpable
Fig. 2
Fig. 3
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Orthotown July/August 2024

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