The William Houston Gold Medal of the Royal College ofSurgeons of Edinburgh 2014, orthodontic cases

Mohammed AlmuzianOrthodontic Department, Glasgow Dental Hospital & School, Scotland, UK

The William Houston Medal is awarded to the individual achieving the highest mark at, the Membership in

Orthodontics (MOrth) examination at the Royal College of Surgeons of Edinburgh. As part of the examination the

candidate must submit five clinical cases. Details of two cases treated by the winning candidate are presented in this

paper.

Key words: Clinical case report, William Houston Medal, rapid maxillary expansion, functional appliance

Received 26 November 2014; accepted 03 March 2015

IntroductionThis paper describes the orthodontic management of

two cases treated by the winner of the William Houston

Gold medal in Orthodontics. The first case presentation

is Class I malocclusion treated by a combination of

Rapid Maxillary Expansion and fixed appliance treat-ment, the second case presentation is Class II Division 1

malocclusion treated by a combination of functional

appliance and fixed appliance.

Case oneA 123/4-year-old Caucasian female presented concernedabout the appearance of her front teeth. Her medical

history was unremarkable.

Extra-oral assessmentExtra-orally, she presented with a mild Class II skeletalbase, an average Frankfort mandibular planes angle and

reduced lower anterior face height. There was an

acceptable facial symmetry. Soft tissue examination

revealed competent lips, average nasolabial and labio-

mental angles with wide buccal corridors and a retrusive

profile in relation to the E-line (Figure 1).

Intra-oral assessmentIntra-oral examination revealed a full permanent

dentition with the exception of the upper right permanent

second molar (UR7) and all third molars. There was a

remnant of the lower right primary first molar (LRD),

whichwas associatedwith a localized gingivitis (Figure 2).

The mandibular arch form was square-shaped withaverage inclination of the incisors, moderate crowding

and well-aligned buccal segments. The maxillary

arch form was narrow U-shaped with severe crowding.

The posterior teeth were well aligned and upright.

Upper right central incisor (UR1) appeared to has an

average inclination.

At retruded cuspal position (RCP), the incisor

relationship was Class I with an overjet of 3 mm

measured at UR1. There was an open bite anteriorly,

although the upper left permanent central incisor (UL1)had a positive and complete overbite. The upper cen-

treline was shifted 4 mm to the right of the facial mid-

line. The buccal segment relationship on the left and

right side was 1/4 unit Class II molar and 1/2 unit Class

II canine relationship. There was an anterior cross-bite

affecting UR2 and a unilateral buccal cross-bite that was

associated with 2 mm of mandibular displacement to the

left side on closure (ICP).

Radiographic assessmentThe pre-treatment panoramic radiograph confirmed the

presence of the complete permanent dentition with

favourable position of the developing L8s and potential

impaction of the U7s (Figure 3). A periapical radio-

graph of the upper right permanent lateral incisor (UR2)

demonstrated no evidence of pathology or abnormal

root morphology (Figure 4).

Cephalometric findings confirmed the clinical findingsof bimaxillary retrognathia, mild Class II skeletal base

relationship with reduced vertical proportions, slight

tendency to posterior growth rotation, and average in-

clination of the upper and lower incisors (Figure 5,

Table 1).

Treatment needThe patient expressed great concern regarding the

appearance of her teeth and was extremely motivated

Address for correspondence: Mohammed Almuzian, Orthodontic Department,

Glasgow Dental Hospital & School, Scotland, United Kingdom.

Email: dr_muzian@hotmail.com

# 2015 British Orthodontic Society DOI 10.1179/1465313315Y.0000000007

CLINICAL Journal of Orthodontics, Vol. 00, 2015, 1–19

towards treatment, with a high need for orthodontic

treatment based on the IOTN DHC of 4d and AC

assessed as 8.

Aims and objectives of treatment

. secure and maintain optimum oral hygiene and dental

health throughout treatment;. accept the underlying Class II skeletal pattern;. correct cross-bite, eliminate displacement and coor-

dinate the arches;. normalize the overbite and overjet;. relieve crowding;. align and level arches;. achieve Class I molar and canine relationship;. correct the non-coincident centrelines;. monitor eruption of the unerupted teeth;. retain the final orthodontic result.

Treatment plan

. extraction of the remnant LRD;

. maxillary expansion appliance (RME) bonded Hasstype;

. intermediate phase using a modified transpalatal arch

with bilateral horizontal arms;. extraction of upper second premolars (U5s) and lower

second premolars (L5s) (Extraction planned and

performed after correcting the cross-bite);. upper and lower pre-adjusted edgewise fixed appli-

ances (0.0220|0.0280 slot) with MBT prescription;. upper and lower bonded retainers supported by upper

and lower pressure formed retainers (PFRs) during

the night.

Treatment progressionTreatment started effectively after the improvement oforal hygiene using a bonded RME cemented with Glass

Ionomer Cement (GIC) and activated twice per day. The

patient was reviewed every week until over-expansion

had been achieved (McNamara et al., 2003). At this

stage, the screw was secured with light cure composite

and the appliance left in place for retention (Figure 6a).

Three months later, the RME was removed (Figure 6b)

and replaced (on the same day) with a modified trans-palatal arch (TPA), with horizontal arms. The patient

Figure 1 Pre-treatment extra-oral photographs

Clinical2 Almuzian JO 2015

was encouraged to brush the palatal and buccal mucosa

more frequently and the daily use of a mouthwash was

prescribed, which minimized the gingival inflammation

(Figure 6c).Following the post-expansion retention phase,

extraction of all second premolars was arranged, the

upper/lower pre-adjusted fixed edgewise appliance

(0.0220|0.0280 slot) with MBT prescription were

bonded (except UR2) and 0.0140 nickel titanium (NiTi)

arch wires were placed (Figure 7a). Two months later,

the upper archwire was replaced with 0.0180 stainless

steel (SS) wire, a NiTi open coil spring was placed to

create a space for the UR2 and the upper first premolars

(U4s) were retracted using power chain elastic.The archwire sequence in the lower arch progressed

from 0.0180 NiTi to 0.0160|0.0220 NiTi and then

0.0190|0.0250 SS customized and co-ordinated arch-

wire. By this stage, the space closure in the lower arch

had started, 0.0120 NiTi piggy back mechanics were

added to align the UR2 (which was bonded with eyelets)

Figure 3 Pre-treatment orthopantomogram

Figure 2 Pre-treatment intra-oral photographs, in RCP

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 3

and the TPA was sectioned and removed owing topalatal trauma (Figure 7b). When the UR2 approached

its final position, an inverted UR2 bracket was bonded,

to improve root torque of the UR2, and the upper

archwire was replaced with 0.0200|0.0200 Heat Acti-

vated (HA) NiTi (Figure 7c). Subsequently, the upper

archwire was replaced with an expanded 0.0190|0.0250SS, with a progressive buccal root torque placed bilat-erally to control the upper posterior teeth inclinations,

and class II elastics were prescribed for night-time wear

(TP orthodontics 1/40, 3.5 oz; Figure 7d). The finishing

stage involved the use of settling zig–zig elastics (3/80, 3.5oz) on upper 0.0190|0.0250 SS and lower

0.0160|0.0220 braided SS archwire (Figure 7e).

At debond, lower (canine-canine) and upper (lateral–

lateral) bonded retainers were fitted (Figure 8a) alongwith a modified upper and conventional lower PFR

retainer were provided for night-time use only. The

upper PFR was modified with embedded supporting

0.9 mm SS wire (Figure 8b).

Treatment changesIn general, there was a mild forward–downward growth

of the maxilla, which could be the result of growth

during treatment or the short-term effect of RME

(Figure 9, Table 1). Point B appeared to have been

moved anteriorly; this could be owing to anterio-pos-

terior (A-P) growth or labial crown torque of the lower

incisors. The maxillary-mandibular plane angleincreased by 2˚while both the upper anterior and lower

anterior face heights increased by 1 and 3 mm, respect-

ively. This may have been owing to vertical growth or

owing to extrusion of the posterior teeth that caused the

mandible to rotate down. The changes, however, were

modest and the face height ratio remained close to

normal values. The lower lip to Ricketts E-plane

dimension increased by 2 mm while the nasolabial angle

Figure 4 Pre-treatment periapical radiograph of upperright lateral incisor

Table 1 Pre-treatment and near end of treatment lateral cephalometric values. Red denotes values out withthe normal range. (Houston et al., 1992; Jacobson, 1975; McNamara, 1984; Arnett and Bergman, 1993a, 1993b).

Variable Pre-treatment Near end of treatment Normal

SNA 748 758 828 ^ 3SNB 738 748 798 ^ 3ANB 18 (EC ¼ 4.58) 18 (EC ¼ 48) 38 ^ 1SN to maxillary plane 108 108 88 ^ 3Wits appraisal þ2mm þ2mm 0mmA-N perpendicular (McNamara) 25mm 24mm 0.4mm ^ 2.3Pog-N perpendicular (McNamara) 28mm 28mm 21.8mm ^4.5MM differential length (McNamara) 24mm 26mm 29.2mm ^ 3.3Upper incisor to maxillary plane angle 1078 1118 1088 ^ 5Lower incisor to mandibular plane angle 968 948 928 ^ 5Interincisal angle 1308 1268 1338 ^ 10Li- upper incisor root centroid þ3mm þ4mm 0–2mmMM angle 278 298 278 ^ 5Upper anterior face height 58mm 59mm 55mm ^ 3Lower anterior face height 63mm 66mm 70.5 ^ 4.5Face height ratio 52% 52.8% 55% ^ 4Lower incisor to APog line 2mm 2mm 0–2mmLower lip to Ricketts E Plane 25mm 27mm 22mmNaso-labial angle 1058 1038 958 ^ 10PFH: AFH ratio (Jarabak ratio) 56% 54% 62% ^ 3

Clinical4 Almuzian JO 2015

decreased by 2 ;̊ this was probably owing to nasal

growth and treatment changes, although landmark

identification error cannot be ruled out. The maxillary

superimposition on Bjork’s stable maxillary structures

confirmed proclination and extrusion of the upper inci-

sors (possibly owing to the effect of the open coil springand the settling elastics, retrospectively), while the upper

molars were moved mesially and extruded. The man-

dibular superimposition confirmed that the lower incisor

roots had been torqued labially while the molars had

been moved forward and slightly extruded during

treatment (Table 1).

Occlusal indicesTable 2 shows the changes in IOTN and PAR achieved

as a result of treatment.

PrognosisThe prognosis for stability of the occlusion was good,

although it was anticipated that there would be some

Figure 5 Pre-treatment lateral cephalogram and its tracing

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 5

future growth, particularly vertically, which might

reduce the overbite.

The upper inter-canine width had increased by 4 mm

while the upper inter-molar width had also increased

from 40 to 48 mm after the RME, owing to combined

skeletal and dental expansion. The latter measurementthen decreased to 40 mm by the end of the treatment,

which could have been owing to transverse relapse and

the effect of extraction that caused mesial shift of the

molars towards the narrow part of the maxillary arch.

However, the age of the patient at the start of RME

treatment, the long-term retention regime, over-

correction during expansion and the positive overjet/overbite with well-digitated occlusion should aid in the

Figure 6 RME phase. (a) End of active phase; (b) Immediately after removing RME appliance and (c) Post-RME retentionphase.

Clinical6 Almuzian JO 2015

stability (Kaplan, 1988). Overcorrection of the torque of

UR2 and achievement of a positive overjet and overbiteaimed to improve the stability of that tooth. Long-term

wear of the modified upper (2 mm thick reinforced with

0.9 mm SS wire) and lower (1.5 mm thick) PFRs during

the night was advocated if the patient wished to main-

tain archform as well as the alignment of the teeth.

Treatment rationaleAn orthodontic camouflage approach was considered

appropriate for correction of the patient’s malocclusion

as the Class II skeletal base discrepancy was mild.

The expansion of the upper arch was expected to

increase the arch circumference and create spaces

between the teeth. However, the space created from

expansion was not expected to be sufficient to allow for

the accommodation of the whole upper dentition.In view of Royal London Space Analysis (Kirschen

et al., 2000a, 2000b) following RME, the lower and

upper arches were treated on an extraction basis,

(Table 3). In turn this controlled the overbite, aided in

correction of centreline and provided space to relieve

molar crowding.

The presence of the narrow upper arch, unilateral

cross-bite with displacement and upright upper molars,favoured the use of the RME (particularly the bonded

type) to correct the transverse discrepancy and to

control upper molar inclination (Sarver and Johnston,

1989). In addition, the age of the patient was considered

to be optimal for the use of RME to open the mid-palate

Figure 7 Stage of the fixed appliance treatment. a: Upper and lower 0.01400 NiTi archwires in place, b: Upper 0.01800 SS/0.01200 NiTi wire piggy-back and lower archwire 0.01900 £ 0.02500 SS in place, c: Upper 0.02000 £ 0.02000 HA NiTi and lower0.01900 £ 0.02500 SS in place, d: Upper and lower 0.01900 £ 0.02500 SS in place and E: Upper 0.01900 £ 0.02500 SS customizedand co-ordinated. Lower 0.01600 £ 0.02200 SS braided archwire in place

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 7

suture, which would permit skeletal as well as dental

expansion (Lagravere et al., 2005).

An upper and lower pre-adjusted edgewise fixed

appliance with a 0.0220|0.0280 slot and a MBT

prescription were used to treat the patient. The third-order prescription of the posterior teeth ({7 ,̊ {7 ,̊

{14 ,̊ {14 )̊ controlled the posterior teeth inclination

resulting from the RME. In the lower arch, bonding

the lower second premolar (L5) brackets on the lower

first premolars (L4s) avoided significant torque pro-

gression between these teeth after space closure. In-

itially, the use of a traction hook on UR2 helped to

reduce possible archwire binding during the initialalignment of the UR2, which was subsequently

replaced by an inverted UR2 bracket that helped in

improving root torque.

Figure 8 Post-orthodontic and retention phase. (a) Extra- and intraoral photographs without retainer and (b) intraoralphotographs with retainer

Clinical8 Almuzian JO 2015

The overbite was reduced during the treatment andwas improved later by the use of rectangular wires,

which corrected the buccal root torque of upper molars.

Theoretically, the extraction pattern aided in the over-

bite correction by allowing hinge axis rotation of the

mandible. Lower second permanent molars (L7s) were

bonded and aligned at a late stage with the view that this

may avoid molar extrusion and worsening of the

overbite.Small black triangular spaces between lower incisors

(Lis) appeared towards the end of the treatment, which

were discussed with the patient and her parents. Several

options were offered but the patient opted to accept

them as she was happy with the outcome and eager to

finish active treatment.

Case twoA medically fit and well 131/4-year-old Caucasian male

presented, and he complained that his front teeth were

prominent and crooked.

Extra-oral assessmentOn extra-oral examination, he presented with mild Class

II skeletal base with average Frankfort mandibular

planes angle and lower anterior face height. There was

an acceptable facial symmetry. Soft tissue examination

revealed a potential competent lip (owing to trapping of

the lower lip behind the upper incisors) and average

naso-labial and labio-mental angles (Figure 10).

Table 2 Occlusal indices.

Index Parameter Value

Index of Orthodontic Treatment Need (IOTN)Dental Health component Start 4d

Finish 2gAesthetic component Start 8

Finish 1Peer Assessment Rating (PAR)

Start 43Finish 2Change 41% Change 95.3%

Table 3 Royal London Hospital Space Analysis/ortho-dontic space planning.

Lower Upper

Space requirementsCrowding and spacing 25mm 210mmLevelling occlusal curve 21mm 0mmArch width change 0mm þ2.5mmIncisor AP change 0mm 0mmAngulation/inclination change 0mm 22mmTOTAL 26mm 27.5mmSpace creation/utilizationTooth reduction/enlargement 0mm 0mmExtractions þ13mm þ13mmSpace opening for prosthetic replacement 0mm 0mmMolar distal movement 0mm 0mmMolar mesial movement 27mm 25.5mmDifferential U/L growth 0mm 0mmTotal þ6mm þ7.5mmResidue 0mm 0mm

þ ¼ Space available or gained 2 ¼ Space required or lost

Figure 9 Cephalometric superimposition registered onBjork’s stable structures (a) Overall, (b) maxillary and (c)mandibular superimposition.

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 9

Intra-oral assessmentIntra-oral examination revealed a full permanent dentition

with the exception of all third molars (Figure 11).

The mandibular arch was U-shaped with moderate

crowding, proclined central incisors and lingually posi-tioned lateral incisors. The maxillary arch had a V-shaped

form with severe crowding and proclined incisors.

In occlusion, the incisor relationship was Class II

Division 1 with an overjet of 9.5 mm. The overbite was

increased and complete to the palate but not traumatic.

The upper centreline was shifted 2 mm to the right

of facial midline, with the lower 1 mm to the right of chin

midpoint. The buccal segment relationship on the left sidewas 1/2 unit Class II molar and 1/2 unit Class II canine

relationship while on the right side, it was a full unit Class

II molar and canine relationship.

Radiographic assessmentThe pre-treatment panoramic radiograph confirmed thepresence of the complete permanent dentition with

favourable position of the developing third molars.

There was no evidence of any pathology or abnormalroot morphology/length (Figure 12).

The cephalometric findings confirmed the clinical

findings of a Class II Division 1 incisor malocclusion

on a mild Class II skeletal pattern owing to man-

dibular retrognathia with average vertical proportion

and proclined upper and lower incisors. (Figure 13,

Table 4).

Treatment needThe patient demonstrated a high level of perceived

need, notably complaining that his top front

teeth were sticking out. An IOTN dental health com-

ponent score of 5a suggested a ‘very great need’ fortreatment.

Aims and objectives of treatment

. investigate the possibility of dental caries in the firstpermanent molars;

Figure 10 Pre-treatment extra-oral photographs

Clinical10 Almuzian JO 2015

. improve oral hygiene, diet control and secure opti-

mum dental health;. functional appliance to harness mandibular growth,facilitate dentoalveolar compensation and reduce

anchorage demand;

. relieve crowding;

. align and level the dental arches;

. correct inter-maxillary relationships;

. coordinate the dental arches;

. retain the post-treatment occlusion.

Figure 12 Pre-treatment orthopantomogram

Figure 11 Pre-treatment intra-oral photographs (The patient is displacing his mandible in left side view)

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 11

Treatment plan

1. Phase 1: A Modified Clark Twin Block functionalappliance (TBA) with the following design:

. Upper midline expansion screw.

. Recurved spring (0.7 mm SS) for initial alignment

of upper permanent lateral incisors (U2s).

. Double Adams clasps (0.8 mm SS) on second

premolars and first molar in the four quadrants.

. Heat-cured acrylic baseplate with 7 mm thick

posterior bite blocks at 70˚ inclination to theocclusal plane.

2. Intermediate phase: Upper removable appliance with

inclined bite plane.3. Phase 2:

. Extractions of U4s and L4s planned and per-

formed after functional appliance treatment.

. Upper and lower pre-adjusted edgewise fixed

appliances (0.0220|0.0280 slot) with MBT

prescription.

4. Retention phase: A lower bonded retainer

supported with upper and lower PFRs on nightlybasis.

Figure 13 Pre-treatment lateral cephalogram and its tracing

Clinical12 Almuzian JO 2015

Table

4Pre-treatm

ent,

post-functionalandtoward

theendoftreatm

entcephalometric

analysis.

(Houstonetal.,1992;Jaco

bson,1975;McN

amara,

1984;Arnett

andBergman,1993a,1993b).

Variable

Pre-treatm

ent

Endoffunctional

Nearendoftreatm

ent

Norm

al

SNA

848

848

84.58

828^

3SN

B79.58

818

828

798^

3ANB

4.58

38(EC¼

28)

2.58(EC¼

1.58)

38^

1SN

tomaxillary

plane

48

5.58

58

88^

3W

itsappraisal

þ2mm

0mm

21mm

21mm

A-N

perpendicular(M

cNamara)

1mm

1mm

1mm

1.1

^2.1

mm

Pog-N

perpendicular(M

cNamara)

26mm

23mm

23mm

20.3

^3.8

mm

MM

differentiallength

(McN

amara)

27mm

30mm

32mm

34^

4mm

Upperincisorto

maxillary

planeangle

1278

1158

1118

1088^

5Lo

werincisorto

mandibularplaneangle

988

1028

968

928^

5Interincisalangle

1118

1188

1258

1338^

10

Li-upperincisorrootcentroid

þ4mm

þ6mm

þ5mm

0–2mm

Maxillary

mandibularplanesangle

248

258

268

278^

5Upperanteriorface

height

56mm

60mm

61mm

55mm

^3

Loweranteriorface

height

68mm

73mm

74mm

70.5

mm

^4.5

Face

heightratio

53%

55%

55%

55%

^4mm

Lowerincisorto

APoline

0mm

þ3mm

þ3mm

0–2mm

Lowerlipto

RickettsEPlane

22mm

21mm

22mm

22mm

Naso-labialangle

1138

1158

1168

958^

10

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 13

Treatment progressionFirstly, a TBA was prescribed for 12 months (Figure 14)

with progressive grinding of the acrylic lingual to the

lower incisors to reduce their proclination (Ball and

Hunt, 1991). At the end of the functional appliance

phase (Figure 15a), the TBA was replaced with an upper

removable appliance (URA) with inclined bite plane forfull time use (Figure 15b) and an extraction of L4s was

arranged. A lower fixed appliance was bonded, except-

ing the lower permanent lateral incisor (L2s) which were

excluded at this visit and the space maintained with a

bumper sleeve; 0.0140 NiTi archwire was placed in

conjunction with full time use of the URA. Two months

later, L2s brackets were bonded and the lower archwire

was replaced with 0.0200|0.0200HANiTi (Figure 16a).When the lower archwire was replaced with

0.0190|0.0250 SS wire, extraction of U4s was arranged,

followed by bonding an upper fixed appliance, and

omitting the use of the URA. Progression of the arch-

wire in the upper arch continued from 0.0140 NiTi to

0200|0.0200 (HA NiTi; Figure 16b) followed by an

expanded 0.0190|0.0250 SS with a posterior progressive

buccal root torque bilaterally. A unilateral class IIelastic (1/40, 3.5 oz) was prescribed to correct the midline

(at that stage, the upper centreline was displaced to

the right) and active ties on the four quadrants were

used to close the spaces (Figure 16c). As a finishing

protocol, an upper 0.0190|0.0250 SS, lower

0.0160|0.0220 braided SS wire and vertical settling

(Zig–Zig) elastics (5/80, 3.5 oz) were used (Figure 16d).

Subsequently, upper and lower appliances were debon-ded and a lower fixed retainer wire was bonded and

supported with modified upper and conventional lower

PFRs (Figure 17a and b).

Treatment changesThe cephalometric superimposition and analysis taken

at the end of functional appliance treatment (Figure 18,

Table 4) revealed no noticeable A-P maxillary growth;

there was also little mandibular growth in the A-P

dimension which would account for the change in SNB

and ANB. However, there was some vertical maxillary

and mandibular growth, which would account for theincrease in the vertical proportion. The maxillary

superimposition, on Bjork’s stable maxillary structure,

showed that the upper molars had been slightly tipped

distally and extruded while the upper incisors had been

extruded and retroclined. The mandibular super-

imposition, on Bjork’s stable mandibular structure,

showed that the lower molars had been moved mesially

and extruded while the lower incisors had beenproclined.

Advancing towards the end of the overall treatment, the

cephalometric superimposition and analysis (Figure 19,

Table 4) showed that there had been downward

growth of the maxilla relative to the anterior cranial base.

The apparent lack of A-P change of the maxilla

could be owing to a genetically determined growth

Figure 14 Intraoral photographs during functionalappliance phase

Clinical14 Almuzian JO 2015

pattern, growth restriction’s effect of functional

appliance or alveolar bone modelling associated with

movement of the upper incisors. Additionally, the

mandible had grown in a predominantly vertical direc-

tion with some A-P growth. The maxillary super-

imposition showed that the upper molars had been

tipped mesially and extruded while the upper incisorshad been extruded and retroclined. The mandibular

superimposition showed that the lower molars had been

tipped mesially and extruded while the lower incisors

had retroclined.

Occlusal indicesTable 5 shows the changes in IOTN and PAR achieved

as a result of treatment.

PrognosisThe upper incisors had been brought within the controlof the lower lip, and lip competency had been achieved.

This had created a favourable soft tissue environment

for maintenance of a Class I incisor relationship. Any

further growth was unlikely to be detrimental to the

occlusion and further forward mandibular growth

would continue to correct the skeletal relationship.

In light of this and the significant irregularities of the

lower labial segment pre-treatment, a lower fixed retainerwas placed for long-term use. Although it would be better

if an upper bonded retainer was used, the limited incisor

clearance could have led to increased bonding failure, so

it was decided to assess the need for an upper bonded

retainer based on the findings of the review visits.

Figure 15 Extra- and intra-oral (a) Post-functional phase photographs; (b) Transional phase

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 15

Treatment rationaleIn view of the patient’s age, dental development

stage, growth status and Class II skeletal pattern, a

functional appliance was considered to be an appro-

priate option. A modified TBA was used to facilitate

dentoalveolar change with possible harnessing of

favourable anterio-posterior facial growth. The func-

tional appliance enabled lip competency that improved

the aesthetics of the facial profile and created a morefavourable soft tissue environment for correction of the

overjet.

Significant anchorage gain was achieved with the

TBA; this was reflected in the space requirement of

the upper arch at the end of the functional appliance

phase, as a result of overjet reduction and lateral

expansion.

The design of the TBA included an upper midlineexpansion screw to allow for expansion of the upper

arch, as the mandible was advanced. A large recurved

spring to align U2s was prescribed to start early

correction of palatally standing U2s with no aim to

procline the central incisors. An alternative design mighthave included two conventional Z springs on UL2 and

UR2 and might have been just as effective as the

recurved spring, or the upper arch alignment correction

may even have been left until after extraction. However,

the recurved spring was used as it could align the U2s

simultaneously, provide an extended range of action and

was easy to place by the patient.

Although the use of the inclined bite plane would likelyprocline lower incisors even more, its main uses were to

maintain the class II correction and transverse expansion

as well as to allow the settling of the occlusion.

Following functional appliance treatment, the mal-

occlusion and treatment plan were reassessed. Accord-

ingly, extraction of the four first premolars was carried

out to relieve crowding to correct lower incisors incli-

nation and the centreline discrepancy.The use of the MBT prescription aided the

treatment by having z17˚ labial crown torque in

Figure 16 Stages of the fixed appliance phase of treatment. a: Lower 0.02000 £ 0.02000 HA NiTi archwire in conjunctionwith URA, b: Upper 0.02000 £ 0.02000 HA NiTi archwire and lower 0.01900 £ 0.02500 SS in place, C: Upper andlower 0.01900 £ 0.02500 SS archwires in place and D: Upper 0.01900 £ 0.02500 SS and Lower 0.01600 £ 0.02200 braidedSS archwire placed.

Clinical16 Almuzian JO 2015

the upper incisors, which in turn aided the maintenance

of the inclination of these teeth while space closure

took place. The {6˚ lingual crown torque in the lower

incisors was helpful in controlling the inclination of

the lower incisors secondary to the TBA phase.

The increased buccal root torque of the upper posteriorteeth aided in correcting buccal flaring that resulted

from arch expansion during functional appliance treat-

ment. A self-reflection lesson obtained from treating

this case was that the process may have been improved

if the active ties (Reverse Berman closing elastic)

had been substituted with a NiTi coil spring

(Dixon et al., 2002). One could argue that there was a

slight tendency to Class II canine relationship, owing to

improper molar rotation, and that the U2s had not

been torqued properly. It would have been preferable

to correct this minor irregularity; however, as the

patient’s oral hygiene had deteriorated by the end

of treatment, it was decided to accept this minor

problem.A lower bonded retainer (0.01950 multi-strand

round SS wire) was used on the lower incisors on the

basis of their pre-treatment irregularities and to main-

tain their altered position for the long term. The

patient was provided with upper (2 mm thickness

reinforced with 0.9 mm round SS wire) and

lower pressure-formed retainers to be worn on a nightly

basis.

Figure 17 Post-orthodontic and retention phase. (a) Extra- and intraoral photographs without PFRs and (b) intraoralphotographs with PFRs

ClinicalJO 2015 The William Houston Medal of the Royal College of Surgeons 17

Figure 18 End of functional appliance cephalomtericsuperimposition registered on Bjork’s stable structures (a)Overall, (b) maxillary and (c) mandibular superimposition

Figure 19 Toward the end of overall treatment cephalom-teric superimposition registered on Bjork’s stable structures(a) Overall, (b) maxillary and (c) mandibular superimposition

Table 5 Occlusal indices.

Index Parameter Value

Index of Orthodontic Treatment Need (IOTN)Dental Health component Start 5a

Finish 2gAesthetic component Start 8

Finish 1Peer Assessment Rating (PAR)

Start 44Finish 3Change 41% Change 93.2%

Clinical18 Almuzian JO 2015

Disclaimer statements

Contributors The sole author of this approval was

responsible for undertaking the research and writing the

paper.

Funding None.

Conflicts of interest No conflict of interest.

Ethics approval None.

AcknowledgementThe author would like to thank Mr. Philip Benington,

Mr. Alastair Gardner, Prof. Jim McDonald, Dr. Bridget

Doubleday and Mr. Jamie Deans for their support and

Prof. Martyn Cobourne for his helpful comments.

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