1 -- We have a class II bite and crowding along with extreme protrusion of both arches. We have taken out upper first bicuspids and lower second bicuspids. Removing the upper first bicuspids leaves more anchorage distal to the upper extraction spaces so the upper incisors can be moved back as far as possible in relation to the rest of the mouth. On the other hand, removing lower second bicuspids leaves more anchorage in front of the extraction spaces to help move the lower molars further mesially to help to get to a class I molar relationship in the buccal segments.
2 -- Here is the Beginning Cephalometric Tracing. This patient has a very deficient mandible. The lower incisors are 15 millimeters ahead of the NB line. This is way farther labial than we would like.
Treatment Time - 17 Months to finish treatment (plus 5 months with a headgear before the treatment began).
3 -- A double headgear was placed to the upper first molars. We have only a 10% overbite so I used the double headgear to keep from opening the bite any more. The braces won't be placed for another five months. This will allow the upper arch to get a head start and give time for the upper left cuspid to erupt. The patient is to wear the headgear at least 12 hours a day until the end of active treatment.
Note:
With a double headgear we have a distalizing component with the neck strap and a high pull component with the head strap that together gives us a resultant force that would be the same as pulling directly through the middle of the ear. This will help to keep the maxilla up and back and give us the best result we can get.
4 -- When a rectangular archwire is placed in the upper arch make sure it is placed passively so the incisor teeth do not have any negative torque on them. Negative torque results when the torquing force is moving the apex of the incisor roots in the opposite direction of the linear force closing the extraction spaces in the buccal segments. Negative torque can damage the apex of the roots very quickly.
We will close the remaining extraction spaces on an upper arch using a 19 x 25 Stainless Steel rectangular upper archwire. This archwire will move all the teeth toward each other in translation. The remaining lower extraction spaces will be closed on a 20 stainless steel archwire with horizontal loops mesial to both cuspids.
5 -- The space and the lower arch will be closed on a round 20 stainless steel archwire with horizontal loops mesial to the cuspids and compensating curves in the buccal segments. We removed first bicuspids in the upper arch and second bicuspids in the lower arch to help move all the incisor teeth distally and at the same time reduce the Class II to a Class I bite in the buccal segments.
6 -- It has been 17 months from when the braces were placed and the spaces are all closed. The braces have been removed and the patient will continue wearing the headgear 12 hours a day. If the patient will wear the headgear, the overjet can be reduced. We will depend more on stripping the upper incisor contacts to reduce the overjet because the patient is probably pretty well worn out with the treatment to date. If we can get the overjet down to 3 mm, we will be happy.
7 -- Because of the extreme ANB discrepancy the upper incisors were moved further lingually into the extractions space then I would have liked. Removing second bicuspids on the lower arch allowed the lower crowding to be unraveled but there was no space left to move the lower incisors any further lingually. We can assume that the lower incisors are still stable because
they have not been moved any farther labially than they were before the braces were placed.
8 -- All braces have been removed except for the upper first molar bands so that the headgear can continue to be worn. Impressions were taken for occlusal retainers that were placed two days later.
This was a very difficult mouth to treat. The patient did everything that could be asked of him. The treatment was a marathon and we did as much as could be expected.
The bite will settle in a little better, especially in the anterior. We will help to reduce the overjet by stripping the contacts from the distal of the cuspids all away across the front. A chin implant would also help the patients profile.
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