Pacific Coast Society of Orthodontists Bulletin Summer 2020 - 53

Case Report

How would you treat this malocclusion?
Posttreatment
Case S.L., 17 years, 4 months

Treatment Objectives and Treatment Plan
The treatment objectives were (1) to establish Class I molars and canines with normal
overbite and overjet, (2) to improve the facial
profile, (3) to reduce anterior facial height as
well as relieve mentalis strain, (4) to obtain
proper tongue posture, (5) to obtain coincident midlines, (6) to level the curve of Spee,
and (7) to resolve crowding.
The parents and patient chose the first option because they preferred to avoid surgery,
and they were aware of the complexity of
a nonsurgical treatment approach and the
potential for microimplant failure.
Treatment Progress
The patient was referred for extraction of
the maxillary first premolars, mandibular
right second and left first premolars. After
extraction, 0.022-in slot MBT™ prescription
brackets were bonded on the U5-5 and L4-5,
and all 6s were banded. Tongue spurs were
bonded on the lingual surfaces of the U2-2
and L1-1 to help manage tongue posture
(Figures 5 and 6). Leveling and aligning were
started with a 0.014-in NiTi archwire, and
an open coil spring was placed between the
L2-2 to create space for the L1s. The patient
was also instructed to wear high-pull headgear 12 to 14 hours per day.
After one month of treatment, one microimplant (8 mm in length, 1.4 mm in diameter; VectorTAS™, Ormco) was placed at the
mid-palatal suture at the level of the U6s
coronally. A removable Trans-Palatal Arch
(TPA) was installed on the U6s, and both ends
of this TPA were connected by a elastomeric
chain to the microimplant. The upper wire
was increased to 0.018-in NiTi during the
leveling stage. The intrusion of the maxillary
molars continued until the microimplant was
found to be loose and was removed. Subsequently, a new microimplant was placed 3
mm anteriorly, and a piece of power chain
was used to continue the intrusive mechanics.

Summer 2020    PCSO Bulletin	

Figure 5. Progress photos showing lingual spurs on the maxillary incisors to control tongue
position and palatal mini-implant, removable TAP, and power chain to intrude maxillary
posterior teeth

Figure 6. Progress photos showing upper molar intrusion with microimplants and TPA

Figure 7. Progress photos showing Class II correction using Forsus
At this time, the U7s and L7s were bonded,
and both archwires were changed to 0.020-in
NiTi. The headgear was discontinued due to
poor compliance after four months of treat-

ment. The upper archwire was changed to
0.019 × 0.025-in NiTi, the lower archwire was
upgraded to 0.017 × 0.025-in stainless steel,
and the elastomeric chain was placed from

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Pacific Coast Society of Orthodontists Bulletin Summer 2020

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