Case Report*A. J. WILDMAN, D.D.S., M.S.D.Eugene, OregonThis case was selected for presenta-tion because the anchorage probleminvolved presented an interesting chal-lenge. I felt that achievement of an ex-cellent face and an acceptable oc-clusion might be a difficult task.HISTORYThe patient was eleven years oldwhen she presented for treatment. Hermedical history included the usualchildhood diseases but no serious ill-ness. There was no history of adversehabit patterns.DIAGNOSISWhen the skeletal pattern was com-pared with the Downs' analysis, it ap-peared excellent. It may be seen inTable 1 that all measurements for theskeletal pattern were well within thenormal range. Measurements for theDowns' analysis involving tooth posi-tion indicated a slightly protrusivelower incisor and a very protrusiveupper incisor.Analysis of the models, which areshown in Figure 1, reveals that thispatient had a Class I malocclusion.There was 6 mm. crowding in the up-per arch and 9 mm. crowding in thelower arch. An overbite problem exist-ed and there was considerable overjet.The profile, seen in Figure 2, was verypoor. It was possible for the patient toclose her lips completely only with con-siderable difficulty.ETIOLOGYDiscrepancy between tooth size andbasal arch length seemed to be thePresented before the Northwest Componentof the Angle Society, 1958.basic problem in this case. No evidenceof perverted swallowing could be de-tected. No definite familial patternscould be established.TREATMENTIt was obvious that this case present-ed an anchorage problem. It seemedthat if care were not taken, enoughanchorage might be lost retracting thecuspids to preclude satisfactory reduc-tion of the existing protrusion. Thetreatment plan was devised to protectanchorage to the utmost. The four firstbicuspid teeth were removed and anedgewise appliance was placed. Theremaining teeth with the exception ofthe third molars were banded. The up-per second molar bands carried .045buccal tubes as well as the edgewisetubes. A Kloehn-type headgear wasconstructed. Stops were placed on theheadgear arch in a position which al-lowed the posterior of the arch to pro-trude from the buccal tubes to providean extension for accommodatingelastics.Round arches were used while thecuspids were being retracted. Elasticswere worn from the end of the head-gear arch to sliding hooks acting againstboth the upper and lower cuspids. Atthe same time Class I11 elastics wereworn from the posterior of the head-gear to sliding hooks acting against thelower second bicuspids to provide adistal force on the lower buccal teeth.In order to conserve anchorage thesethree pairs of elastics were worn onlywhen the headgear was in place. Thisfirst phase of treatment continued forabout ten months.When the cuspids were retracted suf-123 124WildmanApril, 1959Fig. 1Left, inodela before ,treatment. Right, during retention. Vol. 29, No. 2Case ReportFig. 2 Above, photographs before treatment and below, ndter treatment.125 126Wildman April, 1959Table I9-20-56 3-25-58Facial Plane .................. 85 87Convexity ...................... 5 5A-B Plane ...................... 4 4Mand. Plane .................. 24 26Y Axis ............................ 60 59Occlusal Plane .............. 7 10Interincisal .................... 110 128 221 to Occlusal .............. 25 91 to Mand. Plane ...... 8--- 1 to AP Plane (mm) .. 14 5ficiently to allow reduction of the an-terior crowding, a series of round, andlater, edgewise archwires with closingloops were used to close spaces. Class I1elastics were worn in conjunction withthe closing archwires. This second phasewas completed in about eleven months.The final phase of treatment consist-ed of perfecting the details of occlusionwith edgewise finishing arches. Thisphase took eight months.RETENTIONUpper and lower acrylic retainerswere used to close the band space andto refine some details of occlusion. Theteeth were cut from plaster models,which were made after the bands wereremoved, and reset in wax. This ar-rangement was similar to set-ups madefor Kesling positioners, except that theteeth were cut off the models at thecervical enamel junction. A conven-tional, rigid acrylic retainer constructedon a set-up of this type might nothave gone to place. Therefore, whenthe acrylic portion of the retainer wasmade, a thin layer of flexible self-cur-ing acrylic was sprayed against some ofthe teeth, which might have been mov-ed into a position of interference. Thena hard, self-curing acrylic was moldedin the conventional manner to com-plete the acrylic portion of the retainer.The upper and lower retainers car-ried cuspid clasps which crossed thearches between the cuspids and bicus-pids and ended in hooks. Elastics wereworn from these hooks across the an-terior teeth. The ends of these hookswere placed well into the cuspid-lateralembrasure to allow the elastics to en-gage the lateral incisors as well as thecentrals.The action of the flexible acrylic un-der pressure and the action of theelastic bands against the anterior teethproduced tooth movements similar tothose possible with a positioner. Re-tainers of this type seem to be veryeffective for closing band space andrefining minor details of occlusion dur-ing the retention period.RESULTSDuring treatment the crowdingproblem was resolved. The upper in-cisors were retracted from 14 mm to 5mm when measured to the AP plane.Fig. 3 Composite showing growth andchanges of maxilla and mandible duringtreahent. Vol. 29, No. 2Case Report127Fig. 4Compnsite tr:rcing orientcd nil XS and registerecl at S.When tracings of the mandible beforeand after treatment were superimposedon the lower border and gnathion, asshown in Figure 3, it may be notedthat the lower incisor was retractedabout 3 mm. The composite tracingshown in Figure 4, which was super-imposed on NS and registered on s, re-veals that a favorable growth spurt tookplace during treatment.CONCLUSIONMy reason for presenting this par-ticular case was to demonstrate thepossible advantages of one particularmethod of preserving anchorage. Al-though the treatment time might heconsidered extended, the profile andocclusion seem satisfactory.1200 High Street