Crowding and Class II Skeletal Discrepancy

Both lower second premolars are tipped forward. The primary teeth that they are supposed to replace have two roots - one front and one back root. You can see that because the second premolars erupted with a forward tip, they resorbed the front root but not the back roots of the primary teeth. In this situation the primary teeth usually cannot fall out by themselves (depending on how much of the root of the primary tooth is remaining) and the primary teeth need to be extracted. After the primary teeth were out, the second premolars erupted enough that I was able to get braces on them and upright them.

Also notice that his lower front teeth (seen in the middle of the film) are up higher than the lower back teeth. This is a typical occurrence when the lower jaw is back relative to the upper and can be the major cause of excessive overbite (vertical overlap). The curvature that is made by connecting the tips of the front through the back teeth as viewed from the side is called the Curve of Spee. This patient had what is called a bi-planar Curve of Spee: there is a vertical step between the plane that the incisors are on and the plane that the posteriors are on.

His lower jaw was back relative to his upper jaw. You can see how much his top teeth were forward relative to the bottom teeth.
The positions of his upper left canine and the lower canines were such that the gum tissue was very thin on their outer facing surfaces. Before orthodontic treatment, he had free gingival grafts done by a periodontist to protect these teeth from gum loss.
His bottom teeth were half a tooth width back relative to the upper teeth (from the jaw bone discrepancy).

After the periodontal grafts had healed, braces were placed on his upper and lower teeth. The first stage of his treatment involved leveling the Curve of Spee (see the xray below and compare it to the starting xray) and correcting the alignment of his teeth. The second stage involved addressing his jaw bone discrepancy. This was accomplished with a MARA. Total treatment time was 39 months.

The second premolars are fully in. (I referred him to an oral surgeon after the braces were removed to evaluate the third molars for extraction).
The jaw bone discrepancy is corrected.
The lighter areas on his gums by the canines were where the grafts were done. They appear whiter due to the increased thickness of the tissue. This is the usual appearance of a free gingival graft.

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